Bowties

a risk communication tool

DNV Healthcare Risk Forum
30th October 2013

What we will cover today

-

Introduction (risk recap using a Bowtie)

The uses of Bowties
Useful rules/guidance to follow to develop quality Bowtie diagrams
Workshop

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Introduction (risk recap using a Bowtie)

How do accidents happen?

Barrier 1

Barrier 2

Barrier 3

Causes
Consequences

Harm /
Loss

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Risk Management explained using a Bowtie

HAZARD:
EVENT:
CAUSE:
PREVENTIVE
The
Event,
Condition
release
BARRIER:
situation,
or
or practice
loss
or
Barriers
condition
of control
with
tothe
the
the
that
ofright
potential
the
left
results,
hazard
of
the
to
or
event
cause
being
could
(before
modeled
harm
result,
itinclude
directly
has
people,
in usually
ahappened).
Bowtie.
orthe
CONSEQUENCE:
MITIGATION
BARRIER:
Direct,
Barriers
undesirable
to
result
of
ofmeasures
an
the
accident
event
(after
sequence
has
happened).
BARRIER:
Barriers
are
physical
risk
reduction
(devices,
systems,
or
RISK ACTIONS:
Actions
to
better
manager
your
risks.
They
canitto
adding
environment,
Note:
indirectly
They
reduce
Events
an
the
reputation,
are
accident
sometimes
orassets
ofe.g.
the
referred
or
event.
business
Note:
toPreventive
as
Causes
risk
impact.
events
are
barriers
sometimes
orMitigation
are
top
sometimes
events.
referred
toreferred
as
involving
ainloss
orlikelihood
severity
damage,
ofincident.
the
consequence
financial,
production,
event.
Note:
customer
loss
and/or
barriers
damage
are
actions).
barriers,
strengthening
barriers
and
assurance
/ verification
of
barriers.
threats.
as controls.
to
sometimes
brand,
assets,
referred
people,
to as the
contingencies
environment, etc.
or recovery measures.
Hazard

Cause
Barrier

Barrier

Event

Cause
Barrier

Barrier

Barrier

Barrier

Cause
Barrier

(Processes, procedures to
maintain and assure / verify that
barriers are in place and
effective)

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Medium

High

High

High

One in ten to one in a

hundred per patient year

Medium

Medium

High

High

One in a hundred to one

in a thousand per patient
year

Low

Medium

Medium

High

One in a thousand to
one in ten thousand per
patient year

Low

Low

Medium

Medium

High

One in ten thousand to

one in a hundred
thousand per patient
year

Reduced Risk
3

Low

Low

Low

Medium

Medium

One in a hundred
thousand to one in a
million per patient year

Less than one in a

million per patient year

Likelihood

Risk Management
Activities and Actions

Greater than one in ten

per patient year

NPSAs Patient Safety Risk

Matrix

High

Initial Risk
High

High

Reduce
Likelihood

Reduce
Consequence
Severity
Low

Low

Low

Low

Medium

Low

Low

Low

Low

Low

Negligible /
Very Low

Low
(Minimal
Harm)

Barrier

Moderate
Severe
(Short Term
(Long
Harm)
Term/Perm.
Harm)
Consequence

E
Fatality
(one or
more)

Consequence
Consequence
Consequence

The uses of Bowties

Simple Communication - To explain a risk

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Simple communication To explain barrier types

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Simple communication To explain barrier strengths

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Simple communication To explain barriers degrading

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Simple communication To explain barriers criticality

Only strong barrier
/ control on a branch

Few barriers
/ controls

Repeating barrier
/ control

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Simple communication To Management System, etc.

Direct link to
design standards

Defined
Responsibilities

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Direct link to
procedures
and requirements

Use in accident investigations

This is a simple BSCATTM BowTie that presents the investigation of the root causes for failures of barriers in
an event on the cause side of a BowTie using SCAT (Systematic Causal Analysis Technique). Why barriers
on the consequence side failed are yet to be investigated. Note that only one branch on the causal side is
shown, as this was the path that lead to the event. For each barrier / control the immediate cause (green
text), root cause (red text) and the management system element that failed (blue text) are shown. This can
now be used to explain to those not undertaking the accident investigation what happened. It illustrates that
two areas of their safety management system need to be addressed, namely safety hazard identification
and evaluation and process safety leadership.

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13

Use in accident investigations

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14

Useful rules / guidance to follow to develop

quality Bowtie diagrams

15

Useful rules bowties and barriers

Causes / threats should be specific and unique (single route to the event)

Any or all consequences / impacts could result (multiple routes from the event)

Barriers / Controls:
- Should be independent of each other
- Stop occurrence of the risk event
- Should be equipment or activities (pieces of paper are not barriers!)
- Stop a cause or consequence of the risk event
- Reduce the magnitude of the consequence on the risk event
- Can appear more than once on the bowtie diagram, however they:
- Should appear on one side of the bowtie only (generally)
- Should appear only once on any branch in the bowtie diagram

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Workshop Develop Bowtie

17

Workshop
Hazard

Cause

Cause

Cause

Instructions:
Place on the diagram barriers that
help prevent or mitigate the event

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Consequence

Event

Consequence

Consequence

Safeguarding life, property

and the environment
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