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Practical HSE Risk Management – An Introduction to Bow-tie Method Slide 1

Risktec Solutions

Practical HSE Risk Management – An Introduction to theBow-tie Method

Presentation to the International Conference for Achieving Health & Safety

Best Practice in Construction, Dubai, UAE, 26

th

- 27

th

February 2007By Gareth Book, Risktec Solutions Ltd

risk management and assessment for business

www.risktec.com

http://www.risktec.com/

http://www.risktec.com/




Purpose of presentation

Introduce bow-tie method

Describe its practical uses andbenefits

Outline an example bow-tie

Provide some tips for successful use




History of bow-tie method

Exact origins of bow-tie methodology are hazy –believed to originate from ICI in the late 1970’s?

Royal Dutch/Shell Group first major company tointegrate bow-ties fully into business practices

Use of bow-ties now widely spread betweencompanies, industries, countries and from industry toregulator, e.g.:

– Abu Dhabi National Oil Company (ADNOC) – UK Health and Safety Executive – French Government

– Australian State Regulator – Land Transport Safety Authority of New Zealand – International standards (e.g. ISO 17776:2000) – International Association of Drilling Contractors

(IADC)


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Risk evaluation & management

Policy & Strategic Objectives

Organisation, Resources & Competence

Risk Evaluation & Management

Planning, Standards & Procedures

Implementation & Monitoring

Audi t

Management Review

Leadership &

CommitmentCorrective

Actions

Continuous Improvement

HSE Management System

An HSE-MS is a structured set of controls formanaging HSE risk in a business

Identify

Assess

Control

Recover



Basic risk evaluation & managementmodel

Identify Assess Control Recover

Risk Tolerability & ‘ALARP’

Document



Link with HSE-MS

Unlike traditional risk evaluation tools, the bow-tie method makes the link link between risk controlsrisk controls

and the HSEHSE--MSMS:

Considerabl

e impact

Severity

P eo pl e A ss et s EnvironmentReputation

CONSEQUENCE FREQUENCY

A B C D E

0

1

2

3

4

5

No injury

Minor

injury

Major

injury

1 - 3

fatalities

Multiple

fatalities

Slight

injury

No

damage

Minor

damage

Localised

damage

Major

damage

Extensive

damage

Slight

damage

No effect

Minor

effect

Localised

effect

Major

effect

Massive

effect

Slight

effect

No impact

Limited

impact

National

impact

Internation

al impact

Slight

impact

Never heard

of in

industry

Has

occurred in

industry

Has

occurred in

company

Occurs

several

times per

year in

company

Occurs

several

times per

year at

location

Manage forContinuousImprovement

Incorporate riskreductionmeasures

Intolerable

Considerabl

e impact

Severity

P eo pl e A ss et s EnvironmentReputation

CONSEQUENCE FREQUENCY

A B C D E

0

1

2

3

4

5

No injury

Minor

injury

Major

injury

1 - 3

fatalities

Multiple

fatalities

Slight

injury

No

damage

Minor

damage

Localised

damage

Major

damage

Extensive

damage

Slight

damage

No effect

Minor

effect

Localised

effect

Major

effect

Massive

effect

Slight

effect

No impact

Limited

impact

National

impact

Internation

al impact

Slight

impact

Never heard

of in

industry

Has

occurred in

industry

Has

occurred in

company

Occurs

several

times per

year in

company

Occurs

several

times per

year at

location

Manage forContinuousImprovement

Incorporate riskreductionmeasures

Intolerable

Policy & Strategic Objectives

Organisation, Resources & Competence

Risk Evaluation & Management

Planning, Standards & Procedures

Implementation & Monitorin g

Aud it

Management Review

Leadership &

CommitmentCorrective

Act ion s

Continuous Improvement

Links are made via HSE-critical roles andresponsibilities, HSE critical procedures, HSEcritical equipment and systems, etc. identified onthe bow-tie diagram



