bowtiexp training handout
TRANSCRIPT
Driving a car
Losing control over
the car
Driver loss of attention (due to
phone, controlling radio,
fatigue, eating etc.)
Intoxicated driving
Blowout (tire)
Unexpected manoeuvre from
nearby car
Slippery road conditions
Uneven road surface
Poor visibility (external)
Crash into other car or
motionless object resulting
in injury
Crash into deep water resulting
in confined space
Hitting a pedestrian/cycli
st
Vehicle roll-over
The Hazard is the potentially dangerous aspect in your organi-sation
Unwanted scenarios
BowTies give you an overview of all the scenarios that you do not want to happen, centered around the Top Event
These are Threats, they cause the central Top Event
These are Consequences, they are the different scenarios that can result from the Top Event
Driving a car
Losing control over
the car
Regular driving breaks
Limit mobile phone use in car
Driver loss of attention (due to
phone, controlling radio,
fatigue, eating etc.)
Provide hands free set
Driver needs to communicate
urgently
Agreeing on a designated driver
Breath alcohol ignition interlock
device
Periodic medical examination for
professional drivers
Intoxicated driving
Defensive drivingTyre integrity system
Blowout (tire)
ABSDefensive drivingAdjust car mirrors
Unexpected manoeuvre from
nearby car
ABSListen to weather report and adjust driving schedule
accordingly
Slippery road conditions
ABSPre-journey planning
Uneven road surface
Defensive drivingCar lights are turned on
Poor visibility (external)
Head rest adjusted to appropriate
heightWearing a seatbelt Crumple zone Airbag
Crash into other car or
motionless object resulting
in injury
Forgetting/refusing to wear
seatbelt
Competence in confined space
rescue
Crash into deep water resulting
in confined space
Impact knocks driver
unconscious
External airbag
Hitting a pedestrian/cycli
st
Roll-over protection
Vehicle roll-over
Controlling those scenariosControls can be proactive, prevent-ing or stopping a scenario before it develops into an uncontrolled state
Controls can also be reactive. They get you back to a controlled situa-tion once control is lost.
Escalation fac-tors weaken the integrity of a Control Escalation
Factor Controls control Escala-tion Factors
Driving a car
Losing control over
the car
Regular driving breaks
DR DriverPE People
Limit mobile phone use in car
DR DriverPE People
Driver loss of attention (due to
phone, controlling radio,
fatigue, eating etc.)
Provide hands free set
DR DriverPR Process
Driver needs to communicate
urgently
Agreeing on a designated driver
DR DriverPE People
Breath alcohol ignition interlock
device
EN EngineerHW Hardware
Periodic medical examination for
professional drivers
DR DoctorPR Process
Intoxicated driving
Defensive driving
DR DriverPE People
Tyre integrity system
MM Maintenance Manager
PR Process
Blowout (tire)
ABS
EN EngineerHW Hardware
Defensive driving
DR DriverPE People
Adjust car mirrors
DR DriverPE People
Unexpected manoeuvre from
nearby car
ABS
EN EngineerHW Hardware
Listen to weather report and adjust driving schedule
accordingly
DR DriverPE People
Slippery road conditions
ABS
EN EngineerHW Hardware
Pre-journey planning
DR DriverPR Process
Uneven road surface
Defensive driving
DR DriverPE People
Car lights are turned on
DR DriverPE People
Poor visibility (external)
Head rest adjusted to appropriate
height
DR DriverPE People
Wearing a seatbelt
DR DriverPE People
Crumple zone
EN EngineerHW Hardware
Airbag
EN EngineerHW Hardware
Crash into other car or
motionless object resulting
in injury
Forgetting/refusing to wear
seatbelt
Competence in confined space
rescue
DR DriverPE People
Crash into deep water resulting
in confined space
Impact knocks driver
unconscious
External airbag
EN EngineerHW Hardware
Hitting a pedestrian/cycli
st
Roll-over protection
EN EngineerHW Hardware
Vehicle roll-over
Adding extra information
Control effectiveness can be assessed and visualised using colors.
Control types help to analyse where potential common mode failures in the organisation are
People can be made responsible for Controls, and see why they are important for a safe organsiation
Dri
vin
g a
ca
r
Losi
ng
co
ntr
ol o
ver
the
ca
r
Re
gu
lar
dri
vin
g
bre
ak
s
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-08
-
Sch
ed
ule
dri
vin
g
bre
ak
sR
esp
on
sib
le:
DR
-
Dri
ver
Lim
it m
ob
ile p
ho
ne
u
se in
ca
r
DR
Dri
ver
PE
Pe
op
le
Dri
ver
loss
of
att
en
tio
n (
du
e t
o
ph
on
e,
con
tro
llin
g r
ad
io,
fati
gu
e,
ea
tin
g
etc
.)
