slides from the back to basics bowtie workshop

Copyright © 2012 IP Bank BVCopyright © 2012 IP Bank BVCopyright © 2012 IP Bank BVCopyright © 2012 IP Bank BVCopyright © 2012 IP Bank BV

Barrier Based Risk Management Workshop11 October 2016

Wing WTW

Copyright © 2012 IP Bank BVCopyright © 2012 IP Bank BVCopyright © 2012 IP Bank BV

Agenda

08:30 Welcome: coffee / tea

09:00 The BowTie method in Risk Management

10:00 Interactive Workshop building BowTie Diagrams; step by step diagram building

11:00 Coffee break

11:20 Group exercise applying the BowTie method

12:15 Lunch

13:15 Group exercise applying the BowTie method

14:00 Three simple questions & knowing your barrier state

15:15 Coffee break followed by a Q&A session


1979

1988

90’s

00’s

Bowtie history


Barrier thinking


BowTie analysis in 8 steps


Integrate with management system

Policy

Procedure Standard

H S E Q

PolicyStandard

ProcedurePolicy

Activity

Activity

Procedure

Integrated Management System


Bowtie uses

We use it to Structure thinking

We use it for Risk based decision making

We use it for Communication & Training

We use it for Monitoring barrier performance


4 very specific advantages of a BowTie


VS.

1


Proactive or Reactive2


Reduces complexity3


Risk based Management System4


Workshop BowTie Building


HAZOP HAZID as starting pointPick out the high potential hazards to do a Bowtie on


Application Overview

Diagram

Tree view


Step 1. Identify Hazards

Anything that has the potential to cause harm

Hazard


Odd one out

Uncontrolled Fire

Birds around aerodrome

H2S

Explosives in underground

mineDriving a car

Negative stories in press

Hydrocarbons DerailmentLanding aircraft


Step 2. Define Top Event

The point in time when control over the Hazard is lost

Top

Event


Top Event


Define a top event for each hazard below:

(operational department)

Storage of Flammable Liquids

1.

Working at Height

2.

Storage ofToxic Chemicals

3.

Helicopter transport

4.

Confined Space Entry

5.

2

3

4

5

1


Storage of Flammable Liquids

Ignition of Flammable

Liquids

Working at Height

Fall from Height / Dropped objects

Storage ofToxic Chemicals

Loss of Containment

Helicopter transport

(Inadvertent) Entry into

Icing Conditions

Confined Space Entry

Lack of Oxygen

2

3

4

5

1


Step 3. Define Threats

A possible cause for the Top Event

Threat


Identifying Threats

Review past incidents

Checklists and industry guidelines

Check rules – direct, barrier failure

Consider frequency – is it credible?

Can you control it?

Not too broad or narrow

Inclusive? “What about…?”

Tip: Draw the situation

23


Threats

Threats should lead to the Top Event directly


Independent Threats

Beer available

Driver disposition to

drink

Intoxicated driving

Threshold level to cause

Top Event


Barrier Failures


Threat or Barrier failure?


Tip: Threat categories

People

Primary equipment

Environment

Concurrent operations


Step 4. Define Consequences

An unwanted event caused by the Top Event

Consequence


Consequences

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Damage vs. Events

Injury / fatality

Equipment damage

Environmental damage

Reputation damage

Go into Risk matrices on Consequences

Smoke inhalation / blunt impact

Object impacts live equipment

Oil spill into sea


Step 5 & 6. Defining Barriers

Measures taken to prevent or mitigate events

Barrier


Barrier Function


Barrier systems

Barriers systems are the implementation of the barrier function.How does the barrier eliminate, prevent, control or mitigate?

Detect Decide Act


Barrier Perspective


Can a Barrier appear on both sides?


Tip: Split long chains


Proactive or reactive?


Step 7. Define Escalation Factors

A condition that defeats or reduces the effectiveness of a Barrier

Escalation Factor


Escalation Factor


Four main categories

There are four main Escalation Factor categories:

Human Factors

Mechanical Failures

Abnormal Conditions

Loss of Critical Services


Pressure Relief Valve (PRV)

Loss of containment /

200 barrels

Tank Overfilling

Crude oil in storage tank

1.

1

Define an escalation factor for the following diagram:


Pressure Relief Valve (PRV)

Loss of containment /

200 barrels

Tank Overfilling

Crude oil in storage tank

PRV removed for maintenance

1


Step 8. Defining EF Barriers

A Barrier for an Escalation Factor

EF Barrier


Escalation Factor Barrier


Fire

Release of LPG

Non smoking policy

LPG in refinery

1.

2.

2

1

Define an escalation factor and an escalation factor barrier for the following diagram:


Fire

Release of LPG

Non smoking policy

LPG in refinery

Not aware of non-smoking area

“No smoking allowed” signs

2

1


50

Time for a short break


Group Exercise


Group Exercise

Take all the pieces and build a bowtie. Hazard & Top event are below

Work out what is a threat, consequence, escalation factor, barriers, escalation factor barriers

Put together each threat & consequence line as a team.


53

Time for a lunch break


Demo


THREE SIMPLE QUESTIONS TO ANSWER

Basic view of Risk Management


Video is taken from the Press Statement post the conclusion of the Buncefield court case.

Gordon MacDonald HID, HSE UK making the statement.

We took his statement to our hearts.

Do we understand what can go

wrong?

Do we know what our

systems are to prevent this happening?

Do we have information to assure us they

are working effectively?

Why do something?


UNTYING THE KNOT -ANSWERING THE THREE SIMPLE QUESTIONS WITH BOWTIES

Managing Risk by answering the three simple questions


Understand

Know

Assure

The data you need exists already

Audit

Hazard identification

HAZOPs

Corporate Standards/ good practice

Learning from Incidents

PSM Performance Indicators

HAZOP details

Past Incidents

Risk assessments

But we struggle to make sense of it

Maintenance System Data


Understand

Know

Assure

Mapping all your data on to a BowTie

Hazard identification

HAZOP details

Past Incidents


Understand

Know

Assure


Hazards, Top Events,

Threats & Consequences


Understand

Know

Assure


HAZOPs

Risk assessments

Corporate Standards/ good practice




Understand

Know

Assure


What barriers are needed?

Are they there in place?




Understand

Know

Assure




Audit



Maintenance System Data




Understand

Know

Assure


Barrier Performance








Knowing the actual state of your barriers – Advanced Barrier Management


Trainin

g &

Co

mp

etency

Main

tenan

ce

Wo

rk pro

cedu

res

Time sch

edu

ling

Management system

Traditional audit


Barrier-based audit

Easy to spot weak spots

Intuitive display

Results focus on risks, not categories


Audit approaches

Traditional Barrier-based

Maintenance

Compliance

95%

Training

Compliance

90%



Incidents tend treated in silos

No theme trending or collating what multiple incidents mean to an organisation

Lack of a big picture


Feedback incident data on to your barriers


Understand

Know

Assure


Barrier Performance








Q&A Session


Risk Management

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slides from the back to basics bowtie workshop

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