Bow Tie Analysis

Bowties - History Early Stages The exact starting point of the Bowtie Methodology has been lost in time but it is believed that they were originally called Butterfly diagrams and evolved from the Cause Consequence Diagram of the !"#s$ %t is then thought that David &ill of %C% plc developed the methodology and called them bowties in the late "#'s$ %t is generally accepted that the earliest mention of the bowtie methodology appears in the %C% (a)an Course *otes !"!+ presented by The ,niversity of -ueensland+ .ustralia$ Early 1990's The technique was given a huge boost in the early to mid !#'s when the /oyal Dutch01hell &roup developed the technique as a result of the 2iper .lpha disaster$ The team started wor3ing with 1hell in the late !#s to improve the quality and effectiveness of the bowties being developed and allow the company to get the most out of the technique$ 1hell is ac3nowledged as the first ma4or company to integrate the whole bowtie methodology fully into its business practices but as the !!#5s grew to an end the approach became a standard method within many other companies$ The structured approach of the bowtie methodology was particularly popular in ris3 analysis within safety cases where quantification is not possible or desirable$ Bowtie analysis can be used for assessing any type of ris3+ e$g$ environmental+ safety+ business+ political+ security+ etc$ and is currently used in a wide range of companies+ industries+ countries and regulators$ The bowtie diagram provides a powerful graphical representation of the ris3 assessment process which is readily understood by the 6non7specialist'$

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What is a bowtie diagram? The bowtie has become popular as a structured method to assess ris3 where a qualitative approach may not be possible or desirable$ The success of the diagram is that it is simple and easy for the non7 specialist to understand$ The idea is a simple one of combining the cause 9fault tree: and the consequence 9event tree:$ ;hen the fault tree is drawn on the left hand side and the event tree is drawn on the right hand side with the ha)ard drawn as a <3not< in the middle the diagram loo3s a bit li3e a bowtie+ as shown$

bowties - The Pro ess . bowtie diagram can easily be created by defining the=

Event to be prevented Threats that could cause the event to occur Consequences of the event occurring Controls to prevent the event occurring Controls to mitigate against the consequences

This is shown in the example below where we have a tiger escaping from a cage$

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The threats that will cause the tiger to escape are identified and listed to the left+ i$e$ it could escape if the cage is not strong enough or the gate is left open$

The consequences of the tiger escaping have been identified and displayed to the right+ i$e$ it could maul03ill a member of the public or could itself be 3illed$

The level of ris3 associated with each consequence can be assigned according to the organi)ation's ris3 matrix and displayed on the diagram$ *ow that the ha)ard has been defined+ we can put threat controls in place which will stop the ha)ard from occurring and consequence controls which will prevent the outcome$ 9clic3 on the image to see a larger version:

Controls can be lin3ed to specific sections or procedures of the organi)ation's safety management system+ can have responsibilities and inspection frequency assigned+ and be ran3ed and colour coded for effectiveness$ The diagram below represents a simple bowtie diagram$ ?n each control there is the ability to identify=

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the tas3 who is responsible for the tas3 classify the control as appropriate .ny documents that may be applicable (ow the tas30control will be validated

The controls can be categorised by Basic /is3 Aactors 9B/As: 0 &eneral Aailure Types 9&ATs: as described by Bames /eason$ The control can also have <Threats to the Controls< 9sometimes called escalation factors: which wea3en the effectiveness as shown below$ Cach threat to the control can in turn have barriers to prevent the threat from occurring$

bowties - The !ses The bowtie methodology can be used for any type of ha)ard analysis+ from ma4or accidents+ through occupational and environmental to business+ %T and security ris3s$ Typical examples are= "emonstrating ontrol o# $is%s The bowtie methodology is an effective way of demonstrating that an organi)ation's ris3s are reduced to .D./2 9.s Dow .s /easonably 2racticable: without the over reliance on qualitative ris3 assessments that has been apparent in the past$ The bowtie methodology is accepted by safety case regulators as a demonstration of .D./2$ Controls on the diagrams can be categorised by 1afety %ntegrity Devels 91%D:+ Cffectiveness and other types of control that may be required$

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&omm'ni ation and Training .s the bowtie is a graphical representation of the issue and is readily understood by a wide audience it is commonly used in communication$ Bowtie diagrams have been printed out in anything from full colour . si)e posters to .8 poc3et boo3lets as an aid in communicating (1C issues$ .s bowtie diagrams are easy to understand+ all members of the wor3force can participate in the process$ (rgani)ational *m+ro,ements %t is possible to use bowties in con4unction with numerous techniques to identify the branches which are wea3$ The use of BowTie allows ownership and critical tas3s to be given to controls ensuring that critical controls do not get over loo3ed$ %n a similar way BowTie also allows the controls to be categorised by Basic /is3 Aactors 9B/As: 0 &eneral Aailure Types 9&ATs: as described by Bames /eason and so lin3ed into an accident investigation$ *denti#ying $is%s Bowtie diagrams are an effective means of systematically identifying ha)ards+ assessing the controls and promoting discussion$ The bowtie diagram graphically demonstrates that controls are in place to reduce the ris3 to .D./2 and document the (.F%D results$ -aintaining a $is% $egister Bowtie diagrams provide a simple+ easily understood and readily updated representation of the ha)ards involved in an organi)ation's activities and the measures ta3en to control the ris3$

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