Bow-tie diagram

I m p a c t s

Businessupset

C a

u s e s

Preventive

controls Recoverypreparedness



RecoverControl

AssessIdentify

Bow-tie diagram

Hazard and Hazard SourceConsequence1

Consequence 1

Consequence1Consequence 2

Consequence

1Consequence 3

Threat 1

Threat 2

Threat 3

TopEvent

ThreatControl Recovery

Measure

RecoveryMeasure

RecoveryMeasure

RecoveryMeasure

RecoveryMeasure

RecoveryMeasure

ThreatControl

ThreatControl

ThreatControl

ThreatControl Threat

Control



Typical application of bow-tie method

Potential Risk

LevelLevel of Analysis &

Control

But method is equally applicable toroutine risks as major risks

Major J udgementStandard

Competences

Procedures

ResponsibilitiesPerformanceMeasurement

Detailed Analysis

e.g. bow-tiesHigh Risk

Medium

Risk

Low Risk

Reduce to medium or low risk

Demonstrate Risk reduct ionto ALARP

Continue to managefor improvement

Risk ManagementObjective



Practical uses

Logical structuredapproach

What are our major risks? Do we have any gapsin risk control?

Formal demonstration Can we really demonstrate control of our risks?

Specific risks Are these risks properly understood andcontrolled?

Communication How do we engage non-risk specialists?

Critical roles Do our people know what is expected of them?

Competencies Are competence and control requirementsaligned?

Procedures Are they complete and effective?

Auditing How can we focus audits on what reallymatters?

Critical systems andperformance standards

What are they?

Li k b t b ti & HSE iti l




Link between bow-ties & HSE-criticaltasks

Prevention Mitigation

HSE Critical Tasks

Responsible parties

Visually demonstrate andcommunicate the link

between controls and the

management system




HSE-critical task catalogue

Client/Project Name Senior Supervisor

Task 01.01 Making live and Closing of Hot Work Permits

Ensure that all permits aresigned out ‘made live’ andclosed by the AuthorisedPerson

Permit registerRecords of Hot WorksSafety Meetings

Task 01.02 Ensure that Hot Work is incompliance with permit conditions

Ensure that permit is incompliance with MSN 102Land work is undertaken insafe manor

Permit registerWalk roundcheck/inspection of worksPre-job briefing sign off

Safety meeting actionsDaily records

Task 02.04 Ensuring that lifting gear is taggedand colour coded

Ensure that lifting gear iscoded as per procedureMSN 205LEnsure competence of

certifying contractor

Audit and InspectionSign off from certifyingcompany.

Task 04.04 Confirm portable electricalequipment is fit for purpose and inpossession of integrity certification

Ensure that externalelectrical equipment istested on a 3 month cycleand internal equipment istested on a 6 month cycle

as per MSN 23L.

Visual check Audit of Portableappliances

HSE-CriticalRole

VerificationHSE-criticalprocedure

HSE-Criticaltask

Link between bow ties and




Link between bow-ties andcompetence

Typical Competence Assurance System Job Profile

Weldingperformed by

certified weldersonly

Verify thatcompetence andcontrol requirements

are aligned

A t bilit k f h




Accountability pack for eachHSE-critical role

HSE-critical role

HSE-critical tasks, procedures

& verification

HSE-critical competencies

Sign-off

Accountability Sheet

Role/Post : Maintenance Supervisor

Identified Safety Critical Role(Document OD-SA-03-46):

Yes, Level 1 and 2

HSE Critical Task Specification SheetTask Ref Task Title Input / Procedures Task Verification

BON-06.01.03 Maintain, test and inspect cargo and crude export pumps,meters and protection systems

• OPRM-2003-0304 : POPM Volume 4 - OilStorage Handling and Ballast• OPRM-2003-0305 : POPM Volume 5 : OilMetering and Export• OPRM-2005-0057 : Maintenance andInspection Management System Manual

Maintenance plan, maintenancerecords, test results checked andverified by Operations Supervisor

BON-06.01.08 Maintain, test and inspect the inert gas system

• OPRM-2003-0319 : POPM Volume 19 -Inert Gas• OPRM-2003-0203 : Maintenance andIntegrity Manual• OD-OP04-006 : Operations VerificationManagement System

Maintenance Records.Reviewed by Ops Supervisor.Test records

Safety Critical Role Competencies

(Document OD-SA-03-46)Competence

RequirementsPrerequisites for

Assessment Assessment

Format(Standard )

Assessor / Verifier

Re-Asses.Frequency

Maintenance of Competence

Skill at ValidatingPTW

Computer BasedTraining toSignatory standard

Computer Based Assessment

PTW Coordinator /Line Verifier

_ Maintained through ongoingdaily activities and annualstaff appraisal whilst inposition

