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Operational Safety & Risk
management
Based on Bow Tie methodology

Arthur Groot
04 februari 2014
What is risk management?
Four elements in risk management:




Risk Treatment

Avoidance

Optimization

Transfer

Re...
Risk Management Process

ISO 31000

3

04 februari 2014

ISO 17776:2000(E)
Why Bow Tie?



Visual overview



Clear and understandable diagram



Makes communication easy



4

The full pictur...
History of the BowTie



Possibly evolved from CauseConsequence-Diagrams of the 70’s



Assessing Hazards and Operation...









Oil & Gas
Chemical
Aviation
Medical
Financial
Government
IT

04 februari 2014


IADC HSE Case Guidelines




Demonstrate Internal Assurance
Meet Stakeholders Expectations

04 februari 2014

Global ...
Why the need for BowTie






8

04 februari 2014
Quantitative vs Qualitative

9

04 februari 2014
Why qualitative risk management?



Multi causality in previous incidents



Involvement of the workforce



10

Compl...
Quantitative vs Qualitative


Quantification works best in static or linear environments
where the number of outcomes is ...
Quantitative vs. Qualitative





12

QRA and BowTie method are complementary to each other
Bowtie is in principle a qu...
Barrier thinking

04 februari 2014
Bowtie’s parents
Fault tree

04 februari 2014

Event tree
Connect them

04 februari 2014
Flatten them out

04 februari 2014
The BowTie can be applied to any kind of risk!














17

Oil spill of explosive and toxic substance in...
Applying risk graph/matrix into the Bow Tie
Residual risk = likelihood x severity
 Likelihood = sum of the independent
ca...
Barrier types

Source: Guldenmund, F., Hale, A., Goossens, L., Betten, J., &
Duijm, N. J. (2006). The development of an au...
Safety Barrier Management

20

04 februari 2014
Safety Barrier Management

21

04 februari 2014
Incidents and BowTies

22

04 februari 2014
Incident analysis methods
BSCAT

Barrier Failure Analysis

23

Tripod Beta

Root Cause Analysis

04 februari 2014
Incident analysis as feedback to BowTie

24

04 februari 2014
Services Royal HaskoningDHV
Policy and strategy

Culture

•Development of Environment & Safety Policy
•Corporate Environme...
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Bow Tie methodology for Operational Safety & Risk Management

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Bow Tie methodology for Operational Safety & Risk Management

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Bow Tie methodology for Operational Safety & Risk Management

  1. 1. Operational Safety & Risk management Based on Bow Tie methodology Arthur Groot 04 februari 2014
  2. 2. What is risk management? Four elements in risk management:   Risk Treatment  Avoidance  Optimization  Transfer  Retention  Risk Acceptance  2 Risk Analysis  Source Identification  Risk Estimation Risk Communication 04 februari 2014
  3. 3. Risk Management Process ISO 31000 3 04 februari 2014 ISO 17776:2000(E)
  4. 4. Why Bow Tie?   Visual overview  Clear and understandable diagram  Makes communication easy  4 The full picture Extra focus on recovery, consequences 04 februari 2014
  5. 5. History of the BowTie   Possibly evolved from CauseConsequence-Diagrams of the 70’s  Assessing Hazards and Operational Risks  Piper Alpha incident 1988  5 “Butterfly diagrams” The Royal Dutch / Shell Group 90’s 04 februari 2014
  6. 6.        Oil & Gas Chemical Aviation Medical Financial Government IT 04 februari 2014
  7. 7.  IADC HSE Case Guidelines   Demonstrate Internal Assurance Meet Stakeholders Expectations 04 februari 2014 Global Leadership for the Drilling Industry
  8. 8. Why the need for BowTie    8 04 februari 2014
  9. 9. Quantitative vs Qualitative 9 04 februari 2014
  10. 10. Why qualitative risk management?   Multi causality in previous incidents  Involvement of the workforce  10 Complexity of the world Most often the world is too complex to accurately quantify 04 februari 2014
  11. 11. 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 11 04 februari 2014
  12. 12. Quantitative vs. Qualitative    12 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 04 februari 2014
  13. 13. Barrier thinking 04 februari 2014
  14. 14. Bowtie’s parents Fault tree 04 februari 2014 Event tree
  15. 15. Connect them 04 februari 2014
  16. 16. Flatten them out 04 februari 2014
  17. 17. The BowTie can be applied to any kind of risk!             17 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. 04 februari 2014
  18. 18. 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 18 04 februari 2014 An unwanted event resulting from the release of the Hazard
  19. 19. 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. 19 04 februari 2014
  20. 20. Safety Barrier Management 20 04 februari 2014
  21. 21. Safety Barrier Management 21 04 februari 2014
  22. 22. Incidents and BowTies 22 04 februari 2014
  23. 23. Incident analysis methods BSCAT Barrier Failure Analysis 23 Tripod Beta Root Cause Analysis 04 februari 2014
  24. 24. Incident analysis as feedback to BowTie 24 04 februari 2014
  25. 25. Services Royal HaskoningDHV Policy and strategy Culture •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 •SHWE growth model (based on Hearts and Minds) •Safety culture scan •Incident analysis (TRIPOD) •Management system audits •Compliance Audits 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 25 04 februari 2014 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)

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