bowtie curso bscat

5
BSCAT Barrier based Systematic Cause Analysis Technique

Upload: roberto-burgos

Post on 08-Apr-2016

16 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: BowTie Curso BSCAT

BSCATBarrier based

Systematic Cause Analysis Technique

Page 2: BowTie Curso BSCAT

Immediate causes

Basic causes

Management system factors

SCAT

EventEventEvent

Barrier

Immediate CauseBasic Cause

Management System Factor

Barrier

Immediate CauseBasic Cause

Management System Factor

BSCAT no confundir bowtie con bscat…bscat es un solo escenario

Immediate cause

Basic cause

Management system factor

Immediate cause

Basic cause

Management system factor

Page 3: BowTie Curso BSCAT

Main Cause – Effect

relationships

SCAT causation path

Barriers: failed, missing,

unreliable, effective

EventEventEvent

Barrier

Immediate CauseBasic Cause

Management System Factor

Barrier

Immediate CauseBasic Cause

Management System Factor

Page 4: BowTie Curso BSCAT

EventEventEvent

Barrier

Immediate CauseBasic Cause

Management System Factor

Barrier

Immediate CauseBasic Cause

Management System Factor

Highway: Losing control over the car

H01 Driving a car

Regular driving breaks

Driver loss of attention (due to phone, controlling radio, fatigue, eating etc.)

Tyre integrity system

Blowout (tire)

ABS

Slippery road conditions

Competence in confined space rescue

Crash into deep water resulting in confined space

External airbag

Hitting a pedestrian/cyclist

Roll-over protection

Vehicle roll-over

B4 C1 C0 C0

C3 C0 C0 C1

C4 C1 C0 C0BSCAT no confundir bowtie con bscat…bscat es un solo escenario

Page 5: BowTie Curso BSCAT