Skill atSupervising HSE

On the jobexposure whilecompleting OIMportfolio

Area SupervisorCompetence

Assessment Manual

Installation Manager / Line Verifier


Knowledge of the NigerianLegislation(Mineral Oils(Safety)Regulations1997.The NigerianFactories Act)

Training Course Demonstration of knowledge

Line Assessor / Line Verifier


I understand and accept the HSE Critical Tasks and Safety Critical Role Competencies

assigned to me.Name Signature

Position Date

Etc…

Etc…

Li k b t b ti d




Link between bow-ties andtraining & development

Competent people provideresilience against major risks

HSE-critical task

HSE-critical role

Task competencies

Training requirements

HSE-critical task catalogue

Accountability packs

…to ensure each risk control works…

Assess peopleagainst

requirements

Personal T&D plans

…use

CompetencyMgmt System




Competency management system

Sample training matrix

• Personnelinformation

• Trainingmanagement

• Competencymanagement

• Documentmanagement

• Reporting

Link between bow-ties and




Link between bow-ties andprocedures

Task Responsible Person/Task Description

Inputs/Documents Verification

ABC-22.05 Area Supervisor –Maintain Safety Signage

Ensure safety related signs are maintainedup-to -date and in good order

- escape routes- exit signs- fire equipment signs- life saving appliance signs

- Inspection and Audit

ABC-12.03 HSE – Manager –Management of Hazardous

Materials

Ensure correct storage and handling of hazardous materials in accordance with the

requirements identified in the MSDS- secure storage- segregation of incompatible chemicals- use of PPE- appropriate means of transport-inventory management

- HSE audit- area inspections

- manifests- non compliance reports

ABC-06.03 Site foreman –Weekly area Inspections of process facilities

Carry out weekly inspections of all siteareas:- housekeeping- general condition of equipment- general condition of structures- condition of safety equipment- availability of escape routes

- Inspection checklist- Non compliance reports- Unsafe act/condition reports- HSE Meetings

Verify procedures forconducting HSE-criticaltasks are complete and

effective




Link between bow-ties and auditing

HSE-CRITICAL TASK LIST

Task 1: …………………………..

Task 2: …………………………..Task 3: …………………………..

Responsible

Person: Supervisor

AUDIT CHECKLIST

Task 1 …….Task 3 …….

Foreman

Task 5 …….Task 9 …….Task 11 …...

Supervisor

Audits can be focused on whatreally matters

Link between bow-ties and




Link between bow-ties andHSE-critical equipment & systems

Establish performanceperformancestandardsstandards for thesesystemsMaintenance management

system should flagflag HSEHSE--critical systemscritical systems and taskstasks

Prevention Mitigation




Consequence

In the end you must have all connections in place for effectivehazard control

Total hazard control

HazardHazard

ThreatThreat

Threat

control

Threatcontrol

TaskPeople

Recovery

measure

Recovery

measure

Release

of hazard

Release

of hazard

Location/

operation

Location/

operation

Risk Evaluation &

Management

Competence

Performance

measures Activity to

control riskStandards &

Procedures




Example bow-tie

Hazardous Site:Failure of Stored

cylinders

5.4.4.5 PropaneInternal Corrosion

External Corrosion

Overpressure

Dropped / Fallen Object

Vehicle Impact

Fire / Explosion

B5 B5 B3 B4

Projectile damage f romexploding cylinders

Building damage, possiblyextending offsite

Human Error




Example bow-tie: threats


cylinders

5.4.4.5 Propane


Cylinders only moved whenstrapped in purpose designedpallets (Company Handling)

W-4.2.06 (Prod)

Fork lift truck drivers aretrained and have theircompetence assessed

W-4.1.03 (Prod)

Vehicle Impact

LPG storage area designed toHSE Guidelines to minimisevehicle impact possibility

W-1.1.06 (Design)

LPG cylinders are designed toBS5045 Part 2 as

Transportable Gas containers

W-2.3.01 (Tan)


W-4.1.03 (Prod)




Example bow-tie: consequence


cylinders

5.4.4.5 Propane

Fire / Explosion

B5 B5 B3 B4

No smoking policy andmonitoring to minimise

unnecessary combustibles

W-2.4.01 (Prod)W-5.2.01 (Prod F)

PTW System and Safe Systemof work minimise ignition

sources on site

W-2.3.08

Quantity of LPG stored limitedin accordance with HSE

Guidelines

W-2.1.02

LPG storage area designed toHSE Guidelines to minimise

ignition sources

W-1.1.02 (Design)

