Bow-tie Analysis Research Articles

Gas Leakage Risk Management Of Biogas Powerplant Using Aloha Gas Dispersion Modelling And Bowtie Analysis

Biogas, a fuel derived from organic waste, has gained popularity as a sustainable energy source. The adaptability of biogas allows its utilization for electricity and heating. This study aims to evaluate the risk of biogas leakage using ALOHA gas dispersion modeling and Bowtie analysis to identify hazard zones and evaluate the effectiveness of preventive and mitigation measures. The research method using Gas dispersion modeling in ALOHA software can simulate the spread of leaked biogas, identify potential hazard zones, and inform emergency response planning. The results show that gas dispersion reaches up to 296 meters from the leak source in a worst-case scenario without ignition, with significant implications for safety. The ignition scenario produces high thermal radiation, further exacerbating the risk. In conclusion, these findings highlight the intolerable risk of biogas leakage, requiring comprehensive risk mitigation measures. This study recommends the implementation of a robust control system, routine maintenance, and emergency response plan to ensure the safety and sustainability of biogas facility operations

Root causes analysis for improved containment integrity in LPG storage: A case study

AbstractA liquefied petroleum gas (LPG) storage system is a critical component designed for the storage of liquefied petroleum gas. LPG storage systems for hazardous materials require rigorous safety protocols to prevent catastrophic containment losses. However, complex interactions between equipment failure, human factors, and external events make prevention a persistent challenge. This study demonstrates the application of structured methods to systematically analyze, correct, and prevent loss of containment in LPG systems. In order to realize this, 8D methodology was used to analyze and solve the problem which included fault tree analysis (FTA) to identify the root causes. Additionally, the bow tie analysis (BTA) will be integrated into the analysis process to implement permanent mitigative actions and prevent the recurrence of similar issues in the future. As a result of this work, it was determined that by applying the proposed approach, the risk of undesired consequences was reduced compared to baseline levels. This study demonstrated the value of a structured suggested approach to improve containment integrity in high‐risk storage systems.

Insight process safety of a hydrogen turbine supply system: A comprehensive dynamic risk assessment using a fuzzy Bayesian network

This study conducts a comprehensive risk assessment for a selected hydrogen supply system within a pilot hydrogen power plant. The assessment begins with hazard identification through Hazard and Operability (HAZOP) analysis, followed by quantification using bow-tie analysis and consequence modeling to evaluate the impacts of credible scenarios resulting from random failures. Furthermore, a fuzzy Bayesian network is employed to address uncertainties inherent in the quantitative approaches and to account for event combinations and dependencies. Sensitivity analysis is subsequently conducted to identify critical events. Utilizing three quantitative approaches, fault tree analysis, the Bayesian network, without and with evidence updating, the probability of the top event is determined to be 4.52 × 10−2/year, 4.50 × 10−2/year, and 4.70 × 10−2/year, respectively. Additionally, the estimated firezone resulting from the explosion's 300 mbar overpressure was 12 m. The findings highlight the significant role of pressure regulator valve and pressure transmitter failures, with posterior probabilities of 0.17/year and 1.90 × 10−3/year, in ensuring the system's safety.

Application of the bow-tie analysis to improve patient safety - a lesson learned from clinical practice.

This study aimed to assess the risk management of drug safety in an operating theater setting within a hospital-based treatment facility.

IT Risk Management Analysis Based on ISO 31000 and Bow Tie Analysis (BTA) in Higher Education Institution

The Division of Applications and Software is a part of the Academic Support Unit (UPA) for Information and Communication Technology at Universitas Jember (UNEJ) or UPA TIK UNEJ. Based on interviews, UPA TIK UNEJ has not yet implemented risk management, leading to recurring issues in their IT services. Risk management is crucial for preventing and mitigating negative impacts that can harm the organization. Additionally, it is a requirement for internal quality management system audits, according to UNEJ Rector's Decision Number 20588/UN25/LL/2018. This study aims to identify, analyze, and assess potential risks in the Division of Applications and Software at UPA TIK UNEJ and to apply Bow Tie Analysis (BTA) to identify preventive and mitigative actions for the highest-rated risks. The approach used is ISO 31000:2018, which provides a comprehensive framework for risk management. For in-depth risk analysis, the BTA method, combining event tree analysis (ETA) and fault tree analysis (FTA), is utilized. The research begins with context establishment through interviews, followed by risk identification, analysis, assessment, and mitigation. The results show 21 risks identified in the process of developing information systems or applications. The top three priority risks are coded R02, R04, and R19. The second priority includes 17 risks, and the third priority includes 1 risk.

