Operational Safety & Risk management

Based on Bow Tie methodology

Arthur Groot
04 februari 2014

What is risk management?

Four elements in risk management:

Risk Analysis
o Source Identification
o Risk Estimation

Risk Treatment
o Avoidance
o Optimization
o Transfer
o Retention

Risk Acceptance

Risk Communication
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Risk Management
Process
ISO 31000

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ISO 17776:2000(E)

Why Bow Tie?

The full picture

Visual overview

Clear and understandable diagram

Makes communication easy

Extra focus on recovery, consequences

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History of the BowTie

Butterfly diagrams

Possibly evolved from CauseConsequence-Diagrams of the 70s

Assessing Hazards and Operational

Risks

Piper Alpha incident 1988

The Royal Dutch / Shell Group 90s

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Oil & Gas

Chemical
Aviation
Medical
Financial
Government
IT

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IADC HSE Case Guidelines

o Demonstrate Internal Assurance
o Meet Stakeholders Expectations

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Global Leadership for the Drilling Industry

Why the need for

BowTie

The gap between technical possibilities and what

organizations are designed needs to be closed

To understand the complexity of the processes in

organizations

If organizations would be very able in dealing with low

frequency, high consequence risks, we would not have a
problem, so called Black Swan scenarios

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Quantitative vs
Qualitative

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Why qualitative risk management?

Complexity of the world

Multi causality in previous incidents

Involvement of the workforce

Most often the world is too complex to accurately quantify

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Quantitative vs
Qualitative

Quantification works best in static or linear environments

where the number of outcomes is finite or known

Qualification works best in dynamic or non-linear

environments (e.g. human factors present) where the
number of outcomes is infinite or uncertain

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Quantitative vs.
Qualitative

QRA and BowTie method are complementary to each other

Bowtie is in principle a qualitative method
o Barrier effectiveness
o Risk assessment
o Acceptance criteria
But also when to stop
o Threats
o Consequences
o Escalation factors

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Barrier thinking

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Bowties parents
Fault tree

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Event tree

Connect them

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Flatten them out

Hazard

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Top
Event

Threat

Consequence

Threat
Barrier

Recovery
Measure

Escalation
Factor

Escalation
Factor
Control

The BowTie can be applied to any kind of risk!

Oil spill of explosive and toxic substance inside the process plant
Tank rupture
Confined space entry with internal hazards, fall protection, silica,
falling brick hazards
Falling ice from high structure
Slip, trip and fall on ice
Welding/cutting hot work, ignition prevention
Oil spill to soil
Working with chemicals
Working near/with cranes
Working in open trenches
Fire pumps impaired
Etc.
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Applying risk graph/matrix into the Bow Tie

Residual risk = likelihood x severity

Likelihood = sum of the independent
causes (taking into account
only the proactive controls)
Severity incl. reactive controls

Likelihood

severity

Consequence
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An unwanted event resulting from the release

of the Hazard

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Barrier types
Detect

Decide

Act

Behavioural
e.g.: double check,
defensive driving

Socio-Technical
e.g.: calling fire brigade
on alarm, fire watch
activates fire fighting
system
Active Hardware
e.g.: sprinkler system,
pressure relief valve

Source: Guldenmund, F., Hale, A., Goossens, L., Betten,

J., & Duijm, N. J. (2006). The development of an audit
technique to assess the quality of safety barrier
management. Journal of hazardous materials, 130(3),
234-41.

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Continuous Hardware
e.g.: ventilation system,
active corrosion
protection
Passive hardware
e.g.: dike, blast wall, anti corrosion
paint

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Safety Barrier
Management

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Safety Barrier
Management

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Incidents and BowTies

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methods
BSCAT

Tripod Beta

Barrier Failure Analysis

Root Cause Analysis

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Incident analysis as feedback to BowTie

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Services Royal HaskoningDHV

Policy and strategy

Development of Environment & Safety

Policy
Corporate Environment Plan
Stakeholder Analysis
Carbon Capture and Storage
REACH and GHS
Corporate Social Responsibility
Carbon Trading
Policy on the Prevention of Serious
Accidents
Energy

Organization and processes

Environmental Management Systems

Safety Management Systems
Occupational Health Management
Systems
HSE Risk Management
Interim HSE Management
Training and Coaching
Environmental and Sustainability
Reporting
Process
safety2014
management
04 februari

Culture

HSE engineering

SHWE growth model (based Safety Case

on Hearts and Minds)
HAZID and HAZOP
Safety culture scan
ENVID
Incident analysis (TRIPOD) Fire Protection Analyses
Management system audits QRA, IRPA
Technical Safety Review
Compliance Audits
Process Hazard Analysis
Hazard Consequence
Modeling
Compliance
Asset integrity studies (SIL,
Environmental impact
IPF
assessment (EIA)
and LOPA)
Environmental permitting Reliability, Availability &
Maintainability Studies
Safety Report
(RAMS)
Fire Report
FME(C)A studies
QRA/external Safety
BowTie Risk Analyses
EIA
Escape, Evacuation &
Emission studies
Rescue Analysis (EERA)
Noise/odor dispersion studies
IPPC studies

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HSE engineering
Safety Case
HAZID and HAZOP
ENVID
Fire Protection Analyses
QRA, IRPA
Technical Safety Review
Process Hazard Analysis
Hazard Consequence Modeling
Asset integrity studies (SIL, IPF
and LOPA)
Reliability, Availability & Maintainability Studies (RAMS)
FME(C)A studies
BowTie Risk Analyses
Escape, Evacuation &
Rescue Analysis (EERA)
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