Electrical Equipment

Design - ElectricalClassification

W-1.1.02 (Design)

Task Related IgnitionSources

Operator Intervention - Work Permit

W-2.4.01 (Prod)

Electrical Storm - lightning

Copy of Design - ElectricalClassification

W-1.1.02 (Design)




Example bow-tie: complete


cylinders

5.4.4.5 Propane

Internal Corrosion

Cylinders examined in

accordance with companystandards and HSE Guidelines

LPG Product standard

controlled in accordance withHSE Guidelines

External Corrosion

Cylinders examined inaccordance with company

standards and HSE Guidelines

Overpressure

Storage cylinder design/fillingpreculdes overpressure from

environmental heating

Propane area storagecomplies with companystandard HSE Guidelines

W-2.3.07


Cylinders only moved whenstrapped in purpose designedpallets (Company Handling)

W-4.2.06 (Prod)


W-4.1.03 (Prod)

Vehicle Impact

LPG storage area designed toHSE Guidelines t o minimisevehicle impact possibility

W-1.1.06 (Design)

LPG cylinders are designed toBS5045 Part 2 as

Transportable Gas containers

W-2.3.01 (Tan)


W-4.1.03 (Prod)

Fire / Explosion

B5 B5 B3 B4

No smoking policy andmonitoring to minimise

unnecessary combustibles

W-2.4.01 (Prod)W-5.2.01 (Prod F)

PTW System and Safe Systemof wor k minimise ignition

sources on site

W-2.3.08

Quantity of LPG stored limitedin accordance with HSE

Guidelines

W-2.1.02

LPG storage area designed toHSE Guidelines to minimise

ignition sources

W-1.1.02 (Design)

Electrical Equipment

Design - ElectricalClassification

W-1.1.02 (Design)

Task Related IgnitionSources

Operator Intervention - Work Permit

W-2.4.01 (Prod)

Electrical Storm - lightning

Copy of Design - ElectricalClassification

W-1.1.02 (Design)

Projectile damage fromexploding cylinders

Implement emergencyprocedures (evacuation, fire

response etc.)

W-6.1.03 (Prod)

LPG storage area physicallyseparated f rom other high

risk areas of the site asrequired by HSE Guidelines

Building damage, possiblyextending offsite

Activate Onsite emergencyResponse Plan, Offsite Plan if

required

W-6.1.03 (Prod)W-6.1.04 (Prod)

Evacuation of area onindication of fire

W-2.3.03W-3.4.02 (Eng)

ildi b i




Building bow-ties

Software helps but don’tget hung up on it!

Benefits are fromapproach and involvingworkforce

Benefits of bow tie method




Benefits of bow-tie method

Communication – “a picture paints athousand words”

Ownership – involves people, gainsbuy-in, practical approach

International application – overcomes

language difficulties All risks – not just HSE

Risk reduction - identifies whereresources should be focussed for risk reduction, i.e. prevention or mitigation

B fit t




Benefits cont...

Fit for Purpose MS – Links elements

of the organisation’s MS to specificcontrol

Auditable Trail – the diagrams andcritical tasks provide protocol aroundwhich auditing by internal depts

focuses on what people are actuallydoing rather than physical systems

Limitations




Limitations

Entirely qualitative

Does not replace other techniques

(JSA, method statements, etc.) – iscomplementary to them

Depends on experience of personneland active workforce involvement

Ensure controls in bowtie are truly

independentBut if you want to remove mystique of risk management and obtainBut if you want to remove mystique of risk management and obtaininsights into your risk controls that are easy to understand andinsights into your risk controls that are easy to understand and easyeasyto communicate, there is no better method than bowto communicate, there is no better method than bow--tiesties

Ti f




Tips for success

1. Keep end objective in mind -

pitch at the right level

2. Involve the right people

3. Avoid barrier counting

4. Use method to full potential

5. Verify controls and tasks

Summary




Summary

The Bow-tie Diagram is a user-friendly,graphical illustration of how hazards are

controlledEffective risk management is only possibleif people are assigned responsibilities forcontrols via HSE-Critical Tasks

Visible links are made to HSE-criticalsystems and competencies and auditing

The total methodology demonstrates notonly what controls are in place today , butwhy they will still be there tomorrow