Risktec Solutions

risk management and assessment for business

Practical HSE Risk Management – An Introduction to the

Bow-tie Method
Presentation to the International Conference for Achieving Health & Safety
Best Practice in Construction, Dubai, UAE, 26th- 27th February 2007
By Gareth Book, Risktec Solutions Ltd
Practical HSE Risk Management – An Introduction to Bow-tie Method
www.risktec.com
Slide 1
 Purpose of presentation

Introduce bow-tie method

Describe its practical uses and
benefits
Outline an example bow-tie
Provide some tips for successful use

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 2

 History of bow-tie method

Exact origins of bow-tie methodology are hazy –

believed to originate from ICI in the late 1970’s?
Royal Dutch/Shell Group first major company to
integrate bow-ties fully into business practices
Use of bow-ties now widely spread between
companies, industries, countries and from industry to
regulator, e.g.:

– Abu Dhabi National Oil Company (ADNOC)

– UK Health and Safety Executive
– French Government
– Australian State Regulator
– Land Transport Safety Authority of New Zealand
– International standards (e.g. ISO 17776:2000)
– International Association of Drilling Contractors
(IADC)

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 3

 Risk evaluation & management

Identify Policy & Strategic Objectives

Organisation, Resources & Competence

Risk Evaluation & Management

Assess
Leadership & Corrective
Planning, Standards & Procedures
Commitment Actions
Implementation & Monitoring
Control
Audit

Management Review
Recover
Continuous Improvement

HSE Management System

An HSE-MS is a structured set of controls for
managing HSE risk in a business

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 4

 Basic risk evaluation & management
model

Risk Tolerability & ‘ALARP’

Identify Assess Control Recover

Document

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 5

 Link with HSE-MS

Unlike traditional risk evaluation tools, the bow-

tie method makes the link between risk controls
and the HSE-MS:
MS

CONSEQUENCE FREQUENCY
A B C D E Policy & Strategic Objectives
People Assets Environment Reputation Never heard Has Has Occurs Occurs
of in occurred in occurred in several several
industry industry company times per times per
Severity year in
company
year at
location
Organisation, Resources & Competence

0 No injury No No effect No impact

damage Risk Evaluation & Management
1
Slight Slight Slight Slight Manage for
injury damage effect impact
Continuous Leadership & Corrective
Planning, Standards & Procedures
Minor Minor Minor Limited Improvement Commitment Actions
2 injury damage effect impact

Major Localised Localised Considerabl Incorporate risk Implementation & Monitoring

3 injury damage effect e impact reduction
measures
1-3 Major National
4 fatalities damage
Major
impact Audit
effect
Intolerable
Multiple Extensive Massive Internation
5 fatalities damage effect al impact
Management Review

Continuous Improvement

Links are made via HSE-critical roles and

responsibilities, HSE critical procedures, HSE
critical equipment and systems, etc. identified on
the bow-tie diagram
Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 6
 Bow-tie diagram

Impacts
Causes

Preventive Business Recovery

controls upset preparedness

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 7

 Bow-tie diagram

Identify Assess
Consequence
Consequence 1
Hazard and Hazard Source 1
Threat 1
Recovery
Threat Measure
Control Recovery
Threat Measure
Control Top Consequence
Consequence 2
Threat 2
Event Recovery Recovery
1
Threat Threat
Control Control Measure Measure

Threat 3 Threat
Threat Recovery
Control
Control Measure Consequence
Recovery
Consequence 3
1
Measure

Control Recover

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 8

 Typical application of bow-tie method
Potential Risk Risk Management Level of Analysis &
Level Objective Control

Detailed Analysis
High Risk Reduce to medium or low risk e.g. bow-ties

Procedures
Demonstrate Risk reduction Responsibilities
to ALARP
Medium Performance
Risk Measurement

Major Continue to manage Judgement

Low Risk for improvement
Standard
Competences

But method is equally applicable to

routine risks as major risks
Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 9
 Practical uses
Logical structured What are our major risks? Do we have any gaps
approach in risk control?
Communication How do we engage non-risk specialists?

Formal demonstration Can we really demonstrate control of our risks?

