Operational Safety & Risk management

Based on Bow Tie methodology

Arthur Groot04 februari 2014

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What is risk management?

Four elements in risk management:

Risk Analysis Source Identification Risk Estimation

Risk Treatment Avoidance Optimization Transfer Retention

Risk Acceptance

Risk Communication

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ISO 17776:2000(E)

Risk Management Process

ISO 31000

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Why Bow Tie?

The full picture

Visual overview

Clear and understandable diagram

Makes communication easy

Extra focus on recovery, consequences

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“Butterfly diagrams”

Possibly evolved from Cause-Consequence-Diagrams of the 70’s

Assessing Hazards and OperationalRisks

Piper Alpha incident 1988

The Royal Dutch / Shell Group 90’s

History of the BowTie

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Oil & Gas Chemical Aviation Medical Financial Government IT

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IADC HSE Case Guidelines

Demonstrate Internal Assurance Meet Stakeholders Expectations

Global Leadership for the Drilling Industry

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Why the need for BowTie

The gap between technical possibilities and what organizations are ‘designed’ needs to be closed

To understand the complexity of the processes in organizations

If organizations would be very able in dealing with low frequency, high consequence risks, we would not have a problem, so called Black Swan scenario’s

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Quantitative vs Qualitative

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Why qualitative risk management?

Complexity of the world

Multi causality in previous incidents

Involvement of the workforce

Most often the world is too complex to accurately quantify

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Quantitative vs Qualitative

Quantification works best in static or linear environments where the number of outcomes is finite or known

Qualification works best in dynamic or non-linear environments (e.g. human factors present) where the number of outcomes is infinite or uncertain

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Quantitative vs. Qualitative QRA and BowTie method are complementary to each other Bowtie is in principle a qualitative method

Barrier effectiveness Risk assessment Acceptance criteria

But also when to stop Threats Consequences Escalation factors

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Barrier thinking

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Bowtie’s parents

Event treeFault tree

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Connect them

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Flatten them out

Hazard TopEvent

ConsequenceThreatThreatBarrier

RecoveryMeasure

Escalation Factor Escalation

Factor Control

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The BowTie can be applied to any kind of risk! Oil spill of explosive and toxic substance inside the process

plant Tank rupture Confined space entry with internal hazards, fall protection,

silica, falling brick hazards Falling ice from high structure Slip, trip and fall on ice Welding/cutting hot work, ignition prevention Oil spill to soil Working with chemicals Working near/with cranes Working in open trenches Fire pumps impaired Etc.

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ConsequenceAn unwanted event resulting from the release of the Hazard

Applying risk graph/matrix into the Bow Tie

Residual risk = likelihood x severity Likelihood = sum of the independent

causes (taking into account only the proactive controls)

Severity incl. reactive controls

seve

rity

Likelihood

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Detect Decide Act

Behaviourale.g.: double check, defensive driving

Socio-Technicale.g.: calling fire brigade on alarm, fire watch activates fire fighting system

Active Hardwaree.g.: sprinkler system, pressure relief valve

Passive hardwaree.g.: dike, blast wall, anti corrosion paint

Continuous Hardwaree.g.: ventilation system, active corrosion protection

Barrier types

Source: Guldenmund, F., Hale, A., Goossens, L., Betten, J., & Duijm, N. J. (2006). The development of an audit technique to assess the quality of safety barrier management. Journal of hazardous materials, 130(3), 234-41.

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Safety Barrier Management

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Safety Barrier Management

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Incidents and BowTies

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EventEventEvent

Barrier

Immediate Cause

Basic Cause

Management System Factor

Barrier

Immediate Cause

Basic Cause

Management System Factor

BSCAT Tripod Beta

Barrier Failure Analysis Root Cause Analysis

EventAgent

Object

Barrier

Immediate CausePreconditionUnderlying Cause

Event Event Event

Barrier

Primary Cause

Secondary Cause

Tertiary Cause

Barrier

Primary Cause

Secondary Cause

Tertiary Cause

Incident analysis methods

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Incident analysis as feedback to BowTie

Driving a car / Losing control over the car Hitting a pedestrian / cyclistDriver loss of attention

External airbagRegular driving breaks

Losing control over the car

Driving a car

Regular driving breaks

Used on 1 Incident

Failed: 1

Missing: 0

Unreliable: 0

Effective: 0

Driver loss of attention

External airbag

Used on 1 Incident

Failed: 0

Missing: 1

Unreliable: 0

Effective: 0

Hitting a pedestrian / cyclist

C3 C0 C0 C1

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Policy and strategy•Development of Environment & Safety Policy•Corporate Environment Plan• Stakeholder Analysis•Carbon Capture and Storage•REACH and GHS•Corporate Social Responsibility•Carbon Trading•Policy on the Prevention of Serious Accidents•Energy

Organization and processes•Environmental Management Systems• Safety Management Systems•Occupational Health Management Systems•HSE Risk Management• Interim HSE Management•Training and Coaching•Environmental and Sustainability Reporting•Process safety management

Culture• SHWE growth model (based

on Hearts and Minds)• Safety culture scan• Incident analysis (TRIPOD)•Management system audits•Compliance Audits

Compliance•Environmental impact

assessment (EIA)•Environmental permitting• Safety Report• Fire Report•QRA/external Safety•EIA•Emission studies•Noise/odor dispersion studies• IPPC studies

HSE engineering• Safety Case•HAZID and HAZOP•ENVID• Fire Protection Analyses•QRA, IRPA•Technical Safety Review•Process Hazard Analysis •Hazard Consequence Modeling •Asset integrity studies (SIL, IPF

and LOPA)•Reliability, Availability &

Maintainability Studies (RAMS)• FME(C)A studies•BowTie Risk Analyses•Escape, Evacuation &

Rescue Analysis (EERA)

Services Royal HaskoningDHV