Bow Tie XP

Barrier Based Risk Management Workshop
11 October 2016
Wing WTW
Copyright © 2012 IP Bank BV

Agenda
08:30 Welcome: coffee / tea
09:00 The BowTie method in Risk Management
10:00 Interactive Workshop building BowTie Diagrams; step by step diagram building
11:00 Coffee break
11:20 Group exercise applying the BowTie method
12:15 Lunch
13:15 Group exercise applying the BowTie method
14:00 Three simple questions & knowing your barrier state
15:15 Coffee break followed by a Q&A session

Bowtie history
1979
1988
90’s
00’s
Barrier thinking

BowTie analysis in 8 steps

Integrate with management system
H S E Q
Policy Activity Procedure Standard Policy
Procedure Standard Policy Procedure Activity
Integrated Management System

Bowtie uses
We use it to Structure thinking
We use it for Risk based decision making
We use it for Communication & Training
We use it for Monitoring barrier performance

4 very specific advantages of a BowTie

1
VS.

2 Proactive or Reactive

3 Reduces complexity

4 Risk based Management System

Workshop BowTie Building

HAZOP HAZID as starting point
Pick out the high potential hazards to do a Bowtie on

Application Overview
Tree
view
Diagram

Step 1. Identify Hazards
Hazard
Anything that has the potential to cause harm

Odd one out
Uncontrolled Birds around

H2S
Fire aerodrome
Explosives in
Negative
underground Driving a car
stories in press
mine
Landing
Hydrocarbons Derailment
aircraft

Step 2. Define Top Event
Top
Event
The point in time when control over

the Hazard is lost

Top Event

Define a top event for each hazard below:
(operational department)
Storage of Storage of Helicopter Confined Space

Working at Height
Flammable Liquids Toxic Chemicals transport Entry
1. 2. 3. 4. 5.

Storage of Storage of Helicopter Confined Space
Working at Height
Flammable Liquids Toxic Chemicals transport Entry
Fall from (Inadvertent)

Ignition of Loss of Entry into
Height / Lack of
Flammable Containment Icing
Dropped Oxygen
Liquids Conditions
objects

Step 3. Define Threats
Threat
A possible cause for

the Top Event

Identifying Threats
Review past incidents
Checklists and industry guidelines
Check rules – direct, barrier failure
Consider frequency – is it credible?
Can you control it?
Not too broad or narrow
Inclusive? “What about…?”
Tip: Draw the situation
23
Threats
Threats should lead to
the Top Event directly

Independent Threats
Threshold
level to cause
Beer available Top Event
Intoxicated
driving
Driver
disposition to
drink

Barrier Failures

Threat or Barrier failure?

Tip: Threat categories
People
Primary equipment
Environment
Concurrent operations

Step 4. Define Consequences
Consequence
An unwanted event caused by the Top Event

Consequences

Damage vs. Events
Injury / fatality Smoke inhalation /

Equipment damage blunt impact
Environmental damage Object impacts live
Reputation damage equipment
Oil spill into sea
Go into Risk matrices on

Consequences

Step 5 & 6. Defining Barriers
Barrier
Measures taken to prevent or mitigate events

Barrier Function

Barrier Function

Barrier Function

Barrier systems
Barriers systems are the implementation of the barrier function.
How does the barrier eliminate, prevent, control or mitigate?
Detect Decide Act

Barrier Perspective

Can a Barrier appear on both sides?

Tip: Split long chains

Proactive or reactive?

Step 7. Define Escalation Factors
Escalation
Factor
A condition that defeats or reduces the effectiveness of a

Barrier
Escalation Factor

Four main categories
There are four main Escalation Factor categories:
Human Factors
Mechanical Failures
Abnormal Conditions
Loss of Critical Services

Define an escalation factor for the following diagram:
Crude oil in
storage tank
Tank Overfilling
Pressure Relief Valve Loss of
(PRV) containment /
200 barrels
1.

Crude oil in
storage tank
Tank Overfilling
Pressure Relief Valve Loss of
(PRV) containment /
200 barrels
PRV removed for

maintenance

Step 8. Defining EF Barriers
A Barrier for an
Escalation Factor
EF Barrier

Escalation Factor Barrier

Define an escalation factor and an escalation factor barrier for the following
diagram:
LPG in refinery
Fire
Release of Non smoking policy

LPG
1.
2.