Perancangan Sistem Pengendalian Risiko Menggunakan Simplified Bowtie Analysis pada Fasilitas FSO Federal II di PT XYZ

The oil and gas industry in Indonesia, including PT XYZ which manages domestic oil and gas, faces high complexity and risk. PT XYZ's operations are supported by several offshore platforms and facilities which have various potential risks. Process safety is a top priority to prevent major incidents or major accidents. PT XYZ uses Process Hazard Analysis (PHA) which needs to be revalidated every five years to ensure procedures comply with current conditions. This research focuses on the FSO Federal II facility owned by PT XYZ, a 200 thousand barrel capacity crude oil storage vessel with a high potential risk of major incidents. PT XYZ uses the HAZOP and HAZID methods in PHA to identify risks. However, PT XYZ does not yet have a direct control system for workers. This research aims to create a risk control system that can be used by Federal II FSO workers as a work guide. This work guide will help in handling undesirable events that have the potential to cause major incidents. Proposed improvements include creating a work guidance document based on risk identification using Bowtie Analysis, which produces a mapping diagram of causes, peak events, hazards and consequences. The bowtie diagram will be simplified to make things easier for workers, considering the large number of processes in FSO Federal II. This guideline will help workers prevent major incidents from occurring.

Practitioners’ perspectives on health and safety risk management in the Ghanaian oil and gas industry

Risk management has been regarded as one way to improve workplace health and safety conditions. However, very little research has been published on the perspectives of practitioners on safety risk management in general and the Ghanaian oil and gas industry in particular. This study bridges this literary gap by presenting findings from an online survey that investigated the perspectives of practitioners on safety risk management processes of the Ghanaian oil and gas industry. The results of 219 respondents indicated that a disparity existed between the risk methods the practitioners were required to use by their companies and the risk management methods the practitioners preferred to use, and this was verified through statistical testing. Whereas the practitioners were required by their organisations to use quantitative methods, they preferred to use qualitative methods, indicating a difference between work as planned/imagined and work as done. It was further observed that risk management tools/techniques were mostly used proactively, with a limited reactive application during accident investigations. This suggests the limited/lack of integration of risk management into accident investigation processes. Furthermore, feedback from the respondents indicated the narrow use of bowtie analysis in the Ghanaian mining industry as over 60 % of the practitioners had received no training and could not use bowtie analysis. The practitioners’ responses generally showed that whereas current risk management processes in the Ghanaian oil and gas industry had some strengths, some weaknesses exist which offer improvement opportunities. These have been discussed throughout the paper.

Revolutionizing Project Resilience through Advanced Risk Mitigation Strategy Launched

This study examines the risks associated with project delays in the Mover Tram rail line repair project at TMII and proposes mitigation strategies using a combination of Risk Breakdown Structure (RBS), Analytical Network Process (ANP), and Bow Tie Analysis methodologies. Through expert interviews, questionnaires, and document analysis, key risks were identified and prioritized. Results indicate that construction management emerged as the dominant risk group, with specific risks including delays in critical path tasks and discrepancies between drawings and methods. Mitigation strategies were developed focusing on these dominant risks. The study underscores the importance of integrating diverse risk assessment techniques for effective project management and suggests avenues for future research to enhance risk management frameworks in construction projects. Highlights: 1. Integrated risk analysis enhances project resilience.2. Construction management pivotal for identifying and mitigating project risks.3. Future research: Explore cost-related risks for improved project outcomes. Keywords: Project delays, Risk management, Construction projects, Mitigation strategies, Analytical methodologies

A probabilistic analysis method for evaluating the safety & resilience of urban gas pipeline network

