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Paulo Rheinboldt
Process and Industrial Safety Consultant
Det Norske Veritas
Objectives
Presentation the Bow-tie methodology basic concepts
Risk Management
Risk
Causes
Consequences
Major
Event
Event
Basic
Causes
Immediate
Causes
Immediate
Consequences
Ultimate
Consequences
Risk: The combination of a event probability and its consequences (ISO/IEC Guia 73).
Risk Management: A process to ensure that all significant risks are identified, prioritized, and
managed effectively(DNV).
Consequences
Event
Major
Event
Basic
Causes
Immediate
Causes
Lack of
Control
Inadequate
System
Inadequate
Standards
Inadequate
Compliance
Immediate
Consequences
Basic
Causes
Personal
Factors
Job / System
Factors
Immediate
Causes
Substandard
Acts or
Practices
Substandard
Conditions
Ultimate
Consequences
Incident
Event
Contact ( or
near) with
energy or
substance
Loss
People
Equipment
Material
Environment
THRESHOLD
LIMIT
Managing Risk
Risk
Recognition
Establish the
context
Risk
Evaluation
Risk
Control
Develop control
plans
Identify all
hazards, threats,
& opportunities
Implement
control plans
WHAT
MATTERS?
WHAT IS THE
RISK?
WHAT DO WE
DO NOW?
SO WHAT?
LETS DO IT!
WHAT CAN GO
WRONG
(OR RIGHT)?
Risk
Monitoring
Monitor risks
& controls
Review & improve
risk management
system
IS IT
WORKING?
CAN WE MAKE IT
BETTER?
Reputation
Benefits
Qualitative
Analysis
People
HAZID
Assets
Decisions
1
2
3
...
Semi-Quantitative
Analysis
Quantitative
Analysis
Costs
ALARP
Environment
Risk Analysis
Risks Evaluation
Why Bow-tie?
Visualization of the relationship between undesirable event, its
causes, accidental scenarios, the preventive and mitigation
measures to limit their consequences
Demonstrates the effectiveness of existing controls
Structured risk analysis where quantification is not possible or
desired
Extremely versatile / Success in various applications
Required multidisciplinary team
Prevent Barriers
Control,
Alarm &
Shut-down
System
HAZARD
Inherent
Design Plant
layout
Learning
from
Events
Relief and
Bow-down
System
Operational
Procedures
Maintenance &
Inspections
Work
Control
Effective
Supervision
Management of
Change
Communication
Training &
Competency
HAZARD
REALIZATION
Loss of
containment
Hydrocarbon
inventory in
plant and
storage
facilities
Ignition
Fire/ Explosion
Facilities
Processes
People
Prevent Barriers
Control,
Alarm &
Shut-down
System
HAZARD
Inherent
Design Plant
layout
Learning
from
Events
Relief and
Bow-down
System
Operational
Procedures
Maintenance &
Inspections
Work
Control
Effective
Supervision
Management of
Change
Communication
Training &
Competency
HAZARD
REALIZATION
Loss of
containment
Hydrocarbon
inventory in
plant and
storage
facilities
Ignition
Fire/ Explosion
Facilities
Processes
People
So what do we
do now?
Detect
Gas, Fire,
Pressure Temperature
High - Low
Mitigate
Limit Effect
(e.g. deluge system)
Control
Limit extent
(e.g. blow-down)
HAZARD
Control,
Alarm &
Shut-down
System
Hydrocarbon
inventory in
plant and
storage
facilities
Inherent
Design
Plant layout
Learni
ng
from
Events
Relief
and Bowdown
System
Operational
Procedures
Maintenance
& Inspections
Audit &
Self
Regulation
Work
Control
Effective
Supervision
Management
of Change
Communication
Training &
Competency
HAZARD
REALIZATION
Loss of
containment
Ignition
Fire/ Explosion
Emergency Response
Evacuation, Escape and
Rescue
Bow-tie Diagram
Bow-tie Diagram
Barriers
Top
Event
Threats
Escalation
Factor
Hazard
Recovery
Measures
Escalation
Factor
Control
Consequences
Escalation
Factor
Control
Escalation
Factor
Control
Escalation
Factor
Control
Escalation
Factor
Bow-tie Example
Working at height
Unsafe
scaffolding
Scaffolding
assembly
standards
Contractor
Inspection
Safety Dept
Inspection
PPE
correct use
Ladder
inadequate
use
Ladder
uses
standards
Contractor
Inspection
Safety Dept
Inspection
Pre-use
Inspection
Maintenance
Supervision
First Aids
Team
Injuries
Workers
Falling
PPE
correct use
Mobile
platform
defective
Workers
awareness
induction
Safety Dept
Inspection
Workers
awareness
induction
Emergency
Plan
Fatality