THE INCREASING BENEFITS OF BOW-TIE DIAGRAMS

IN THE RISK MANAGEMENT PROCESS

James Phipps, Prem P. Sharma
ABS Consulting Inc.
1. INTRODUCTION
Hydrocarbon releases are an inherent hazard associated with the petro-chemicals and associated
industries. Preventing, or minimising the potential for, such releases occurring, is foremost among any
companys safety culture and the effective implementation of a Health, Safety and Environmental
Management System (HSE-MS) is one of the means by which this is achieved.
In many regions of the world, legislation has forced the implementation of such processes. The
notable driving force behind the derivation of the Bow-Tie diagram as a representation of the
Management System stems from the Lord Cullen enquiry into the tragic events of Piper Alpha in the
UK North Sea in 1988, in which some 167 offshore workers lost their lives. Similar events around the
world have triggered further emphasis on the HSE-MS such as Seveso. More recently, with the release
of the Baker Panel report into the BP Texas City disaster an additional drive into such a culture is
expected.
Rather than simply adopt national regulation as a means of suitable compliance, larger
corporations are implementing global standards by which operating divisions are expect to perform in
addition to that which may be required by law.
The purpose of this paper is to overview how a Bow-Tie tool, could be developed and applied
not only to demonstrate the implementation of an HSE Management System but also fostering a culture
of risk management that has become a essential tool in managing business in todays world . The paper
also highlights the benefits and advantages of applying THESIS as opposed to traditional paper-based
approaches.

2. HSE MANAGEMENT SYSTEMS

A HSE Management System is a quality managed system for managing risks within a company,
to assure the protection of the companys people, assets, reputation and for protection of the
environment the company operates within.
In general, HSE Management Systems follow the same basic structure. The following
hypothetical HSE Management System, comprising the main elements shown, is representative of
such a structure (Figure 1).
Leadership and Commitment
Policy and Strategic Objectives

Organisation, Responsibilities
Resources, Standards and Doc.
Hazards and Effects
Management
Corrective Action
Planning and Procedures
Implementation

Monitoring

Audit

Corrective Action
and Improvement

Management Review

Corrective Action
and Improvement

Figure 1 Indicative HSE Management System Hierarchy

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Associated with each of the above elements are specific requirements. These requirements can
be generally categorised as sown in Figure 2.
THESIS can be used to demonstrate how the pertinent HSE Management System element
requirements are met with respect to the control and management of hazards and risks.

Leadership & Commitments

ELEMENTS

REQUIREMENTS
HSE Policy
Strategic Objectives & Targets

Policy & Strategic Objectives

Organisation, Responsibilities,
Resources, Stands & Docs.
Hazard & Effects Management Process
Planning & Procedures
Implementation & Monitoring
Audit

Organisational Structure & Responsibilities

Management Representatives
Resources
Competence
Contractors
Communication
Documentation & its Control
Identification of Hazards & Effects
Risk Evaluation
Recording of Hazards & Effects
Objectives of Performance Criteria
Risk reduction Measures
Asset Integrity
Procedures & Work Instructions
Management of Change
Contingency & Emergency Planning
Monitoring
Records
Non-Compliance & Corrective Action
Incident Reporting & Follow-Up

Review

Internal Audit
Independent Audits
Management Review

Figure 2 Indicative Functional Requirements

3. INTRODUCTION TO BOW-TIES
3.1.

Bow-Ties

Bow-Ties are a graphical display of the relationship between the various components that result
from the Hazard and Effects Management Process (HEMP, see HSE Management System element
above). They depict the relationship between Hazards, Threats, Barriers, Escalation Factors, Controls,
Consequences, Recovery Preparedness Measures and Critical Tasks, as illustrated in Figure 3, below.
The advantage of adopting the Bow-Tie approach is that it is an extremely powerful
representation of a hazard analysis and HEMP Process and are readily understood at all levels in an
organisation.
It is through the linking of Critical Tasks to Barriers, Escalation Factor Controls and Recovery
Preparedness Measures that Bow Ties can demonstrate the implementation of a HSE Management
System in managing the risk associated with hazards, in particular, hydrocarbon release scenarios.
3.2.