Specific risks Are these risks properly understood and

controlled?
Critical roles Do our people know what is expected of them?
Competencies Are competence and control requirements
aligned?
Procedures Are they complete and effective?
Auditing How can we focus audits on what really
matters?
Critical systems and What are they?
performance standards
Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 10
 Link between bow-ties & HSE-critical
tasks

Prevention Mitigation

Visually demonstrate and

communicate the link
between controls and the
management system

HSE Critical Tasks

Responsible parties

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 11

 HSE-critical task catalogue
Client/Project Name Senior Supervisor
Task 01.01 Making live and Closing of Hot Work Ensure that all permits are
Permits signed out ‘made live’ and
closed by the Authorised
Person
Task 01.02 Ensure that Hot Work is in Ensure that permit is in
compliance with permit conditions compliance with MSN 102L
and work is undertaken in
safe manor
Task 02.04 Ensuring that lifting gear is tagged Ensure that lifting gear is
HSE-Critical and colour coded
HSE-critical coded as per procedure
task procedure MSN 205L
Ensure competence of
certifying contractor
Task 04.04 Confirm portable electrical Ensure that external
equipment is fit for purpose and in electrical equipment is
possession of integrity certification tested on a 3 month cycle
and internal equipment is
tested on a 6 month cycle
as per MSN 23L.
HSE-Critical
Role
Permit register
Records of Hot Works
Safety Meetings
Permit register
Walk round
check/inspection of
works
Pre-job briefing sign off
Safety meeting actions
Daily records
Audit and Inspection
Sign off from certifying
company. Verification
Visual check
Audit of Portable
appliances

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 12

 Link between bow-ties and
competence

Welding
performed by
certified welders
only

Verify that
competence and
control requirements
are aligned

Typical Competence
Assurance System Job Profile
Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 13
 Accountability pack for each
HSE-critical role
Accountability Sheet
Role/Post : Maintenance Supervisor HSE-critical role
Identified Safety Critical Role Yes, Level 1 and 2
(Document OD-SA-03-46):

HSE Critical Task Specification Sheet

Task Ref Task Title Input / Procedures
BON-06.01.03 Maintain, test and inspect cargo • OPRM-2003-0304 : POPM Volume 4 - Oil
and crude export pumps, Storage Handling and Ballast
meters and protection systems • OPRM-2003-0305 : POPM Volume 5 : Oil
Metering and Export
• OPRM-2005-0057 : Maintenance and
Inspection Management System Manual
BON-06.01.08 Maintain, test and inspect the • OPRM-2003-0319 : POPM Volume 19 -
inert gas system Inert Gas
• OPRM-2003-0203 : Maintenance and
Etc… Integrity Manual
• OD-OP04-006 : Operations Verification
Management System
Task Verification
Maintenance plan, maintenance
records, test results checked and HSE-critical tasks, procedures
verified by Operations Supervisor
& verification
Maintenance Records.
Reviewed by Ops Supervisor.
Test records

Safety Critical Role Competencies

(Document OD-SA-03-46)
Competence Prerequisites for Assessment Assessor / Re-Asses. Maintenance of
Requirements Assessment Format Verifier Frequency Competence
(Standard)
Skill at Validating Computer Based Computer Based PTW Coordinator / _ Maintained through ongoing
PTW Training to Assessment Line Verifier daily activities and annual
Signatory standard staff appraisal whilst in
position
HSE-critical competencies
Skill at On the job Area Supervisor Installation Manager _ Maintained through ongoing
Supervising HSE exposure while Competence / Line Verifier daily activities and annual
completing OIM Assessment Manual staff appraisal whilst in
portfolio position
Knowledge of Training Course Demonstration of Line Assessor / Line _ Maintained through ongoing
the Nigerian knowledge Verifier daily activities and annual
Legislation staff appraisal whilst in
(Mineral Oils position
(Safety)
Regulations
1997.
Etc…
The Nigerian
Factories Act)

I understand and accept the HSE Critical Tasks and Safety Critical Role Competencies
assigned to me.
Name Signature
Sign-off
Position Date

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 14

 Link between bow-ties and
training & development
Competent people provide
resilience against major risks

