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Operational Safety & Risk management

Based on Bow Tie methodology 

Arthur Groot

04 februari 2014

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What is risk management?

Four elements in risk management:

• Risk Analysiso Source Identicationo Risk !stimation

• Risk "reatmento A#oidanceo $%timi&ationo  "ransfero Retention

• Risk Acce%tance

• Risk 'ommunication

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IS$ 1((():2000*!+

,

Risk Management

ProcessIS$ ,1000

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Why Bow Tie?

•  "he full %icture

• -isual o#er#ie.

• 'lear and understandable diagram

• /akes communication easy

• !tra focus on reco#ery conseuences

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History of the BowTie

• “Butterfy diagrams”

• ossibly e#ol#ed from Cause-Consequence-Diagrams of the (05s

• Assessing 6a&ards and $%erationalRisks

• i%er Al%ha incident 1788

•  "he Royal 9utch Shell Grou% 705s

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• $il ; Gas

• 'hemical

• A#iation

• /edical

• Financial

• Go#ernment• I"

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• IA9' 6S! 'ase Guidelines

o 9emonstrate Internal Assurance

o

/eet Stakeholders !%ectations

Global Leadership or the Drilling !ndustry 

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Why the need for

BowTie•  "he ga% bet.een technical %ossibilities and .hatorgani&ations are <designed5 needs to be closed

•  "o understand the com%leity of the %rocesses in

organi&ations

• If organi&ations .ould be #ery able in dealing .ith lo.freuency high conseuence risks .e .ould not ha#e a%roblem so called =lack S.an scenario5s

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 Qualitative

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Why qualitative risk management?

• 'om%leity of the .orld

• /ulti causality in %re#ious incidents

• In#ol#ement of the .orkforce

• /ost often the .orld is too com%le to accurately uantify

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Quantitative vsQualitative

• >uantication .orks best in static or linear en#ironments.here the number of outcomes is nite or kno.n

• >ualication .orks best in dynamic or non?linear

en#ironments *e@g@ human factors %resent+ .here thenumber of outcomes is innite or uncertain

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Quantitative vs.Qualitative• >RA and =o."ie method are com%lementary to each other

• =o.tie is in %rinci%le a ualitati#e methodo =arrier eecti#eness

o Risk assessment

o Acce%tance criteria

•=ut also .hen to sto%o  "hreats

o 'onseuences

o !scalation factors

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Barrier thinking

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Bowtie’s parents

Event treeFault tree

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Connect them

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Flatten them outHazard Top

EventConsequenceThreat

Threat

Barrier Recovery

easure

Esca!ation"actor  Esca!ation

"actor

Contro!

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The BowTie can be applied to any kind of risk!

• $il s%ill of e%losi#e and toic substance inside the %rocess %lant

•  "ank ru%ture

• 'onned s%ace entry .ith internal ha&ards fall %rotection silica

falling brick ha&ards

• Falling ice from high structure

• Sli% tri% and fall on ice

• Beldingcutting hot .ork ignition %re#ention

• $il s%ill to soil

• Borking .ith chemicals

• Borking near.ith cranes

• Borking in o%en trenches

• Fire %um%s im%aired

• !tc@

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Consequence

 An unwanted event resulting from the release

of the Hazard  18

Applying risk graph/matrix into the Bow Tie

Residua! ris# $ !i#e!ihood % severity

&i#e!ihood $ su' of the independentcauses (ta#in) into account

on!y the proactive contro!s*

+everity inc!, reactive contro!s

     s     e     v     e     r      i      t     y

Likelihood

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9etect 9ecide Act

=eha#iourale@g@: double check

defensi#e dri#ing

Socio?"echnicale@g@: calling re brigadeon alarm re .atchacti#ates re ghtingsystem

Acti#e 6ard.aree@g@: s%rinkler system%ressure relief #al#e

assi#e hard.aree@g@: dike blast .all anti corrosion%aint

'ontinuous 6ard.aree@g@: #entilation systemacti#e corrosion

%rotection

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Barrier types

Source: Guldenmund, F., Hale, A., Goossens, L., Betten, J., & Duijm, N. J. (2006). The development of an audittechnique to assess the quality of safety barriermanagement. Journal of hazardous materials, 130(3),234-41.

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 Management

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 Management

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Incidents and =o."ies

hd

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BSCAT Tripod Beta

Barrier Failure Analysis Root Cause Analysis

2,

methods

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Incident analysis as feedback to BowTie

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Policy and strategy•Development of Environment & SafetyPolicy

•Corporate Environment Plan•Stakeholder Analysis•Carbon Capture and Storage•REACH and GHS•Corporate Social Responsibility•Carbon Trading

•Policy on the Prevention of SeriousAccidents

•Energy

Organization and processes•Environmental Management Systems•

Safety Management Systems•Occupational Health ManagementSystems

•HSE Risk Management•Interim HSE Management•Training and Coaching•Environmental and SustainabilityReporting

•

Process safety management

Culture•SHWE growth model (basedon Hearts and Minds)

•Safety culture scan•Incident analysis (TRIPOD)•Management system audits•Compliance Audits

Compliance•Environmental impactassessment (EIA)

•Environmental permitting•Safety Report•Fire Report•

QRA/external Safety•EIA•Emission studies•Noise/odor dispersion studies•IPPC studies

HSE engineering•Safety Case•HAZID and HAZOP•ENVID•Fire Protection Analyses•QRA, IRPA•Technical Safety Review•Process Hazard Analysis•

Hazard ConsequenceModeling•Asset integrity studies (SIL,IPFand LOPA)

•Reliability, Availability &Maintainability Studies(RAMS)

•FME(C)A studies•BowTie Risk Analyses•Escape, Evacuation &Rescue Analysis (EERA)

Services Royal HaskoningDHV

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HSE engineering•Safety 'ase•6ACI9 and 6AC$•!D-I9•Fire rotection Analyses•>RA IRA• "echnical Safety Re#ie.

•rocess 6a&ard Analysis•6a&ard 'onseuence /odeling•Asset integrity studies *SIE IFand E$A+

•Reliability A#ailability ; /aintainability Studies *RA/S+

•F/!*'+A studies•=o."ie Risk Analyses•!sca%e !#acuation ;Rescue Analysis *!!RA+

2)