The document discusses bowtie diagrams and risk analysis. It provides examples of bowtie diagrams mapping causes, threats, events, consequences, and barriers for incidents like a tiger escape and a chemical spill. It also lists the various training and consulting services provided by Training Solutions International, including in areas like safety, leadership, and ISO standards. Contact information is provided to learn more.

1. T$I presents…………..
Bowtie Concepts
J K M Nair
Director and CEO
Training $olutions International
$olutions
J k m nair/Director-CEO/ TSI - 2010 1

2. ( Training $olutions International )
Here is your one stop solution for training, conference and seminar
related issues of your personal and corporate world.
We deal with all HR, HRD, HRM functions, Strategy planning,
Personnel and company related development programs on:
- Psychology profiling
- Leadership, communication, conflict management, Time management
- Risk management, Safety and Security Management
- Corporate Resource management
- Rational Emotive Responses,
- Emotional Intelligent
- Artificial Intelligence, Expert Systems,
- Behavior Based Safety, Bow Ties,
- Engineering Systems,
- Quality Concepts, Quality Certification, Auditing,
- Public speaking, Human Performance …………………………………
Contact us on : trgsolutions.international@gmail.com
Contact nos: USA: 0016825569455
India: 91-22-28912797/ Cell: 9820133928 Mumbai India
J k m nair/Director-CEO/ TSI - 2010 2

3. Identify Risks, Check why and how,
Analysis what could happen, and for postmortems
Copyright: Trgsolutions.international@gmail.com
J k m nair/Director-CEO/ TSI - 2010 3

4. C E C
J k m nair/Director-CEO/ TSI - 2010
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5. History of Bow Ties
No one knows!
Morphed from Cause Effect Diagram ?
Lifted out from Butterfly diagrams ?
1970s David Gill of ICI plc
1979 Presented in University of Queensland,
Australia
J k m nair/Director-CEO/ TSI - 2010 5

6. Risk Management
Approaches to the RISK
1.We take risk - The return is worth it.
2.We run risk - We can become victims if
something go wrong
People who take risks are not always the
same as those who run them
J k m nair/Director-CEO/ TSI - 2010 6

7. Failures
Active Latent
Failures Failures
Errors and mistakes that
directly impact the system and
break the safety barriers
Unidentified (yet) errors and
mistakes that will impact the
system at a later time
(if not identified in time)
J k m nair/Director-CEO/ TSI - 2010
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8. Risk and failures !
People who make active failures are frequently
running the risk
People who are accepting the latent risk are those
who have taken the original risk
They expect all to go well !
J k m nair/Director-CEO/ TSI - 2010
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9. The Day the Sea Caught Fire
6th July 1988
Training $olutions International
J k m nair/Director-CEO/ TSI - 2010
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10. • Royal Dutch/Shell Group used the
technique in
“ PIPER ALPHA DISASTER ”
• BowTie Pro launched in 2004/shell
Maintenance Work
Pieper Alpha Fire
In 1990, Occidental was out of business in UK
J k m nair/Director-CEO/ TSI - 2010
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11. Cause Event Consequence
Threat
J k m nair/Director-CEO/ TSI - 2010
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12. Cost –
$ 1,500,000,000,
Life lost –
Hazard Incident 167
Company –
Out of business
In 2 years
J k m nair/Director-CEO/ TSI - 2010
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13. H C
O
A N
S
Z E
Incident Q
A E
N
R C
E
D
BARRIERS
J k m nair/Director-CEO/ TSI - 2010 13

14. H
A E
F
Z
Incident F
A E
C
R
T
D
BARRIERS
J k m nair/Director-CEO/ TSI - 2010
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15. C P
R
M
I E
E T
A V I F
E G
U N
Incident
A F
T T
S I I E
O O
E N N C
BARRIERS
T
J k m nair/Director-CEO/ TSI - 2010
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16. Trgsolutions.international@gmail.com
Do A Risk Analysis Now ?
J k m nair/Director-CEO/ TSI - 2010 16

17. Tiger
Cause Escapes Effect
What will happen
HOW
1.
1.
2.
2.
3.
3.
Hazard and Cause analysis
J k m nair/Director-CEO/ TSI - 2010 17

18. Mauls/Kills
Door left open people
C5 C3
Tiger
Escapes HELP
Trgsolutions.international@gmail.com
Cage not strong Loss of tiger
C5
CAUSE EFFECT CONSEQUENCES
J k m nair/Director-CEO/ TSI - 2010 Can we put in the barriers now ?
18

19. Stored
with
Chemica Effect
l drums corrosion
on
Ship Deck
THREAT
EFFECT
Chemical
Leaked out
Damage Effect
in On
handling Human Error Human
EFFECT
THREAT
Damage Trgsolutions.international@gmail.com
When operating
Your Fire Extinguisher Cylinder Leaked out
J k m nair/Director-CEO/ TSI - 2010
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20. Sum up: ; ;
A bowtie diagram can be created by defining:
m
il.co
Event to be prevented a
gm
l@
Threats that could tcause the event to occur
i on
a
a
rn
te
Consequences
ns
.in of the event occurring
io
ut
Controls rgto prevent the event occurring
s ol
T
Controls to mitigate against the
consequences
1
J k m nair/Director-CEO/ TSI - 2010 20

21. ( Training $olutions International )
Know us More……………………………………………………….
Gestalt solutions
Contact us for: RET solutions
Emotional Control Solutions
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- Advance Safety Audit Solutions Incident Investigation
- Root Cause solutions
- Change management Solutions And many more . . . . . . .
J k m nair/Director-CEO/ TSI - 2010 21

22. Thank you
trgsolutions.international@gmail.com
Contact us on : trgsolutions.international@gmail.com
Contact nos: USA: 0016825569455
India: 91-22-28912797/ Cell: 9820133928 Mumbai India
J k m nair/Director-CEO/ TSI - 2010 22