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
 Source Identification
 Risk Estimation
 Risk Treatment
 Avoidance
 Optimization
 Transfer
 Retention
 Risk Acceptance
 Risk Communication

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 Risk Management Process

ISO 31000 ISO 17776:2000(E)

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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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 History of the BowTie

 “Butterfly diagrams”

 Possibly evolved from Cause-

Consequence-Diagrams of the 70’s

 Assessing Hazards and Operational

Risks

 Piper Alpha incident 1988

 The Royal Dutch / Shell Group 90’s

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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


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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

Fault tree Event tree

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Connect them

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Flatten them out

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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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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
An unwanted event resulting from the release
18 04 februari 2014 of the Hazard
 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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 Incident analysis 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 Culture HSE engineering
•Development of Environment & Safety Policy •SHWE growth model (based •Safety Case
•Corporate Environment Plan on Hearts and Minds) •HAZID and HAZOP
•Stakeholder Analysis •Safety culture scan •ENVID
•Carbon Capture and Storage •Incident analysis (TRIPOD) •Fire Protection Analyses
•REACH and GHS •Management system audits •QRA, IRPA
•Corporate Social Responsibility •Compliance Audits •Technical Safety Review
•Carbon Trading •Process Hazard Analysis
•Policy on the Prevention of Serious Accidents •Hazard Consequence Modeling
•Energy Compliance •Asset integrity studies (SIL, IPF
•Environmental impact and LOPA)
Organization and processes assessment (EIA) •Reliability, Availability &
•Environmental Management Systems •Environmental permitting Maintainability Studies (RAMS)
•Safety Management Systems •Safety Report •FME(C)A studies
•Occupational Health Management Systems •Fire Report •BowTie Risk Analyses
•HSE Risk Management •QRA/external Safety •Escape, Evacuation &
Rescue Analysis (EERA)
•Interim HSE Management •EIA
•Training and Coaching •Emission studies
•Environmental and Sustainability Reporting •Noise/odor dispersion studies
•Process safety management •IPPC studies

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