Urban gas pipeline networks (UGPN) provide important support for high-quality urbanization. Therefore, it is imperative to analyze and assess the potential failures of UGPN. A novel probabilistic analysis method is proposed for assessing the safety and resilience of UGPN. Firstly, Bow-Tie analysis is used to identify faults. Then, a four-dimensional resilience assessment network is developed. Bayesian network is utilized to model the relationship between the variables, while dynamic Bayesian network is used to consider the dynamic nature of the system. The results of the study show that the proposed model can accurately estimate faults, consequences, and influence paths. Furthermore, the resilience analysis shows that monitoring the objective conditions is crucial and that the initial failure probability of the UGPN decreases from 0.03767 % to 0.01435 % when connected to a resilience network, indicating that considering resilience can effectively improve the reliability and safety of the UGPN. Two application examples are presented in the paper to validate the functionality of the proposed model. The proposed model can be used to set the state of UGPN to predict the probability of occurrence of a specific event and its consequences and to simulate the improvement trend of UGPN based on the direction of focus of future work.

Planning the implementation of a new oncology compounding information system in an aseptic compounding unit: a mixed methods study

Abstract Introduction Systemic anti-cancer therapy (SACT) compounding is a high-risk process. Traditional mixed method systems for workflow management in aseptic compounding units (ACUs) are inherently prone to risk. Workflow management systems (WFMSs) are recognised internationally to improve safety, reduce costs, and increase ACU capacity.[1] Planning of the implementation of a WFMS has not been characterised before. In our ACU, Clinichemo® will be replaced with BD-CATO®. BD-CATO® is a WFMS and is the vendor for the National Cancer Information System (NCIS), implemented by the National Cancer Control Programme (NCCP).[2] Aim The aim of this study was to demonstrate how the implementation of a new WFMS can be safely planned, managed, and assessed. This aim was achieved using the following objectives: 1. Describe and risk assess the current workflows for SACT compounding. 2. Investigate agreed and published standards for SACT compounding. 3. Define the change management process. 4. Describe and evaluate the benefits, challenges and risks associated with the introduction of a new SACT compounding system. 5. Interview adopters of NCIS/BD-CATO® to assess their experience of the barriers encountered, how challenges were overcome, risks identified, mitigated, and eliminated through the change management process and ongoing. Methods The current workflow and future workflow for SACT compounding were characterised and current process risk assessed. Semi-structured interviews were carried out to evaluate pharmacist and pharmacy technicians’ attitudes and opinions towards the implementation of BD-CATO® in their organisations and the system itself. Participants were recruited by means of purposive and snowball sampling from ACUs across the country that had implemented/were in the process of implementing BD-CATO®/NCIS. Themes identified in interviews were compared to those found in the literature and guidelines. Interviews, a review of guidelines, published standards and the literature were used to guide and risk assess future process development. The change management plan was also defined. Results Nine participants (8 pharmacists and 1 pharmacy technician) were interviewed in June-August 2023. The interviews were conducted across 7 ACUs in Ireland. Thematic analysis of interview data yielded four key themes: 1. Participants discussed the importance of planning activities, such as communication with key stakeholders, discussions around phased implementation, and development of training material. 2. Having a designated individual tasked with change implementation improved outcomes of the implementation project. 3. Participants also discussed benefits and risks associated with BD-CATO®. 4. Participants discussed their reasons for perceived complexity of the system. A combination of interview data, review of guidelines, published standards and the literature were used to devise future process workflow and the change management plan. The future process workflow was also risk assessed using bowtie analysis. Conclusion The introduction of WFMSs has been interpreted both in the literature and within the Irish healthcare setting to increase efficiencies, reduce error rates, and improve the accuracy of SACT compounding. A formal change management strategy devised with resourcing, training, and obtaining stakeholder engagement is key to successful implementation.

