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Operational Safety & Risk management
Based on Bow Tie methodology
Arthur Groot04 februari 2014
04 februari 20142
What is risk management?
Four elements in risk management:
Risk Analysis Source Identification Risk Estimation
Risk Treatment Avoidance Optimization Transfer Retention
Risk Acceptance
Risk Communication
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ISO 17776:2000(E)
Risk Management Process
ISO 31000
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Why Bow Tie?
The full picture
Visual overview
Clear and understandable diagram
Makes communication easy
Extra focus on recovery, consequences
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“Butterfly diagrams”
Possibly evolved from Cause-Consequence-Diagrams of the 70’s
Assessing Hazards and OperationalRisks
Piper Alpha incident 1988
The Royal Dutch / Shell Group 90’s
History of the BowTie
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Oil & Gas Chemical Aviation Medical Financial Government IT
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IADC HSE Case Guidelines
Demonstrate Internal Assurance Meet Stakeholders Expectations
Global Leadership for the Drilling Industry
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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 scenario’s
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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
Barrier effectiveness Risk assessment Acceptance criteria
But also when to stop Threats Consequences Escalation factors
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Barrier thinking
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Bowtie’s parents
Event treeFault tree
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Connect them
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Flatten them out
Hazard TopEvent
ConsequenceThreatThreatBarrier
RecoveryMeasure
Escalation Factor Escalation
Factor Control
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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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ConsequenceAn unwanted event resulting from the release of the Hazard
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
seve
rity
Likelihood
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Detect Decide Act
Behaviourale.g.: double check, defensive driving
Socio-Technicale.g.: calling fire brigade on alarm, fire watch activates fire fighting system
Active Hardwaree.g.: sprinkler system, pressure relief valve
Passive hardwaree.g.: dike, blast wall, anti corrosion paint
Continuous Hardwaree.g.: ventilation system, active corrosion protection
Barrier types
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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Safety Barrier Management
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Safety Barrier Management
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Incidents and BowTies
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EventEventEvent
Barrier
Immediate Cause
Basic Cause
Management System Factor
Barrier
Immediate Cause
Basic Cause
Management System Factor
BSCAT Tripod Beta
Barrier Failure Analysis Root Cause Analysis
EventAgent
Object
Barrier
Immediate CausePreconditionUnderlying Cause
Event Event Event
Barrier
Primary Cause
Secondary Cause
Tertiary Cause
Barrier
Primary Cause
Secondary Cause
Tertiary Cause
Incident analysis methods
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Incident analysis as feedback to BowTie
Driving a car / Losing control over the car Hitting a pedestrian / cyclistDriver loss of attention
External airbagRegular driving breaks
Losing control over the car
Driving a car
Regular driving breaks
Used on 1 Incident
Failed: 1
Missing: 0
Unreliable: 0
Effective: 0
Driver loss of attention
External airbag
Used on 1 Incident
Failed: 0
Missing: 1
Unreliable: 0
Effective: 0
Hitting a pedestrian / cyclist
C3 C0 C0 C1
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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 safety management
Culture• SHWE growth model (based
on Hearts and Minds)• Safety culture scan• Incident analysis (TRIPOD)•Management system audits•Compliance Audits
Compliance•Environmental impact
assessment (EIA)•Environmental permitting• Safety Report• Fire Report•QRA/external Safety•EIA•Emission studies•Noise/odor dispersion studies• IPPC studies
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)
Services Royal HaskoningDHV