Critical Tasks

Each Barrier, Control and Recovery Preparedness Measure should have, as a minimum, one
supporting task, to ensure that the integrity of each barrier, control and recovery preparedness measure
is maintained. These are termed Critical Tasks, and are required to be performed, undertaken or
executed by responsible and competent persons.

AmCham HSSE Conference & Exhibition Trinidad & Tobago

Escalation
factors

Escalation
factors

Control of
escalation
factor

Control of
escalation
factor

Consequences
Barriers to
prevent
threat

Recovery
preparedness
measures

Hazard

Threat
that could
release
hazard

Top event

Consequences

Consequences

Activities & tasks

= HSE-critical task

Figure 3 Schematic Bow Tie Diagram

The tasks may be design, inspection and maintenance, operational or administrative tasks, i.e.:
Design Tasks - which specify the necessary hardware and equipment;
Inspection and Maintenance Tasks - to ensure that this hardware and equipment
maintains its integrity and reliability;
Operational Tasks - to ensure that the equipment is used within the defined limits of
the controls provided; and
Administrative Tasks - which provide the necessary training, awareness and
behaviour conditioning to ensure that people perform predictably in all normal and
abnormal situations.
It can be seen from the above categorisation that the tasks are directly linked to the HSE
Management System elements and their requirements, i.e. it is through the linking of Critical Tasks to
Barriers, etc., that Bow Ties can demonstrate the implementation of a HSE-MS in managing the risk
associated with a hazard, for example a hydrocarbon release scenario.
Critical Tasks can also be used to audit a companys HSE Management System, as depicted in
Figure 4.

H
A
Z
A
R
D

AUDIT CHECKLIST

C
O
N
S
E
Q
U
E
N
C
E
S

THREAT

MAJOR
LOSS

Project Manager
Task 1 .
Task 3 .
Ops. Manager

Check
accuracy

Task 5 .
Task 9 .
Task 11 ...

RISK MANAGEMENT TASKS LIST

Responsible
Person:

Project Manager

Task 1: ..
Task 2: ..
Task 3: ..

Verify
performance

Figure 4 Audits, Bow-Ties & HSE-Critical Tasks

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Once the Critical Tasks are defined, personnel are assigned the responsibility for the execution
of the tasks. Such persons are identified from the organisation at the time of undertaking the work and
should remain, at the least, at a supervisory level. Where possible, one person per task should be
assigned.
3.3.

Illustrative Example of the Linkage Between Bow-Ties, Barriers, Critical Tasks and
HSE Management Systems

To demonstrate the relationship between Bow-ties, Barriers, Critical Tasks and HSE
Management Systems, consider the following example, which is an extract from a study conducted on
offshore asset in the Caribbean.
Figures 5 and 6 show the typical arrangement of the Left (Threat) and Right (Consequence) side
of a Bow Tie diagram, created using the THESIS code.
3.3.1.

Left Side of Bow Tie Threat Barriers

Illustrative (Figures 5) is an example showing Critical Tasks to ensure that the integrity of the
barriers to threat of internal corrosion to pipeline integrity is maintained:
Threat Internal Corrosion & Erosion
o Barrier 1 NDT Inspection (In-Line Inspection/Intelligent Pigging)
Critical Task 1 Periodic In line inspection (ILI) for integrity
assessment of pipeline,
Escalating Factor (a) Inspector/Evaluator Competence,
Lack of ILI Inspection Plan,
o Critical Task (a1) Performance standards &
qualification
o Critical Task (b2) Documenting, approval and
implementation of ILI tool performance standard
o Barrier 2 Well Sampling
Critical Task 2 Monitoring corrosive contents of produced oil &
gas,
Escalating Factor (a) Sampling process not followed
o Critical Task (a1) Operator Training
o Critical Task (b2) Standard Operating Procedures
Fatigue&vibration
Threat

Internal Corrosion &

erosion

Threat

NDT inspection

Well sampling

<None>

<None>

H1-03 Mechanical energy

Inspector competence

Escalation Factor

Performance standards

Approved contractors

<None>

<None>
Loc.:
TE:

Sampling process not

adhered to

Escalation Factor

Teak A Platform
Failure of
equipment

Operator training

Operator monitoring

Company procedures & reports

<None>

<None>

<None>

External Corrosion
Threat

Overload
Threat

Human error
Threat

Figure 5 Threat Barriers & Critical Tasks (Left Side of Bow Tie)

