Upload File

introduction to bowtie methodology for a laboratory setting · 2016-03-20 · introduction to...

  • Home
  • Documents
  • Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of
56
SAFER, SMARTER, GREENER DNV GL © 2016 Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of Chemical Health and Safety Developing, Implementing & Teaching Hazard Assessment Tools Mary Beth Mulcahy, Ph.D., U.S. Chemical Safety & Hazard Investigation Board Chris Boylan, DNV GL 15 March 2016

Upload: others

Post on 26-Mar-2020

19 views

Category:

Documents


1 download

Report

TRANSCRIPT

Page 1: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016 SAFER, SMARTER, GREENER DNV GL © 2016

Introduction to Bowtie Methodology for a Laboratory Setting

1

ACS 251st National Meeting

Division of Chemical Health and Safety

Developing, Implementing & Teaching Hazard Assessment Tools

Mary Beth Mulcahy, Ph.D., U.S. Chemical Safety & Hazard Investigation Board

Chris Boylan, DNV GL

15 March 2016

Page 2: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Accident

Page 3: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Culture

Commitment Policies and

Procedures to Improve Safety

Page 4: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Poor Commitment Good Commitment

Good Safety Policies and Procedures

Poor Policies and Procedures

Safety Culture

Page 5: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Good Commitment

Good Safety Policies and Procedures

Safety Culture

Page 6: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Accident

Page 7: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Loss of Control

Page 8: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Top Event

Loss of Control

Hazard/Top Event

Hazard • Health Hazard (carcinogen, toxin, etc.) • Physical Hazard

(flammable, explosive, etc.)

When do you have to change your response? • Threshold amount •  Loss of containment •  Loss of utilities

Page 9: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Barriers

Major Accident

Top Event

Loss of Control

Page 10: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Barriers

Alarms

Preventative Maintenance

Back-up Systems

PPE

Evacuation

Automatic Shutdown

System

Preventative Mitigative

Major Accident

Top Event

Loss of Control

Page 11: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Management Systems

Preventative Barriers

Mitigative Barriers

• Hazard Identification • Procedures •  Incident Investigations •  Indicators

Top Event

Loss of Control

Page 12: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Loss of Control

Page 13: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

About DNV GL

13

350

offices

100 countries

16,000

employees

150 years

Page 14: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

DNV GL Organization

14

OIL & GAS

MARITIME

ENERGY

BUSINESS

ASSURANCE

SOFTWARE

RESEARCH & INNOVATION

MARINE CYBERNETICS

Page 15: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Together we will cover

2:30pm - Overview of Bowtie

3pm-5:30pm - Workshop

!  Basic principles

!  Best practices (do’s and don’ts)

!  Plenary and group exercises – develop bowties

!  Link to organizational and safety culture

Page 16: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is a bowtie, and how can it be used?

16

Excellent communication tool

Not good for hazard identification

Page 17: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowtie Risk Process

17

Identify – Assess – Control – Recover

Identify

Recover

Identify and Assess

Control and Recover

Page 18: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowties link physical controls to your management system

18

Regulatory

University

Laboratory

Persons accountable (job titles)

Page 19: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Accident Causation Model – James Reason

Page 20: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowties – Brief History

20

1979

1988

1990s

2000s 2016

Page 21: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowties - History

21

!  It is said that the first ‘real’ Bowtie diagrams appeared in the (Imperial Chemistry Industry) course notes of a lecture on HAZAN (Hazard Analysis) given at The University of Queensland, Australia (in 1979), but how and when the method found its exact origin is not completely clear.

!  The catastrophic incident on the Piper Alpha platform in 1988 awoke the oil & gas industry. After the report of Lord Cullen, who concluded that there was far too little understanding of Hazards and their accompanying risks that are part of operations, the urge rose to gain more insight in the causality of seemingly independent events and conditions and to develop a systematic/systemic way of assuring Barrier over these Hazards.

