Embed Size (px)
Citation preview
Geert van LoopikGlobal accountmanager & Trainer
Learning from Incidents - Linking incident analysis
with BowTie based risk assessments
Market
leader In 11 industries
Started in
2004
20-30%annual growth in the last 6
years
1500+ clients in 83 countries
200+
partners around the world
80-90
Eventseach year
We make
barrier basedrisk management
software.
D-REAMS Session / Paris / 12th-14th September 2017
16 - Learning From Incidents2
3
Oil & Gas600 organizations | 3500 users
Aviation500 organizations | 2500 users
Energy350 organizations | 1600 users
Other550 organizations | 2400 users
Copyright © 2012 IP Bank BV
The BowTie, named after its shape, contains eight elements:
Hazard, Top Event, Threats, Consequences, Preventive Barriers,
Recovery Barriers, Escalation (Degradation) Factors and
Escalation (Degradation) Factor Controls
The BowTie method
Copyright © 2012 IP Bank BV
Incidents
Incident feedback about a barrier gives that real world sense on how the barrier has actually performed and what (if anything) failed to do as expected
Incidents tend to be treated in silos
No theme trending or collating what multiple incidents mean to an organization
Lack of bigger picture
Copyright © 2012 IP Bank BV
Incident Data
The barrier functioned as planned and stopped the
next event in the incident scenario.
e.g.: Seatbelt worn, which prevented a fatality.
The barrier stopped the incident sequence, but there
is uncertain if it will do so in the future.
e.g.: Seatbelt prevented a fatality, but the seatbelt is not
always worn in organisation.
The barrier functioned as intended by its design, but
was unable to stop the sequence of events.
e.g. Seatbelt was worn but it broke because it was not
designed to withstand forces of impact which it
encountered during the incident
The barrier was implemented, but did not function
according to its intended design.
e.g. Seatbelt did not prevent a fatality, because it was
not worn.
The barrier was described in the organization’s SMS or
was considered an industry standard, but it was not
successfully implemented.
e.g. Seatbelt is described in policy and acquired, but it
was not yet placed in the vehicle.
Copyright © 2012 IP Bank BV
Visualising Incident Data
Copyright © 2012 IP Bank BV
Visualising Audits AND Incidents
Copyright © 2012 IP Bank BV
Barrier Performance Trends
SIS Barrier Group performance overview Accumulated SIS Barrier Group Performance
Copyright © 2012 IP Bank BV
And finally…
“I have not failed. I've just found 10,000 ways that won't work.”
– Thomas Edison
“The only real mistake is the one from which we learn nothing.”
– Henry Ford
“Learn from the mistakes of others - you can never live long
enough to make them all yourself.”
– John Luther (Groucho Marx)