Pro
vid
e h
an
ds
fre
e
set
DR
Dri
ver
PR
Pro
cess
Act
ivit
y:
SC
A-0
4 -
M
ain
tain
inte
rna
l
car
safe
ty d
evi
ces
Re
spo
nsi
ble
: E
N -
E
ng
ine
er
Dri
ver
ne
ed
s to
co
mm
un
ica
te
urg
en
tly
Ag
ree
ing
on
a
de
sig
na
ted
dri
ver
DR
Dri
ver
PE
Pe
op
le
Bre
ath
alc
oh
ol
ign
itio
n in
terl
ock
d
evi
ce
EN
En
gin
ee
rH
W H
ard
wa
reA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
Pe
rio
dic
me
dic
al
ex
am
ina
tio
n f
or
pro
fess
ion
al
dri
vers
DR
Do
cto
rP
R P
roce
ssA
ctiv
ity
: S
CA
-06
-
Me
dic
al
ex
am
ina
tio
n d
rive
rR
esp
on
sib
le:
DR
-
Do
cto
r
Into
xic
ate
d
dri
vin
g
De
fen
sive
dri
vin
g
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-03
-
De
fen
sive
dri
vin
g
tra
inin
gR
esp
on
sib
le:
TM
-
Tra
inin
g M
an
ag
er
Ty
re in
teg
rity
sy
ste
m
MM
Mai
nte
na
nce
M
an
ag
er
PR
Pro
cess
Act
ivit
y:
SC
A-0
1 -
In
spe
ctio
n o
f ca
r
tire
sR
esp
on
sib
le:
MM
-
Ma
inte
na
nce
M
an
ag
er
Act
ivit
y:
SC
A-0
2 -
T
yre
pre
ssu
re
che
ckR
esp
on
sib
le:
DR
-
Dri
ver
Blo
wo
ut
(tir
e)
AB
S
EN
En
gin
ee
rH
W H
ard
wa
reA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
De
fen
sive
dri
vin
g
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-03
-
De
fen
sive
dri
vin
g
tra
inin
gR
esp
on
sib
le:
TM
-
Tra
inin
g M
an
ag
er
Ad
just
ca
r m
irro
rs
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-09
-
Ge
ne
ral c
ar
safe
ty
tra
inin
gR
esp
on
sib
le:
TM
-
Tra
inin
g M
an
ag
er
Un
ex
pe
cte
d
ma
no
eu
vre
fro
m
ne
arb
y c
ar
AB
S
EN
En
gin
ee
rH
W H
ard
wa
reA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
List
en
to
we
ath
er
re
po
rt a
nd
ad
just
d
rivi
ng
sch
ed
ule
a
cco
rdin
gly
DR
Dri
ver
PE
Pe
op
le
Slip
pe
ry r
oa
d
con
dit
ion
s
AB
S
EN
En
gin
ee
rH
W H
ard
wa
reA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
Pre
-jo
urn
ey
p
lan
nin
g
DR
Dri
ver
PR
Pro
cess
Act
ivit
y:
SC
A-1
0 -
P
re-j
ou
rne
y
pla
nn
ing
Re
spo
nsi
ble
: D
R -
D
rive
r
Un
eve
n r
oa
d
surf
ace
De
fen
sive
dri
vin
g
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-03
-
De
fen
sive
dri
vin
g
tra
inin
gR
esp
on
sib
le:
TM
-
Tra
inin
g M
an
ag
er
Ca
r lig
hts
are
tu
rne
d o
n
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
Po
or
visi
bili
ty
(ex
tern
al)
He
ad
re
st a
dju
ste
d
to a
pp
rop
ria
te
he
igh
t
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-09
-
Ge
ne
ral c
ar
safe
ty
tra
inin
gR
esp
on
sib
le:
TM
-
Tra
inin
g M
an
ag
er
We
ari
ng
a s
ea
tbe
lt
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
Cru
mp
le z
on
e
EN
En
gin
ee
rH
W H
ard
wa
re
Air
ba
g
EN
En
gin
ee
rH
W H
ard
wa
reA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
Cra
sh in
to o
the
r
car
or
mo
tio
nle
ss
ob
ject
re
sult
ing
in
inju
ry
D4D2D0D1
Forg
ett
ing
/re
fus
ing
to
we
ar
sea
tbe
lt
Co
mp
ete
nce
in
con
fin
ed
sp
ace
re
scu
e
DR
Dri
ver
PE
Pe
op
leA
ctiv
ity
: S
CA
-05
-
Co
nfi
ne
d s
pa
ce
tra
inin
gR
esp
on
sib
le:
TM
-
Tra
inin
g M
an