Rockburst risk control and mitigation in deep mining

It is important to understand and manage rockburst challenges in deep mining operations. This paper presents a systematic study of rockburst risk in underground mining, offering a detailed examination of influencing factors, risk assessment, and various control and mitigation methods. The complexities of rockburst phenomena are explained by examining factors that lead to the occurrence of rockbursts. A rockburst risk assessment using a bow-tie analysis is conducted, which provides insights into both risk evaluation and proactive control and mitigation systems.The core of the paper presents a comprehensive array of rockburst risk control and mitigation methods, which range from controls to reduce rockburst hazard, and excavation vulnerability, to controls and mitigations to reduce exposure. Strategic engineering control methods, including mine design and mining sequencing, are discussed. Tactical engineering control measures, such as ground pre-conditioning and rock support, are scrutinized, along with administrative controls like evacuation and re-entry protocols and the use of mechanized equipment. A multiple-line defense system is advocated for rockburst risk management to address the uncertainties involved in the process.Finally, emerging technologies and innovations as well as challenges are discussed, providing a roadmap for continued advancements in rockburst risk management in the future. This work serves as a valuable resource for mining professionals, researchers, and policymakers seeking a comprehensive understanding of rockburst risk management in deep mining.

Occupational safety & health risk analysis in formwork in high-rise building projects

The implementation of Occupational Health and Safety Management systems remains a significant concern, particularly in the context of multi-storey building construction projects. Within the realm of these complex endeavors, the management of work-related accidents during formwork operations is of paramount importance. This research employs a rigorous methodology involving questionnaire distribution and interviews, complemented by advanced analytical tools such as the Frequency Adjusted Importance Index (FAII) and Bow Tie Analysis. The study focuses on the Indonesian Development University’s high-rise building project, systematically assessing potential hazards associated with formwork activities. Furthermore, this research evaluates the inherent risk levels and proposes comprehensive control measures to mitigate these hazards effectively. By shedding light on the intricate interplay between safety management and high-rise construction, this study contributes to the enhancement of occupational safety and health practices in the construction industry, ultimately promoting safer and more efficient work environments.

Implementation Risk Control Law Number 2 of 2022 By Commission V House of Representatives of The Republic of Indonesia Period 2019 – 2024

Controlling Risks in the Implementation of Law of the Republic of Indonesia No. 2/2022 concerning Road by Commission V DPR RI for the 2019-2024 Period. Jakarta: Postgraduate Program at the Christian University of Indonesian Jakarta, 2022. This research is aiming to analyze the control of the implementation of Law RI No. 2/2022 about Road based on revision result of UU RI No. 38/2004. The qualitative method is used this research and had designed 2 main constructs, namely risk control which refers to the Bow Tie Analysis (BTA) paradigm that recommended by ISO 31000: 2008 and George Edwards' implementation paradigm which has 4 variables as following Communication, Resources, Attitudes, and Bureaucratic Structure. The research objects are members of Commission V DPR RI for the 2019-2024 period in carrying out supervisory/control functions. The results of this research indicate that implementation risks include communication distortions that use sharing information meetings (RDP) as transmission. The risk of resource variables is the occurrence of imbalances in human resources, finance/systems, processes and methods. Meanwhile, the most significant risk is the bureaucratic structure variable, the occurrence of slowness and confusion due to Standard Operational Procedures (SOP) and fragmentation of authority between institutions and ministries regarding the acceleration of increasing regional road connectivity as mandated in Presidential Instruction No. 3/2023.

Evaluation of risk associated with treatment of fat, oil, and grease: Grease interceptor from food processing industry effluent using bowtie analysis

AbstractFat, oil, and grease (FOG), a deposit in wastewater, develops from any processes in food and processing industries. FOG deposits in wastewater management systems can cause blockages in sewer systems. Grease Interceptor (GI) is one of the control measures to treat and prevent the blockage of FOG deposits in the sewer system. Nevertheless, few studies evaluate the extended hazard of GI application in FOG treatment. This study aims to assess the risk of GI in FOG treatment by using a bowtie technique. The hazard identified is FOG itself, whereas the top event was GI failure. The high contributions of the threats were an unsuitable variation of GI's type and design, no GI cleaning process schedule, and a clogged outflow pipe from GI. GI design according to standard and cleaning FOG deposits in GI by a licensed grease hauler were two suitable preventive barriers. The desludging process is essential to guarantee that the GI operates smoothly and is identified as an excellent recovery barrier. Inter‐rater reliability (IRR) analysis to measure the consistency of their ratings on the data provided. The experts had a 75% overall agreement value of IRR risk rating value on assets, while 50% agreement value on people.