!  In the early nineties the Royal Dutch / Shell Group adopted the Bowtie method as company standard for analysing and managing risks. Shell facilitated extensive research in the application of the Bowtie method and developed a strict rule set for the definition of all parts, based on their ideas of best practice. The primary motivation of Shell was the necessity of assurance that appropriate risk Barriers are consistently in place throughout all worldwide operations.

!  Following Shell, the Bowtie method rapidly gained support throughout the industry, as Bowtie diagrams appeared to be a suitable visual tool to keep overview of risk management practices, rather than replacing any of the commonly used systems.

!  In the last decade the Bowtie method also spread outside of the oil & gas industry to include aviation, mining, maritime, chemical and health care to name a few.

Page 22: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowtie’s parents . . .

Event tree Fault tree

Page 23: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

. . . Connect them

Causation Top Event Consequences

Page 24: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

. . . Flatten them out = Bowtie

Threats ⇒ Prevention barriers ⇒ Top Event ⇒ Mitigation Barriers ⇒ Consequences

Page 25: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Next

!  Discuss bowtie elements !  Best practices, do’s and don’ts

!  Class exercise – identify the bowtie faults

25

Page 26: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Example Bowtie diagram

!  Underpinned by Fault Tree and Event Tree methodology !  Excellent tool for hazard and risk communication

–  Simple for a diverse team to understand

–  But easy to get it wrong

26

Page 27: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Best practices

! Construct in order: 1.  Hazard / Top Event (most important step) 2.  All Consequences

3.  All Threats

4.  Preventive Barriers 5.  Mitigation Barriers

6.  Escalation Factors

Page 28: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Example – Do’s and Don’ts

28

ISO 17776, Haz-01.02 Hydrocarbons in Formation

Anything wrong?

Page 29: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Example – Do’s and Don’ts

29

ISO 17776, Haz-01.02 Hydrocarbons in Formation

(Expanded)

What are you communicating? Who is your audience?

Page 30: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What’s wrong with this bowtie? - Driving

30

Page 31: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What’s wrong with this bowtie? - Driving

31

Better?

Page 32: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What’s wrong with this bowtie? - Titanic

32

Page 33: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What’s wrong with this bowtie? - Titanic

Hazard / Top Event are better - what about the barriers?

33

Page 34: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What’s wrong with this bowtie? - Titanic

34

Corrected Bowtie

Page 35: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? - Chemical

35

Page 36: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? - Chemical

36

Page 37: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? - Chemical

37

Page 38: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? - Chemical

38

Page 39: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? – Laboratory

39

Page 40: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? – Laboratory

40

Page 41: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Next

! Group workshops –  Instructors will assign groups

–  15mins to work on 1st exercise + 5mins class discussion

–  30mins for 2nd exercise

–  Then review CSB investigation of laboratory incident and final group work

41

Page 42: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Exercise 1 – Example solution

42

Page 43: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Exercise 2 – Copper Digestion

43

Page 44: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Exercise 2 – Example solution

44

Page 45: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Exercise 3 – TTU Incident

45

Page 46: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Exercise 3 – Example TTU Solution

46

Page 47: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Exercise 3 – Example TTU Solution - Barrier Incident Diagram

47

Page 48: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Conclusions

48

Page 49: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

SAFER, SMARTER, GREENER

www.dnvgl.com

End

49

Page 50: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowtie Risk Model

Prevention Mitigation

50

Page 51: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? - Mechanical

51

Page 52: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

What is wrong with this Bowtie? - Mechanical

52

Page 53: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Crane Ops - Are these Controls independent?

53

Page 54: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Crane Ops - Are these Controls independent?