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Other more generic examples for threat (probability of failure) related critical tasks would be:
Pressure Relief Valve (PRV): Ensure that routine/specific maintenance, inspection
and testing activities undertaken on PRVs are planned, managed and conducted in
accordance with the maintenance frequencies, procedures, guidelines, checklists and
techniques specified in the appropriate documentation to ensure that they are
maintained in a safe and fit-for-purpose condition.
System Strength Tested: Ensure that system is pressure tested in accordance with the
requirements specified in Safe Operating Procedure: Pressure Testing of Equipment.
Illustrative Figure 6 is an example showing Critical Tasks to ensure that the integrity of the
barriers to consequence of equipment failure is maintained. Critical Tasks for pipeline failure would
include:
Consequence Environmental impact due to spill
o Barrier 1 Emergency response plan for spills
Critical Task 1 Execute emergency spill response for containment
and remediation.
Escalating Factor (a) Containment equipment inadequate
or not operating
o Critical Task (a1) QRA/Spill analysis studies
o Critical Task (b2) Equipment Maintenance
Program

Guards and shielding installed

Compressor enclosures

EMTs and first aid area

<None>

<None>

<None>

Injury or fatality (flying

objects, trapped)
Consequence
C3

Inspection and
maintenance not
undertaken per schedule

Escalation Factor

Offshore planning meetings &

supervision
<None>

Inspector competence

H1-03 Mechanical energy

Loc.:
TE:

Teak A Platform
Failure of
equipment

Performance standards

<None>

<None>

Escalation Factor

Loss of power from

generators

+
B4

Stand-by generator

Approved contractors

Consequence
B4
B4
B4

<None>

Production Loss

Consequence

Redundancy in equipment

<None>

Fire and/or explosion

B4

Consequence
B4
B4
B4

Environmental impact

Emergency response plans for oil spill

Mutual assistance agreement with

other parties

Spill clean-up kits

Stand-by boat for clean up

<None>

<None>

<None>

<None>

Consequence
D3
D1

B3

Figure 6 Consequence Barriers & Critical Tasks (Right Side of Bow Tie)
Other more generic examples for consequence related critical tasks would be:
Gas Leak Detection & Alarm: Ensure that routine/specific maintenance, inspection
and testing activities undertaken on Gas Detectors are planned, managed and conducted
in accordance with the maintenance frequencies, procedures, guidelines, checklists and
techniques specified in the appropriate documentation to ensure that they are
maintained in a safe and fit-for-purpose condition.

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Ignition Source Control: Ensure that hazardous area classification and zoning, and
corresponding drawings, are completed prior to construction/modification of
plant/equipment in accordance with procedures and/or requirements. Ensure that
permanent electrical equipment in hazardous zones are appropriately rated. Verify
hazardous area classification drawings against actual design.
As can be seen from the above examples, Critical Tasks are developed from the HSE
Management System as well as other sources.

4. BENEFITS & ADVANTAGES OF USING BOW TIES

There are many benefits and advantages to using and applying Bow Ties, some of which have
already been described above. In summary, subject to the nature of the particular application, they can
be used for/to:
Documents the analysis in a systematic manner and in a way that makes the control of
hazards easier for personnel to understand.
Linking of hazards, controls, etc. to Critical Activities and Tasks via Bow-Ties.
Therefore, it
ensures that controls identified from a risk assessment are linked to the companys
processes and to individuals responsibilities
.Provides reports which can form part of a Formal Safety Assessment, e.g. HSE Case,
or which can be used for communication to those personnel responsible for safetycritical tasks.
Provides an essential source of risk management information a corporate memory
to prevent losses occurring or re-occurring.
Documents all areas where shortfalls have been identified and corrective action is
required, and assigns responsibilities for completion of the actions
Supports audits of HSE Management Systems.
Facilitates a continuous improvement process for risk management.
Promotes visibility and awareness of hazards, risks and HSE Management.
Used for hazard awareness training
Incident investigation
Preparation of emergency exercises
Audit checklists/planning:
e.g. Critical Tasks can be used as the basis for audit checklists
Input into operating procedures, job descriptions, annual tasks and targets, defining
individual roles & responsibilities, etc.