…to ensure each risk

control works…

HSE-critical task HSE-critical task catalogue

HSE-critical role Accountability packs

…use
Task competencies Competency
Mgmt System
Assess people
Training requirements
against
requirements

Personal T&D plans

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 15
 Competency management system

Sample training matrix

• Personnel
information
• Training
management
• Competency
management
• Document
management
• Reporting

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 16

 Link between bow-ties and
procedures
Task Responsible Person/Task Inputs/Documents Verification
Description
ABC-22.05 Area Supervisor – Ensure safety related signs are maintained - Inspection and Audit
Maintain Safety Signage up-to -date and in good order
- escape routes
- exit signs
- fire equipment signs
- life saving appliance signs
ABC-12.03 HSE – Manager – Ensure correct storage and handling of - HSE audit
Management of Hazardous hazardous materials in accordance with the - area inspections
Materials requirements identified in the MSDS - manifests
- secure storage - non compliance reports
- segregation of incompatible chemicals
- use of PPE
- appropriate means of transport-
inventory management
ABC-06.03 Site foreman – Carry out weekly inspections of all site - Inspection checklist
Weekly area Inspections of areas: - Non compliance reports
process facilities - housekeeping Verify procedures foract/condition reports
- Unsafe
- general condition of equipment - HSE Meetings
conducting HSE-critical
- general condition of structures
- condition of safetytasks are complete and
equipment
- availability of escape routes effective

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 17

 Link between bow-ties and auditing

AUDIT CHECKLIST
Supervisor
HSE -CRITICAL TASK LIST Task 1 …….
Responsible Task 3 …….
Person: Supervisor
Foreman
Task 1: …………………………..
Task 2: ………………………….. Task 5 …….
Task 3: ………………………….. Task 9 …….
Task 11 …...

Audits can be focused on what

really matters
Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 18
 Link between bow-ties and
HSE-critical equipment & systems

Prevention Mitigation

Establish performance
standards for these
systems
Maintenance management
system should flag HSE-
critical systems and tasks
Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 19
 Total hazard control
In the end you must have all connections in place for effective
hazard control
Location/
Location/
operation
operation

Hazard Performance
Hazard Activity to measures
Standards & control risk
Procedures
Competence
Threat
Threat
Task
People

Threat
Threat
control
control
Release
Release
of
ofhazard
hazard Recovery
Recovery Consequence
Risk Evaluation & measure
measure
Management

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 20

 Example bow-tie

Internal Corrosion 5.4.4.5 Propane

External Corrosion

Fire / Explosion

Overpressure B5 B5 B3 B4

Hazardous Site:
Failure of Stored
cylinders Projectile damage from
exploding cylinders

Dropped / Fallen Object

Building damage, possibly

extending offsite

Vehicle Impact

Human Error

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 21

 Example bow-tie: threats
Dropped / Fallen Object
Vehicle Impact
LPG storage area designed to
HSE Guidelines to minimise
vehicle impact possibility
W-1.1.06 (Design)
Practical HSE Risk Management – An Introduction to Bow-tie Method
Cylinders only moved when
strapped in purpose designed
pallets (Company Handling)
W-4.2.06 (Prod)
LPG cylinders are designed to
BS5045 Part 2 as
Transportable Gas containers
W-2.3.01 (Tan)
5.4.4.5 Propane
Fork lift truck drivers are
trained and have their
competence assessed
Hazardous Site:
W-4.1.03 (Prod) Failure of Stored
cylinders
Fork lift truck drivers are
trained and have their
competence assessed
W-4.1.03 (Prod)
Slide 22
 Example bow-tie: consequence

5.4.4.5 Propane

Fire / Explosion

LPG storage area designed to Quantity of LPG stored limited PTW System and Safe System No smoking policy and
HSE Guidelines to minimise in accordance with HSE of work minimise ignition monitoring to minimise
ignition sources Guidelines sources on site unnecessary combustibles B5 B5 B3 B4

W-1.1.02 (Design) W-2.1.02 W-2.3.08 W-2.4.01 (Prod)

W-5.2.01 (Prod F)

Electrical Equipment

Design - Electrical
Hazardous Site: Classification
Failure of Stored
cylinders W-1.1.02 (Design)

