Bow-Tie Industrial Risk Management Across Sectors. Luca Fiorentini

74 Calibrated risk graph.

      Figure 75 A typical Bow‐Tie.

      Figure 76 Bow‐Tie as the combination of an FTA and an ETA.

      Figure 77 The Swiss Cheese Model by James Reason.

      Figure 78 Bow‐Tie project risk assessment.

      Figure 79 Bow‐Tie diagram – transfer of a data center.

      Figure 80 Bow‐Tie diagram on virtual classroom training.

      Figure 81 Level of abstraction.

      Figure 82 Zoom level and point in time.

      Figure 83 Example of point in time.

      Figure 84 Basic elements of a Bow‐Tie diagram.

      Figure 85 Determining the threshold level to cause the top event.

      Figure 86 Barrier functions.

      Figure 87 Location of elimination and prevention barriers.

      Figure 88 Location of control and mitigation barriers.

      Figure 89 Barrier systems.

      Figure 90 Using the same barrier on either side of the Bow‐Tie diagram.

      Figure 91 Classification of safety barriers. Source: Sklet, S., 2006.

      Figure 92 Barrier classification promoted by the AIChE CCPS Guidelines.

      Figure 93 The energy model. Source: Haddon, W., 1980.

      Figure 94 Generic safety functions related to a process model. Sources: Hollnagel, E., 2004. Barrier And Accident Prevention. Hampshire, IK: Ashgate; Duijm et al., 2004.

      Figure 95 Layers of defence against a possible industrial accident.

      Figure 96 A comparison between ETA and LOPA’s methodology.

      Figure 97 Actions of a barrier.

      Figure 98 Misuse of escalation factors, with nested structure.

      Figure 99 Defining “activities” for a barrier.

      Figure 100 Quantifying a simplified Bow‐Tie.

      Figure 101 Scale of the effectiveness of a barrier and the relationship between effectiveness and PFD (correct).

      Figure 102 Relationship between effectiveness and PFD (correct).

      Figure 103 Bow‐Tie concatenation example.

      Figure 104 Difference between accident, near‐accident and unintended circumstance.

      Figure 105 Principles of incident analysis.

Figure 106 The importance of accident investigations.

      Figure 107 Steps in the analysis of the operational experience of organizations.

      Figure 108 Steps in accident investigations.

      Figure 109 The pyramid of conclusions.

      Figure 110 Example a Tripod Beta diagram.

      Figure 111 Possible Tripod Beta appearances.

      Figure 112 Example of a BFA diagram 1.

      Figure 113 Example of a BFA diagram 2.

      Figure 114 BFA core elements.

      Figure 115 General structure of a BFA diagram.

      Figure 116 Event chaining in BFA.

      Figure 117 Defeated barriers are not BFA events.

      Figure 118 Barrier identification in BFA.

      Figure 119 Correct and incorrect barrier identification in BFA.

      Figure 120 BFA analysis.

      Figure 121 Events types in a BFA diagram.

      Figure 122 Example of timeline developed for the Norman Atlantic investigation.

      Figure 123 Timeline example.

      Figure 124 The onion‐like structure between immediate causes and root causes.

      Figure 125 Benefit of RCA.

      Figure 126 RCA Process.

      Figure 127 Levels of analysis.

      Figure 128 The Bow‐Tie diagram.

      Figure 129 Bow‐Tie risk assessment and incident analysis.

      Figure 130 Bow‐Tie preparation workflow.

      Figure 131 From organization to critical tasks.

      Figure 132 Example of Barrier Criticality Assessment.

      Figure 133 Steps to identify critical barriers.

      Figure 134 Example of a barrier audit.

      Figure 135 Traditional audit: one element of the management system is analyzed at a time.

      Figure 136 Audit barrier‐based: all elements of the management system identified as relevant to a specific barrier are analyzed.

      Figure 137 General workflow of LOPA.

      Figure 138 The general workflow of a survey.

      Figure 139 Incident barrier states and relation between barrier state and barrier lifecycle.

      Figure 140 Recommendations development and review.

      Figure 141 On the left: pier with a damaged downpipe; the concrete is wet and deteriorated. On the right: a similar pier with a safe downpipe; the concrete is in good condition.

      Figure 142 Effects of ageing and humidity on the concrete. The reinforcement bars are corroded and there are signs of rust on the beams.

Figure 143 Concrete spalling on a Gerber support with a consequent capacity reduction. The cause of the damage has to be searched for on a damaged downpipe on the road joint (recently substituted).

      Figure 144 The spalling of concrete caused the corrosion to progress. The reinforcement bars broken due to the limited cross‐section are causing a reduction of the capacity of the girder.

      Figure 145 Bow‐Tie diagram for “Local reduction of the resisting capacity of a bridge due to ageing”.

      Figure 146 Employee infected with COVID‐19 virus.

      Figure 147 Fire in flight.

      Figure 148 BFA on food contamination (near miss).

      Figure 149 Web‐based software development – Bow‐Tie.

      Figure 150 IT systems protection Bow‐Tie.

      Figure 151 Satellite view of Matera.

      Figure 152 Matera – Piazza Vittorio Veneto. On the right: steps. Source: Google LLC.

      Figure 153 Developed Bow‐Tie to assess crowding‐related risks – zooming the threats and preventive barriers.

      Figure 154 Developed Bow‐Tie to assess crowding‐related risks – zooming the consequences and mitigative barriers.

      Figure 155 Map to develop simulated scenarios.

      Figure 156 Different levels of service.

      Figure 157 Piazza Vittorio Veneto and the bottleneck in Via San Biagio, Matera.

      Figure 158 Impact of the soft obstacles on the pedestrian flow.

      Figure 159 Bow‐Tie Risk assessment (whole picture).

      Figure 160 Helicopter loss of control Bow‐Tie risk assessment.

      Figure 161 Treatment of critically ill patients.

      Figure 162 Treatment of patient with pain.

      Figure 163 Preparing parenterals (excluding cytostatic drugs).

      Figure