ag
er
Act
ivit
y:
SC
A-0
4 -
M
ain
tain
inte
rna
l
car
safe
ty d
evi
ces
Re
spo
nsi
ble
: E
N -
E
ng
ine
er
Cra
sh in
to d
ee
p
wa
ter
resu
ltin
g
in c
on
fin
ed
sp
ace
C4C2C0C1
Imp
act
kn
ock
s
dri
ver
un
con
scio
us
Ex
tern
al a
irb
ag
EN
En
gin
ee
rH
W H
ard
wa
reA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
Hit
tin
g a
p
ed
est
ria
n/
cycl
ist
C4C1C0C2
Ro
ll-o
ver
pro
tect
ion
EN
En
gin
ee
rH
W H
ard
wa
reA
ctiv
ity
: S
CA
-07
-
Ge
ne
ral c
ar
ma
inte
na
nce
Re
spo
nsi
ble
: M
M -
M
ain
ten
an
ce
Ma
na
ge
r
Ve
hic
le r
oll-
ove
r
C4C2C0C1
Map
ping
Saf
ety
Man
agem
ent S
yste
ms
Risk
ass
essin
g Co
nseq
uenc
esA
ctiv
itie
s &
doc
umen
t lin
ks
allo
w y
ou to
defi
ne h
ow c
on-
trol
s ar
e pu
t and
kep
t in
plac
e
Cons
eque
nces
can
be
risk
as-
sess
ed u
sing
risk
mat
rice
s an
d th
en d
ispl
ayed
on
the
diag
ram
Driving a car
Losing control over
the car
Regular driving breaks
DR DriverPE People
SCA-08 (DR)
Limit mobile phone use in car
DR DriverPE People
Driver loss of attention (due to
phone, controlling radio,
fatigue, eating etc.)
Provide hands free set
DR DriverPR ProcessSCA-04 (EN)
Driver needs to communicate
urgently
Agreeing on a designated driver
DR DriverPE People
Breath alcohol ignition interlock
device
EN EngineerHW HardwareSCA-07 (MM)
Periodic medical examination for
professional drivers
DR DoctorPR Process
SCA-06 (DR)
Intoxicated driving
Defensive driving
DR DriverPE People
SCA-03 (TM)
Tyre integrity system
MM Maintenance Manager
PR ProcessSCA-01 (MM)SCA-02 (DR)
Blowout (tire)
ABS
EN EngineerHW HardwareSCA-07 (MM)
Defensive driving
DR DriverPE People
SCA-03 (TM)
Adjust car mirrors
DR DriverPE People
SCA-09 (TM)
Unexpected manoeuvre from
nearby car
ABS
EN EngineerHW HardwareSCA-07 (MM)
Listen to weather report and adjust driving schedule
accordingly
DR DriverPE People
Slippery road conditions
ABS
EN EngineerHW HardwareSCA-07 (MM)
Pre-journey planning
DR DriverPR Process
SCA-10 (DR)
Uneven road surface
Defensive driving
DR DriverPE People
SCA-03 (TM)
Car lights are turned on
DR DriverPE People
SCA-07 (MM)
Poor visibility (external)
Head rest adjusted to appropriate
height
DR DriverPE People
SCA-09 (TM)
Wearing a seatbelt
DR DriverPE People
SCA-07 (MM)
Crumple zone
EN EngineerHW Hardware
Airbag
EN EngineerHW HardwareSCA-07 (MM)
Crash into other car or
motionless object resulting
in injury
D4 D2 D0 D1
Forgetting/refusing to wear
seatbelt
Competence in confined space
rescue
DR DriverPE People
SCA-05 (TM)SCA-04 (EN)
Crash into deep water resulting
in confined space
C4 C2 C0 C1
Impact knocks driver
unconscious
External airbag
EN EngineerHW HardwareSCA-07 (MM)
Hitting a pedestrian/cycli
st
C4 C1 C0 C2
Roll-over protection
EN EngineerHW HardwareSCA-07 (MM)
Vehicle roll-over
C4 C2 C0 C1
Research complian
ce
Improve reliability
Add control
Making recommendations
Actions allow you to make risk based recommendations on how to improve safety.