Task Related Ignition

Sources
Operator Intervention - Work
Permit

W-2.4.01 (Prod)

Electrical Storm - lightning

Copy of Design - Electrical

Classification

W-1.1.02 (Design)

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 23

 Example bow-tie: complete

Fire / Explosion
LPG storage area designed to Quantity of LPG stored limited PTW System and Safe System No smoking policy and
HSE Guidelines to minimise in accordance with HSE of work minimise ignition monitoring to minimise
ignition sources Guidelines sources on site unnecessary combustibles B5 B5 B3 B4

Internal Corrosion W-1.1.02 (Design) W-2.1.02 W-2.3.08 W-2.4.01 (Prod)

W-5.2.01 (Prod F)
Cylinders examined in LPG Product standard
accordance with company controlled in accordance with
standards and HSE Guidelines HSE Guidelines 5.4.4.5 Propane

Electrical Equipment

Design - Electrical
Classification
External Corrosion W-1.1.02 (Design)
Cylinders examined in
accordance with company
standards and HSE Guidelines
Task Related Ignition
Sources
Operator Intervention - Work
Permit

Hazardous Site: W-2.4.01 (Prod)

Overpressure
Storage cylinder design/filling
preculdes overpressure from
environmental heating
Failure of Stored
cylinders
Propane area storage
complies with company
standard HSE Guidelines
Electrical Storm - lightning
W-2.3.07
Copy of Design - Electrical
Classification

W-1.1.02 (Design)

Dropped / Fallen Object

Cylinders only moved when Fork lift truck drivers are

strapped in purpose designed
pallets (Company Handling)
W-4.2.06 (Prod)
trained and have their
competence assessed
W-4.1.03 (Prod) LPG storage area physically
separated from other high
risk areas of the site as
required by HSE Guidelines
Projectile damage from
exploding cylinders
Implement emergency
procedures (evacuation, fire
response etc.)
W-6.1.03 (Prod)

Vehicle Impact

LPG storage area designed to
HSE Guidelines to minimise
vehicle impact possibility
W-1.1.06 (Design)
LPG cylinders are designed to
BS5045 Part 2 as
Transportable Gas containers
W-2.3.01 (Tan)
Fork lift truck drivers are
trained and have their
competence assessed Building damage, possibly
extending offsite
W-4.1.03 (Prod)
Evacuation of area on Activate Onsite emergency
indication of fire Response Plan, Offsite Plan if
required
W-2.3.03
W-3.4.02 (Eng) W-6.1.03 (Prod)
W-6.1.04 (Prod)

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 24

 Building bow-ties

Software helps but don’t

get hung up on it!
Benefits are from
approach and involving
workforce

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 25

 Benefits of bow-tie method

Communication – “a picture paints a

thousand words”
Ownership – involves people, gains
buy-in, practical approach
International application – overcomes
language difficulties
All risks – not just HSE
Risk reduction - identifies where
resources should be focussed for risk
reduction, i.e. prevention or mitigation

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 26

 Benefits cont...

Fit for Purpose MS – Links elements

of the organisation’s MS to specific
control
Auditable Trail – the diagrams and
critical tasks provide protocol around
which auditing by internal depts
focuses on what people are actually
doing rather than physical systems

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 27

 Limitations

Entirely qualitative
Does not replace other techniques
(JSA, method statements, etc.) – is
complementary to them
Depends on experience of personnel
and active workforce involvement
Ensure controls in bowtie are truly
independent
But if you want to remove mystique of risk management and obtain
insights into your risk controls that are easy to understand and easy
to communicate, there is no better method than bow-ties

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 28

 Tips for success

1. Keep end objective in mind -

pitch at the right level
2. Involve the right people
3. Avoid barrier counting
4. Use method to full potential
5. Verify controls and tasks

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 29

 Summary

The Bow-tie Diagram is a user-friendly,

graphical illustration of how hazards are
controlled
Effective risk management is only possible
if people are assigned responsibilities for
controls via HSE-Critical Tasks
Visible links are made to HSE-critical
systems and competencies and auditing
The total methodology demonstrates not
only what controls are in place today, but
why they will still be there tomorrow

Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 30