Operation failure of risk analysis on floating storage and offloading

The need for petroleum in daily life is increasing. The oil comes from the seabed, so it is necessary to have adequate facilities during the exploration and exploitation of crude oil. The process of distributing crude oil to FSO is assisted by the Product Transfer System pipeline. In this process there is a possibility of failure that occurs form several factors, namely tools, weather and sea conditions, and human. In this study, the analysis of the risk of operational failure during loading-unloading of crude oil is discussed. The analysis was carried out using the HAZOP Analysis and Bow-Tie Analysis methods. HAZOP Analysis for hazard identification, and Bow-Tie Analysis for finding the appropriate mitigation. From this method, an overview of the risks than can occur can be obtained so that the risk control required by FSO can be implemented. From the results of this study, it was found that there are 41 potential hazards on the process of loading-unloading crude oil FSO, with the highest risk is inadequate quality of the transfer equipment components with the likelihood rank is 4 and severity rank is 4. The results of Bow-Tie visualization of dominant risk found five causes, namely corrosion, inadequate material quality, eroded material, service life, and material degradation, and five consequences, namely property damage, delayed operational activities, oil spills, environmental damage due to oil spill, and corrosion occurs on the product transfer equipment.

Hazard Identification Using Task Risk Assessment Method and Bowtie Analysis (Case Study: PT. Varia Usaha Beton)

PT. Varia Usaha Beton is a subsidiary of PT. Semen Indonesia Beton, which produces various types of products. PT Varia Usaha Beton (BSP Purwokerto) has an open work area where there are potential hazards such as physical factors, chemical factors and ergonomic factors. The aim of this research is to identify hazards, assess risks and control risks in the production process of ready-mixed concrete so that workplace accidents can be minimized. The methods used in this research are task risk assessment and bowtie analysis. Based on the research results, it was found that 1 risk belonged to the low category, 27 risks belonged to the medium category, and 11 risks belonged to the high category. Based on the bow-tie method, the major risks are exposure to fly ash and cement dust, risk of diesel spills, and risk of electric shock. The main causes of workplace accidents are pipe leaks and improper diesel filling. The main risk effects of workplace accidents are worker injury, and fire. The bowtie analysis method determines that the risk of electric shock is due to a damaged cable and the existing protective barrier is intended to replace the damaged cable. This risk has consequences, namely injuries to workers.

Research on quantitative risk assessment method of dust explosion based on Bayesian network

In order to effectively prevent the occurrence of dust explosion accidents in industrial enterprises and reducing the risk of dust explosion accidents, the article builds dust explosion risk assessment index system for industrial enterprises, taking Fault Tree Analysis (FTA) and Event Tree Analysis (ETA) as theoretical basis and establishes dust explosion risk Bow-Tie Analysis (BT) diagram model. Mapping BT model into Bayesian Networks (BN) reveals the coupling mechanism of dust explosion risk nodes and constructs a generic dust explosion risk assessment BN model, which provides a quantitative assessment of the probability of occurrence of dust explosion accidents. The causative mechanism of dust explosion accidents is investigated by learning risk inference from this model. It is also demonstrated that appropriate safety barrier measures can effectively reduce the probability of accidents, thereby changing the accident level and improving the safety and reliability of the system. Finally, the validity and applicability of the model is verified through empirical analyses. The research results contribute to the scientific prediction of the probability of dust explosion risk and reasoning learning, which provides a scientific basis for enterprises to formulate effective dust explosion safety measures as well as to realize the hierarchical control of dust explosion risk.