54

Page 55: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowtie Analysis – What it really looks like

! Large number of routes ! Large number of barriers ! Only some are critical

! Easier to analyze ! Easier to communicate

55

Page 56: Introduction to Bowtie Methodology for a Laboratory Setting · 2016-03-20 · Introduction to Bowtie Methodology for a Laboratory Setting 1 ACS 251st National Meeting Division of

DNV GL © 2016 15 March 2016

Bowtie Example - Driving Vehicle

56


BowTie BowTieXP Risk Management Made Easy

BowTie Cause Marketing Plan

Active Risk Manager - Sword GRC · 2020-05-27 · Active Risk Manager Risk Vizualisation - ARM BOWtie. ARM BOWtie ARM BOWtie allows users to create classic Bow-Tie structures, including

Agriculture Law: bowtie

Using bowtie methodology to support laboratory hazard … · 2017-04-25 · as a ‘‘bowtie diagram’’ is assessed for application in the laboratory setting. The challenges of

Bowtie diagrams in downstream hazard identification and risk

Final BowTie Cause White Paper

Internship Project - Bowtie

Operational Risk Using BowTie Methodology · Management of risk on COMAH sites relies on diverse methods and technologies to reduce risk. As facilities mature, these safeguards may

Bowtie Pro Methodology

Bowtie Methodology and Hazards ManagementBowtie is popular because of it’scapability to analyze and present complex risks in a single diagram. It shows the critical control measures,

Slides from the Back to Basics BowTie Workshop

Plasmonic Resonance Enhanced Polarization-Sensitive ...yep/Papers/ACS Nano... · enhancement by bowtie plasmonic structures. In the second design, we use bowtie apertures (or bowtie

BowTieXP What is a BowTie

Halves Presetation Bowtie - ETC

Bowtie Analysis without Expert Acquisition for Safety ...depts.washington.edu/sctlctr/sites/default/files/research_pub_files/Bowtie Analysis...reliable manner. Further, a substantial

Bowtie Nebula. Helix Nebula Stingray Nebula Tycho Supernova

WIDEBAND PARTIALLY-COVERED BOWTIE ANT FOR GEO RADARS.pdf

251st Ordnance 251st Ordnance Detachment orders (1964-1965)

BowTie in Healthcare - HU-TECH

RAJYA SABHA Budget Session 251st Session of Rajya Sabha

BowTie - A deep learning feedforward neural network for ... · BowTie-Adeeplearningfeedforwardneuralnetworkfor sentimentanalysis ApostolVassilev NationalInstituteofStandardsandTechnology

Quarters Presetation Bowtie - ETC

Bowtie Methodology Manual...create, which looks like a men's bowtie. The bowtie method has several goals: Provide a structure to systematically analyse a hazard. Help make a decision

Integrated broadband bowtie antenna on transparent substrate

Case for Safety - Bowtie Analysis

Includes use as a wall-diaphragm ... - · PDF fileThe Helifix BowTie connects masonry walls to internal timber floor or ceiling joists.There are two types of BowTie,the standard BowTie

International SOS Foundation Travel Risk Mitigation BowTie

DEVELOPING HSE CASE IMPORTANT THING TO THIS TRAINING …€¦ · For Oil & Gas Operators and O˜shore Contractors Program Overview The Bowtie Methodology lies at the foundation of

BowTie Pro The fast, easy to use assessment tool Introduction to BowTie Pro

Bowtie Risk Management - PRWebww1.prweb.com/prfiles/2017/03/15/14152037/Bowtie in... · Risk Management Concepts in SMS, ISO 9001:2016 and AS9100D The BowTie method in Risk Management

Bowtie Nebula

Bowtie Barrier Risk Management Workshop · Barrier thinking: the history of the bowtie method in risk management -how to build a bowtie diagram, CGE Risk Management Solutions 10:15

BowTie in Aviation: Masterclass using BowTieXP€¦ · BowTie in Aviation: Masterclass using BowTieXP BowTie is a great way to manage high-consequence risk, but BowTie models are

DEVELOPING AND CUSTOMIZING COVID˜19 BOWTIE RISK …