0910 bow tie risk paulo rheinbolt
TRANSCRIPT
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Objectives
Presentation the Bow-tie methodology basic concepts
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Risk Management
Risk Management is growing in importance because ...Increasing complexity and uncertainty in the work space
Increasing opportunitiesIncreasing stakeholders expectations
Need to optimize management of Upside Risks & Downside RisksNeed to optimize management of Enterprise Risk & Operational Risks
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Risk
Risk: The combination of a event probability and its consequences (ISO/IEC Guia 73).Risk Management: A process to ensure that all significant risks are identified, prioritized, and
managed effectively(DNV).
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THRESHOLD
LIMIT
Inadequate
System
Inadequate
Standards Inadequate
Compliance
Lack of
Control
Personal
Factors Job / System
Factors
Basic
Causes
Substandard
Acts or
Practices Substandard
Conditions
Immediate
Causes
Event
Contact ( or
near) with
energy or
substance
Incident
People
Equipment Material Environment
Loss
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Managing Risk
RiskRecognition
RiskEvaluation
RiskControl
RiskMonitoring
Establish thecontext
Identify all
hazards, threats,& opportunities
Analyze the risks
Evaluate the risksImplement
control plans
Develop control
plans
Review & improverisk management
s stem
Monitor risks& controls
WHAT
MATTERS?
WHAT IS THE
RISK?
SO WHAT? LET’S DO IT!
WHAT DO WE
DO NOW?
IS IT
WORKING?
CAN WE MAKE IT
BETTER?
WHAT CAN GOWRONG
(OR RIGHT)?
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Risk Analysis and Assessment
Decisions
1
2
3
...HAZID
People Qualitative
Analysis
Reputation
Semi-QuantitativeAnalysis
xBenefits
sse s
Environment
QuantitativeAnalysis
ALARP
Costs
Risks Evaluation
Risk Analysis
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Why Bow-tie?
Visualization of the relationship between undesirable event, its
causes, accidental scenarios, the preventive and mitigation
measures to limit their consequences
Demonstrates the effectiveness of existing controls
Structured risk anal sis where uantification is not ossible or
desired
Extremely versatile / Success in various applications
Required multidisciplinary team
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The “Swiss Cheese” Barrier Model
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Prevent Barriers
Inherent
Design Plant
layout
Maintenance &
Inspections
Learningfrom
Events
OperationalProcedures
EffectiveSupervision
Work
ControlRelief andBow-down
System
Audit & SelfRegulation
Management of
Change
Communication
Training &
Competency
Control,
Alarm &
Shut-down
System
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Prevent Barriers
Inherent
Design Plant
layout
Maintenance &
Inspections
Learningfrom
Events
OperationalProcedures
EffectiveSupervision
Work
ControlRelief and
Bow-down
System
Audit & SelfRegulation
Management of
Change
Communication
Training &
Competency
Control,
Alarm &
Shut-down
System
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Detect, Control, Mitigate and Recovery Barriers
Mitigate
Limit Effect
(e.g. deluge system)
ControlLimit extent
(e.g. blow-down)
Detect
Gas, Fire,
Pressure Temperature
High - Low
Crisis Management &
Business Recovery
Emergency ResponseEvacuation, Escape and
Rescue
Inherent
DesignPlant layout
Maintenance
& Inspections
Learning
fromEvents
OperationalProcedures
EffectiveSupervision
Work
ControlRelief
andBow-
downSystem
Audit &Self
Regulation
Management
of Change
Communication
Training&
Competency
Control,
Alarm&Shut-down
System
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Bow-tie Diagram
What can cause anImportant Event?
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Bow-tie Diagram
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Bow-tie Diagram Construction
Define the Hazard and the Top Event which is the initial consequence
"What happens when the danger is" released "?"
Identify the Threats which are the Top Event causes
"What causes the release of danger?
"How can lost control?
Identify the existing Protection Barriers each Threat- Prevent the Top Event occurrence
- Can be independents or dependents
"How can controls fail?""How can that their effectiveness can be compromised?"
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Bow-tie Diagram Construction
Identify for each Barrier their Escalation Factors
- Factors that make the Barrier fail
“How can we avoid that the hazard being released?
“How can we keep the control?”
Identify for each Barrier their Escalation Factors Control
- Factors that prevent or minimize the possibility of the Barrier or theRecovery Measures becomes ineffective
"How to ensure that the controls will not fail?"
Identify the consequences- Top Event could have several consequences
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Bow-tie Diagram Construction
Identify the Recovery Measures
- Factors that make the barriers fail
"How can we limit the severity of the event?”
"How can we minimize the effects?"
Identif for each Recover Measure their Escalation Factors and
Escalation Factors Controls
For each Barrier, Recovery Measures and Escalation Factors Controls
identify the Critical Safety Tasks
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Bow-tie Diagram Construction
Critical Safety Tasks
Tasks prevent and/or minimize the possibility of the Barrier, the Escalation
Factor Control or the Recovery Measures fails or becomes ineffective
What tasks can be taken to ensure that the control is working?
- Project engineering, operation, maintenance, management.
"How can we ensure that these tasks are done?"
"Who do these tasks?
"How do you know when to do the tasks?"?
"How do you know what to do?“"Is there a procedure, checklist, instruction?"
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Bow-tie Example
Unsafescaffolding Scaffoldingassemblystandards
Working at height
ContractorInspection
Safety DeptInspection
PPEcorrect use
Workersawarenessinduction
First AidsTeam
Injuries
Workers
Falling
Ladder
inadequateuse
Ladder
usesstandards
Contractor
Inspection
Safety Dept
Inspection
Mobileplatformdefective
Pre-useInspection
MaintenanceSupervision
Safety DeptInspection
PPEcorrect use
Workersawarenessinduction
EmergencyPlan
Fatality
Critical Safety Tasks
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Safeguarding life, property
and the environment
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