A modelling approach to inform regional cumulative effects assessment in northern Ontario

Cumulatively, the effects of resource extraction and climate change have the potential to cause an unprecedented change to the ecosystems and livelihoods of Indigenous communities in Canada’s northern regions. Maintaining environmental and community values in the presence of such change will require a comprehensive understanding of potential long-term risks and opportunities to prevent or mitigate risks at the regional level. However, assessing the cumulative impact and benefits of the multiple disturbances at the regional level is complex due to the interaction of numerous drivers, values, actors, assessment scales, planning, and decision-making processes. We develop an integrated risk and cumulative effects (CE) management methodology to inform regional assessment by combining conceptual modelling through bowtie analysis and quantitative scenario analysis using ALCES Online (AO) simulation. We applied the framework using a case example in the Ring of Fire region of northern Ontario, Canada, to assess the CE of climate change, land use change, and wildlife harvest on the moose (Alces alces)-wolf (Canis lupus)-caribou (Rangifer tarandus) prey-predator system. The bowtie risk analysis provided a mechanism to define the management problem by identifying threats that contribute to risk, associated consequences, and specific management strategies that could be pursued under legislative frameworks and changes to maintain the sustainable dynamics of the moose-wolf-caribou system (MWC). The AO simulation of different levels of development and moose harvest, as well a baseline scenario that excluded climate change and development, allowed for a comprehensive examination of the complex processes driving the social-ecological system. The scenario analysis suggests that moose harvest can promote balance in the MWC system but only if applied in a sophisticated manner that limits moose harvest in areas with high road density, increases moose harvest in more remote regions susceptible to moose population expansion with climate change, and prioritizes Indigenous moose harvest to ensure a sustainable supply of moose for subsistence harvest. The case example shows how conceptual and quantitative modelling can provide the strategic perspective required for regional assessment.

ANALISIS KECELAKAAN KERJA PADA STRUKTUR BAWAH BLENDING SILO PROYEK “EPC TALAVERA” TUBAN MENGGUNAKAN METODE BOWTIE

The "EPC Talavera" Tuban Project is one of the major projects located in Tuban. Given that the construction of the Blending Silo is being built at a considerable height and certainly requires a large foundation structure, the construction of the Blending Silo carries a relatively high risk of workplace accidents. The purpose of this research is to identify workplace accident risks and evaluate the causes, impacts, and risk responses to accidents during the construction of the substructure of the Blending Silo in the "EPC Talavera" project. To determine the dominant workplace accident risks, risk assessment is performed using probability and severity calculations based on the Risk Management Standard AS/NZ 4360:1999, resulting in an Importance Index value. The method used to evaluate the causes, impacts, and risk responses to workplace accidents is the Bowtie Analysis Method. The results of this research indicate that the most dominant workplace accident risks are the risk of workers being pierced by sharp equipment, the risk of fingers getting caught in the bar bender machine, and the risk of workers being shocked/electrocuted by electrical currents. Based on the bowtie method, the most dominant causes of workplace accidents are scattered sharp equipment, careless/inattentive/unhealthy workers, inadequate equipment, poor bar bender machine conditions, bar bender machine operating methods, exposed welding tool cables, rainy/extreme weather conditions, and electrical current leaks in welding tool bodies. The most dominant impacts of workplace accidents are minor injuries, serious injuries/death, fires, and damage to the bar bender machine. Using the bowtie method, risk responses or controls for the most dominant workplace accident risks are also analyzed, along with an analysis of escalation factors and their controls.

A novel dynamic risk assessment method for the petrochemical industry using bow-tie analysis and Bayesian network analysis method based on the methodological framework of ARAMIS project

In order to obtain the actual risk level and assess the performance of the safety barriers, bow-tie (BT) approach proposed by ARAMIS project is applied to accident scenarios identification and risk analysis, but this approach has limitations in dynamic risk assessment due to its static nature. This study takes the floating roof tank as the research object, and further proposes a dynamic risk assessment method based on the methodology proposed by the ARAMIS project. The BT model of the major leak of external floating roof tank was established by comprehensive consideration of the barrier functions and the logical relationship between causes and events. Furthermore, The BT to Bayesian network (BN) mapping algorithm was proposed to characterize system dynamics and uncertainty. The analysis results show that not only the dynamic assessment of the risk level for safety barriers in different states can be implemented, but also whether the current overall safety protection capability of the system is sufficient can be judged. The proposed method and findings can help managers identify safety barriers that play a key role in various accident risks, and provide effective support for risk management decision-making and implementation of preventive strategies.