LPG in refinery
Fire
Release of Non smoking policy

LPG
Not aware of non-

smoking area
“No smoking
allowed” signs

Time for a short break
50

Group Exercise

Group Exercise
Take all the pieces Work out what is a

and build a bowtie. threat, consequence,
Hazard & Top event escalation factor,
are below barriers, escalation
factor barriers
Put together each
threat & consequence
line as a team.

Time for a lunch break
53

Demo

Basic view of Risk Management
THREE SIMPLE QUESTIONS TO

ANSWER

Why do
something?
Video is taken from the Press
Statement post the conclusion of
the Buncefield court case.
Gordon MacDonald HID, HSE UK
making the statement.
We took his statement to our
hearts.
Do we Do we know Do we have
understand what our information to
what can go systems are to assure us they
wrong? prevent this are working
happening? effectively?

Managing Risk by answering the three simple questions
UNTYING THE KNOT -

ANSWERING THE THREE SIMPLE
QUESTIONS WITH BOWTIES
The data you need exists already
Hazard identification
HAZOP details
Past Incidents
Understand
Audit
Learning from Incidents Assure
PSM Performance Indicators
HAZOPs
Maintenance System Data
Know Corporate Standards/ good practice
Risk assessments
But we struggle to make sense of it

Mapping all your data on to a BowTie
Hazard identification
HAZOP details
Past Incidents
Understand
Assure
Know

Hazards, Top Events,
Threats & Consequences
Understand
Assure
Know

Understand
Assure
HAZOPs
Know Corporate Standards/ good practice
Risk assessments

Understand
Assure
Know
What barriers are needed?
Are they there in place?

Understand
Audit
Learning from Incidents Assure
PSM Performance Indicators
Maintenance System Data
Know
What barriers are needed?
Are they there in place?

Understand
Assure
Barrier Performance Know

Learning from Incidents What barriers are needed?
PSM Performance Indicators Are they there in place?

Knowing the actual state of your barriers
– Advanced Barrier Management

Traditional audit
Maintenance
Competency
Training &
Work procedures
Time scheduling
Management system
Barrier-based audit
Easy to spot weak spots

Intuitive display
Results focus on risks, not categories

Audit approaches
Traditional Barrier-based
Maintenance Training
Compliance Compliance
95% 90%

Learning from Incidents
Incidents tend treated in silos

No theme trending or collating what multiple
incidents mean to an organisation
Lack of a big picture

Feedback incident data on to your barriers

Understand
Assure
Barrier Performance Know

Learning from Incidents What barriers are needed?
PSM Performance Indicators Are they there in place?

Q&A Session

Risk Management
Risk Assessment Incident Investigation & Analysis
The visual risk analysis tool BSCAT | Tripod Beta | BFA | RCA
Advanced | Standard | Navigator
Investigate & analyse incidents
Quantify a Bowtie with BowTieXL Short & easy minor

incident analysis

Our clients (1300+)

Bow Tie XP

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Barrier Based Risk Management Workshop

Copyright © 2012 IP Bank BV

09:00 The BowTie method in Risk Management

11:00 Coffee break

11:20 Group exercise applying the BowTie method

13:15 Group exercise applying the BowTie method

14:00 Three simple questions & knowing your barrier state

15:15 Coffee break followed by a Q&A session

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Procedure Standard Policy Procedure Activity

Integrated Management System

Copyright © 2012 IP Bank BV

We use it to Structure thinking

We use it for Risk based decision making

We use it for Communication & Training

We use it for Monitoring barrier performance

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Anything that has the potential to cause harm

Uncontrolled Birds around

Copyright © 2012 IP Bank BV

The point in time when control over

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Storage of Storage of Helicopter Confined Space

Copyright © 2012 IP Bank BV

Fall from (Inadvertent)

Copyright © 2012 IP Bank BV

A possible cause for

Copyright © 2012 IP Bank BV

Tip: Draw the situation

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

An unwanted event caused by the Top Event

Copyright © 2012 IP Bank BV

Injury / fatality Smoke inhalation /

Go into Risk matrices on

Copyright © 2012 IP Bank BV

Measures taken to prevent or mitigate events

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Detect Decide Act

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

Copyright © 2012 IP Bank BV

A condition that defeats or reduces the effectiveness of a

Copyright © 2012 IP Bank BV

There are four main Escalation Factor categories: