Bow-tie Methodology Research Articles

Eliminating the Occurrence and Consequences of Toxic Release in Petrochemical Industry through Intervention of Safety Engineering Tools

The aim in this project is to analyze the risk associated with different toxic releases which is occurring in the chemical industry and to minimize its release using safety engineering tool in order to make the working environment safer. The sector of petrochemical industries is very important and have specific place in our country. Since the beginning, the Indian petrochemical industry has shown an enviable growth rate. This industry also contributes largely to the economy of the country and the growth and development of manufacturing industry as well. Petrochemical industry has a high risk of toxic release. The main causes of accidents are the chemical splashes which can occur for instance when a pipe or a tank burst under pressure or during disassembling operations of pipes or valves. There are a number of ways of toxic release at each and every process of petrochemical industry. We have identified the way in each process of the petrochemical industry. We have taken H2S as toxic gas and performed analysis, with the help of Bowtie methodology. Result obtained by evaluating various processes in petrochemical industry, we found that H2S can be released in three major sections i.e. transportation, storage and processing units. Using bowtie method, resolutions has been done to decrease or eliminate the possibilities of leakage of H2S

161: Risk analysis with bow-tie methodology on radiotherapy process: 3 major adverse events analyzed.

161: Risk analysis with bow-tie methodology on radiotherapy process: 3 major adverse events analyzed.

Risk analysis for confined space accidents onboard ship using fuzzy bow-tie methodology

Confined spaces pose a number of physical and environmental hazards to workers. Risks associated with confined spaces are one of the leading causes of loss of life on board. Therefore, risk assessment is vital to the seafarer's life. In this context, the principal aim of this research is to analyze the risks associated with works in confined spaces on-board through an integrated model. To do this, a fuzzy based bow-tie methodology was performed to identify the causes and the potential consequences of the unsafe confined space operations. The study found that E3 (commercial/time pressure) with probability 9.595E-01 has the highest impact on the top event. The results also indicate that, macro-level revisions such as improvements in industry practices, changes in organizational culture, redefining roles and responsibilities are critical to minimize the potential of recurrence of such accidents. This study makes a significant contribution to the relevant literature as one of the few pieces of research using the combined FTA-ETA as a dynamic risk analysis methodology. In addition to its contribution to knowledge, this study provides vital information to safety operators. Thus, the findings are valuable for developing risk reduction strategies for unsafe confined space operations. Furthermore, it is recommended to use other risk analysis tools and consider rescue operations for further research.

Engineering Poster E8: Dynamic Risk Advisor – real time bowtie risk assessment monitoring system

Poster E8 This paper describes the development of a Dynamic Risk Advisor to improve safety of operations in fleet marine construction and production oil and gas vessels, well, and subsea equipment in process safety management, providing rig management onshore and offshore tools to assess health, safety, and environment (HSE) performance in real time. This tool uses the bowtie methodology, and provides a useful framework to present a risk ‘picture’ and to satisfy management of health and safety at work regulations. The focus of the methodology is the relationship between safeguards (control systems/equipment, process controls, and human factors) and an overview of the safety process monitoring in a simple and visual form. As facilities and equipment age, those safeguards may become less effective or degraded (different from the condition at the moment of risk assessment creation/revision), risks may increase and that is why they must be monitored using an effective, continuous, and temporal-aware method. Ocyan and Viasat/Intelie created a solution to identify and analyse the hazards dynamically (in real time) using the LIVE streaming data platform, providing an interface that allows the client to manage the current risk profile of their assets using a bowtie diagram. Additionally, this also provides a way for the user to assess the effect of degraded safeguards on complex operations in real time, by monitoring the actual residual risk. The study started in 2019 and was developed together with the Ocyan HSE team and was extended to all fleet due to the positive results. The tool can be accessed from mobile phones and tablets. To access the poster click the link on the right. To read the full paper click here

Dynamic Risk Advisor – real time bowtie risk assessment monitoring system

This paper describes the development of a Dynamic Risk Advisor to improve safety of operations in fleet marine construction and production oil and gas vessels, well, and subsea equipment in process safety management, providing rig management onshore and offshore tools to assess health, safety, and environment (HSE) performance in real time. This tool uses the bowtie methodology, and provides a useful framework to present a risk ‘picture’ and to satisfy management of health and safety at work regulations. The focus of the methodology is the relationship between safeguards (control systems/equipment, process controls, and human factors) and an overview of the safety process monitoring in a simple and visual form. As facilities and equipment age, those safeguards may become less effective or degraded (different from the condition at the moment of risk assessment creation/revision), risks may increase and that is why they must be monitored using an effective, continuous, and temporal-aware method. Ocyan and Viasat/Intelie created a solution to identify and analyse the hazards dynamically (in real time) using the LIVE streaming data platform, providing an interface that allows the client to manage the current risk profile of their assets using a bowtie diagram. Additionally, this also provides a way for the user to assess the effect of degraded safeguards on complex operations in real time, by monitoring the actual residual risk. The study started in 2019 and was developed together with the Ocyan HSE team and was extended to all fleet due to the positive results. The tool can be accessed from mobile phones and tablets.

BowTie Methodology for the Risk Management of the Spin Maneuver During Flight Training in Brazil

This paper aims to present the BowTie methodology as a practical tool for the Risk Management of the spin maneuver during flight instruction, identifying hazards, controls and consequences related to the loss of control in-flight (LOC-I). Exploratory research was carried out regarding its objectives, through a literature review. Initially, a comparison is made between the Brazilian and international training programs, then the particularities of this training in Brazil was analyzed. Finally, a step-by-step construction of a BowTie developed is presented to reduce LOC-I occurrences during spin training.

Study on the Application of the Bowtie Methodology for the Assessment of Ergonomic Risks in the Industrial Field

Study on the Application of the Bowtie Methodology for the Assessment of Ergonomic Risks in the Industrial Field

Corruption Risk Analysis at the Project Planning Stage in the Iraqi Construction Sector using the Bowtie Methodology

In this paper, the bowtie method was utilized by a multidisciplinary team in the Federal Board of Supreme Audit (FBSA)for the purpose of managing corruption risks threatening the Iraqi construction sector. Corruption in Iraq is a widespread phenomenon that threatens to degrade society and halt the wheel of economic development, so it must be reduced through appropriate strategies. A total of eleven corruption risks have been identified by the involved parties in corruption and were analyzed by using probability and impact matrix and their priority has been ranked. Bowtie analysis was conducted on four factors with high score risk in causing corruption in the planning stage. The number and effectiveness of the existing proactive measures to prevent threats from resulting in corruption and were examined for each threat.

Bow tie analysis for prioritizing actions to manage the risks of out of stock on shelves in the retail

PurposeThe purpose of this paper is to present a methodology to structure the problem of retail out of stock (OOS). This methodology allows investigating risk factors and barriers related to the main causes and consequences that lead to OOS occurring.Design/methodology/approachThe proposed methodology to structure the OOS problem is based on the bow- ie tool, which allows better visualisation, understanding and analysis of a complete OOS scenario. This proposal comprises exploring the main causes and consequences of OOS, the barriers to prevention and mitigation, the escalation factors to control undesirable events and to define actions to eliminate or mitigate the OSS risk.FindingsSeveral potential causal risk factors, related to technical, behavioural, cultural and organisational aspects, were identified with this methodology. With the analysis of the OOS scenario, it was observed that the factors that lead to the OOS risk are preventable. In order to improve existing barriers or implement new barriers, a set of actions can be recommended to reduce or eliminate OOS risk factors.Originality/valueFrom a better understanding of hazard, the bow-tie methodology allows identifying crucial factors that could be acted upon to reduce the incidence of OSS. Thus, the value is to propose a methodology that allows establishing the preventive and protective barriers necessaries and the escalation factors related to each of these to help structure the problem and consequently reduce the OOS in retail organisations.

Bowtie Methodology for Risk Analysis of Visual Borescope Inspection during Aircraft Engine Maintenance

Background—The inspection of aircraft parts is critical, as a defective part has many potentially adverse consequences. Faulty parts can initiate a system failure on an aircraft, which can lead to aircraft mishap if not well managed and has the potential to cause fatalities and serious injuries of passengers and crew. Hence, there is value in better understanding the risks in visual inspection during aircraft maintenance. Purpose—This paper identifies the risks inherent in visual inspection tasks during aircraft engine maintenance and how it differs from aircraft operations. Method—A Bowtie analysis was performed, and potential hazards, threats, consequences, and barriers were identified based on semi-structured interviews with industry experts and researchers’ insights gained by observation of the inspection activities. Findings—The Bowtie diagram for visual inspection in engine maintenance identifies new consequences in the maintenance context. It provides a new understanding of the importance of certain controls in the workflow. Originality—This work adapts the Bowtie analysis to provide a risk assessment of the borescope inspection activity on aircraft maintenance tasks, which was otherwise not shown in the literature. The consequences for maintenance are also different compared to flight operations, in the way operational economics are included.

Opportunities to enhance barrier management through incident analysis

Many high hazard industries use bowties to analyze and assess risks. In the bowtie risk analysis model, barriers are identified which aim to prevent, control or mitigate unwanted scenarios.However, despite best effort risks assessments, incidents and near misses may still occur. When they do, organizations typically conduct investigations to come up with recommendations to avoid similar situations in the future. Unfortunately, in many cases these investigation reports end up as a collection of largely unstructured documents. They are often treated as single events, making it difficult to clearly identify trends over multiple events.Scenario-based Incident Registration (SIR) aims to provide a more structured process. A user selects a specific scenario from a set of bowties and assesses the effectiveness of the barriers identified on the original bowtie. Specific questions are asked per barrier about the reasons of the failure. These findings are stored on a barrier level. If this process is repeated, the bowtie will accumulate barrier failure data of multiple incidents in a single diagram. This information helps the organization to identify the strength of their barriers, which in turn facilitates risk-based decision-making.Some incidents require in-depth investigations and a registration only is not enough. However, this registration can be used as a starting point for the incident analysis. Doing barrier-based incident analysis allows you to learn from barrier failures and improve their performances in order to prevent similar incidents from happening. This incident data together with the SIR data can be linked back to the bowtie diagram in order to spot the strengths and weaknesses of your visual risk assessment.SIR is a continuous process which is more than a reporting system. The reporter does not require knowledge about the bowtie methodology, while incident managers receive valuable insight to their pro-active risk assessment.

컨테이너 터미널 안전관리 개선방안에 관한 연구 - 위험성 평가 및 보우타이기법이용 -

It is time to study safety improvement on container terminals to maintain a high-quality service to customers’ productivity and safety. The data analyzed was of the past 3 years accidents data from a container terminal in the Busan port. I especially tried to found out the equipment that had the highest number of accidents and what the main causes were. This study suggests the top hazards identified in the container terminal using risk assessment, Moreover, it seeks control measurements to prevent hazards by bowtie methodology.

Operational risk assessment model for marine vessels

This paper presents a practical approach to quantify the risk associated with different systems in a marine vessel using the existing operational database. A structured bow-tie methodology is proposed to assess risk. The first step was the development of probable failure scenarios for four different events, namely, fire and explosion, propulsion engine failure, power failure, and maneuverability failure. The second step includes the formulation of corresponding bow-tie models representing these scenarios using vessel configuration and process information. Using the failure data for different elements obtained from the vessel's maintenance logbook and incident records, the frequency of events and failure rates of the safety barriers are estimated to quantify risk. Operational data from the vessel, a single engine ice-breaker bulk career navigating mainly in the Canadian sub-arctic region, validated the proposed model. The methodology is verified by comparing the model's observations with an alternative dataset (actual failure scenario from the ship). The proposed methodology is expected to serve as a useful tool for marine vessel's safety and risk management.

APPLICATION OF HAZOP AND BOWTIE-XP METHODOLOGIES OF RISK ASSESSMENT ON THE MACONDO OILWELL BLOWOUT

The application of HAZOP and BowtieXP methodologies of risk assessment using the Macondo oil well blowout as a case studyhas been investigated. This study is aimed, to compare and contrast between the HAZOP and BowtieXP methodologies of riskmanagement using the Macondo oil well blowout as a case study. Hence, to accomplish the set aim of the study, the studyenvisions the Macondo oil well blowout as a scenario, which objectively vector: to evaluate risk management of the Macondoblowout using the Bowtie methodology; to assess risk management of the Macondo blow out using the HAZOP methodology; toprioritize risk assessment methodology within the risk management process; and to show the causes, failed controls, top event,impact, and consequences of the Macondo oil well blowout. To perform the Bowtie Analysis, several steps were followed toensure an accurate representation of the Bowtie Diagram. Firstly, The TOP EVENT was established. This was the most criticalstep in Bowtie XP Risk tool. The choice of the TOP EVENT was guided by some questions: What is the risk event? At what pointwas the safety control lost? At what point did the root causes lead to, and that eventually results in the top event? Next, thepreceding events and root causes threats were established. The choices made addressed answered the aforementioned questions relating to the risk controls which failed, the human factors and behaviour which played a role in the elevation of danger and the root causes of the Top Event. This study concludes that the major event of drilling an oil well is a BLOWOUT, which may lead to a catastrophe, and this was identified by both the HAZOP and BowtieXP as STUDY NODES and TOP EVENT, respectively. The consequences of a failed control blowout are Fire, Explosion, Fatal loss of lives, and environmental pollution.

Comparison of STPA and Bow-tie Method Outcomes in the Development and Testing of an Automated Water Quality Management System

The technology available to water quality management applications needs to be advanced due to greater use of automation to increase ease of operation, support remote operation and reduce risks due to operator error. In this case study, a comparison is made between System-Theoretic Process Analysis (STPA) and the Bow-tie methodology for identifying process hazards and countermeasures which can be used to guide the design and testing of an automated water quality management system (AWQMS). For this study, the application considered is a small hydroponics installation where water quality management has been automated. The STPA methodology uses a system theory-based approach to identify hazards, which include operational failures, human errors, and component interactions. The Bow-tie diagram focuses on individual barriers for a given threat which can prevent the realisation of a hazardous event and unwanted consequences. Thus, the 22 preventative barriers and seven recovery barriers identified through the Bow-tie diagram provide the design process with broad requirements for reducing the risks of user error as well as the ones associated with ongoing operations. The STPA method identified many Causal Factors (CF) generated from the Unsafe Control Actions after considering all the feasible scenarios. For design input, the STPA provided the design process with 204 specific CFs which were used to create 94 countermeasures to be included in software and hardware design as well as user information material. Both methods identified useful measures to control the hazards associated with human interaction with the AWQMS. However, the measures differed in the level of detail and the involvement in the evolution in the final system losses. In this study, the STPA process was able to identify several hazards which did not visibly relate to the Bow-tie barriers. However, the Bow-tie diagram illustrates a distinction between preventative and recovery hazard controls.

Using bowtie methodology to support laboratory hazard identification, risk management, and incident analysis

Hazard prevention and control systems for specific laboratory processes must be readily shared between lab workers, their colleagues, and lab supervisors. In order for these control systems to be effective in a transferable and sustainable way, effective risk management communication tools must be present. These tools need to be adaptable and sustainable as research processes change in response to evolving scientific needs in discovery based laboratories. In this manuscript, the application of a risk management tool developed in the oil and gas industry known as a “bowtie diagram” is assessed for application in the laboratory setting. The challenges of identifying laboratory hazards and managing associated risks as well as early experiences in adapting bowtie diagrams to the laboratory setting are described. Background information about the bowtie approach is provided and the technique illustrated using an academic laboratory research scenario. We also outline the role bowtie diagrams could play in a proactive safety culture program by facilitating hazard communication and maintaining hazard awareness across a wide spectrum of stakeholders.

Bow-tie diagrams for risk management in anaesthesia.

Bow-tie analysis is a risk analysis and management tool that has been readily adopted into routine practice in many high reliability industries such as engineering, aviation and emergency services. However, it has received little exposure so far in healthcare. Nevertheless, its simplicity, versatility, and pictorial display may have benefits for the analysis of a range of healthcare risks, including complex and multiple risks and their interactions. Bow-tie diagrams are a combination of a fault tree and an event tree, which when combined take the shape of a bow tie. Central to bow-tie methodology is the concept of an undesired or 'Top Event', which occurs if a hazard progresses past all prevention controls. Top Events may also occasionally occur idiosyncratically. Irrespective of the cause of a Top Event, mitigation and recovery controls may influence the outcome. Hence the relationship of hazard to outcome can be viewed in one diagram along with possible causal sequences or accident trajectories. Potential uses for bow-tie diagrams in anaesthesia risk management include improved understanding of anaesthesia hazards and risks, pre-emptive identification of absent or inadequate hazard controls, investigation of clinical incidents, teaching anaesthesia risk management, and demonstrating risk management strategies to third parties when required.

Application of Bow-tie methodology to improve patient safety.

Purpose - The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU). Design/methodology/approach - Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation. Findings - In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility. Originality/value - The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

The Bowtie method in safety management system: A literature review

The Bowtie method is a qualitative incorporating management system technique. The theory behind the bow tie approach can be found in the “Swiss cheese model” of Reason. The Royal Dutch/Shell Group was the first major company to integrate fully the total bow-tie methodology into its business practices and then the bowtie has become popular as a structured method to assess risk where a quantitative approach is not possible or desirable. Its essence is to establish how many safety barriers there are available to prevent, control or mitigate the identified scenarios, and the quality of those barriers.

Assessment of Technical Airworthiness in Military Aviation: Implementation and Further Advancement of the Bow-tie Model

International Civil Aviation Organization (ICAO) Standards and Recommended Practices (SARPs) serve to harmonize the safety regulation of civil aviation around the world. ICAO SARPs are only applicable to countries signatory to the 1944 Chicago Convention and only to civil aircraft operations. There is no complimentary international organization providing the same standardization of military aviation regulations. NATO provide international standards for interoperability, and the EDA now provide a militarized European regulatory set aimed at harmonizing requirements for European militaries, however there is no political platform to extend this beyond a voluntary adoption, particularly beyond the European Union. Each military aviation regulator has developed a unique airworthiness regulatory system. There is no recognized method for unbiased assessment and comparison of the disparate regulatory frameworks. This poses a significant challenge when establishing acceptance between military regulatory authorities. This paper develops an assessment framework based on assuring technical integrity utilizing a novel implementation of bow-tie methodology. Further, a unique visualization method is presented to facilitate the comparative assessment of the different regulatory frameworks. This visualization method is a powerful tool for conveying the regulator interaction with the organizations performing design, production and maintenance under their regulatory framework.