Bow-Tie Industrial Risk Management Across Sectors. Luca Fiorentini

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 betw...Figure 102 Relationship between effectiveness and PFD (correct).Figure 103 Bow‐Tie concatenation example

      5 Chapter 3Figure 104 Difference between accident, near‐accident and unintended circums...Figure 105 Principles of incident analysis.Figure 106 The importance of accident investigations.Figure 107 Steps in the analysis of the operational experience of organizati...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 investigati...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.

      6 Chapter 4Figure 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 analyz...Figure 136 Audit barrier‐based: all elements of the management system identi...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 ba...Figure 140 Recommendations development and review.Figure 141 On the left: pier with a damaged downpipe; the concrete is wet an...Figure 142 Effects of ageing and humidity on the concrete. The reinforcement...Figure 143 Concrete spalling on a Gerber support with a consequent capacity ...Figure 144 The spalling of concrete caused the corrosion to progress. The re...Figure 145 Bow‐Tie diagram for “Local reduction of the resisting capacity of...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.Figure 153 Developed Bow‐Tie to assess crowding‐related risks – zooming the ...Figure 154 Developed Bow‐Tie to assess crowding‐related risks – zooming the ...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, Mate...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 164 Administration of parenterals (excluding cytostatic drugs).Figure 165 Medication verification in handoff during hospital admission.Figure 166 Medication verification in handoff during hospital discharge (1 o...Figure 167 Medication verification in handoff during hospital discharge (2 o...Figure 168 Administration of medicines.Figure 169 Treatment of patients with acute coronary syndrome.Figure 170 Administering intravascular iodinated contrast media (excluding i...Figure 171 Applying a central venous catheter (CVC).Figure 172 Operating on a patient.Figure 173 Hospitalization of vulnerable elders (>70 years) (1 of 4).Figure 174 Hospitalization of vulnerable elders (>70 years) (2 of 4).Figure 175 Hospitalization of vulnerable elders (>70 years) (3 of 4).Figure 176 Hospitalization of vulnerable elders (>70 years) (4 of 4).Figure 177 Performing surgical procedures.Figure 178 Elaboration of the threat “external corrosion” and main escalatin...Figure 179 Link between controls and the company HSE management system proce...Figure 180 BFA of Flixborough (UK) incident.Figure 181 BFA of Seveso (Italy) incident.Figure 182 BFA of Bhopal (India) incident.Figure 183 BFA of Piper Alpha (UK – offshore) incident.Figure 184 BFA of Pembroke Refinery (Milford Haven) (UK) incident.Figure 185 BFA of Texas City (US) incident.Figure 186 BFA of Macondo (Deepwater Horizon) (US – Offshore) incident.Figure 187 BFA of Fukishima (Daiichi) (Japan) incident.Figure 188 Drug administration Bow‐Tie.Figure 189 Area involved in the accident. Right, unwinding section of the li...Figure 190 The flattener and the area involved in the accident. Details of t...Figure 191 Details of the hydraulic pipe that provoked the flash fire.Figure 192 Map of the area struck by the jet fire and by the consequent fire...Figure 193 Footprint of the jet fire on the front wall.Figure 194 Timescale of the accident. F1 is the time interval in which the i...Figure 195 The domain used in the FDS fire simulations.2013.Figure 196 Simulated area, elevation.Figure 197 Jet fire simulation results: flames at 1 s from pipe collapse....Figure 198 Jet fire simulation results: flames at 2 s from pipe collapse....Figure 199 Jet fire simulation results: flames at 3 s from pipe collapse....Figure 200 Jet fire simulation results: temperature at 1 s from pipe collaps...Figure 201 Jet fire simulation results: temperature at 2 s from pipe collaps...Figure 202 Jet fire simulation results: temperature at 3 s from pipe collaps...Figure 203 Scheme of the hydraulic circuits with two‐position (a) and three‐...Figure 204 Event tree of the accident. The grey boxes indicate a lack of saf...Figure 205 Damages on the forklift.Figure 206 Frames from the 3D video, reconstructing the incident dynamics.Figure 207 Bow‐Tie diagram of the ThyssenKrupp fire.Figure 208 Twente stadium roof collapse Tripod Beta analysis.Figure 209 Water treatment Bow‐Tie analysis.Figure 210 Timeline of the sample (developed with CGE‐NL IncidentXP).Figure 211 Possible RCA of the sample (developed with CGE‐NL IncidentXP).Figure 212 Possible Tripod Beta of the sample (developed with CGE‐NL Inciden...Figure 213 Possible BFA of the event (developed with CGE‐NL IncidentXP).Figure 214 Bow‐Ties developed to assess fire risk in multiple railway statio...Figure 215 Fire load.Figure 216 Bow‐Tie worksheet developed by TECSA S.r.l. and Royal Haskoning D...Figure 217 Barriers/protection layer scores.Figure 218 Weakest barriers and the public.Figure 219 Bow‐Tie model for fire risk assessment in PV plants.Figure 220 Map of ceraunic density in Italy.Figure 221 Annual average temperature in Italy.

      7 ConclusionsFigure 222 Deming Cycle from a barrier‐based perspective.

      8 Appendix 1Figure 223 Bow‐Tie core elements and general structure.Figure 224 Bow‐Tie guiding principles.

      9 Appendix 2Figure 225 BFA core elements.Figure 226 Incident barrier state.Figure 227 Incident barrier state decision support tree.Figure 228 BFA guiding principles.

      10 Appendix 3Figure 229 Classification of human failure.Figure 230 Fault tree Analysis, current configuration (ANTE).Figure 231 Fault tree analysis, better configuration (configuration A).Figure 232 Fault tree analysis, the best configuration (POST configuration)....Figure 233 Frequency estimation of the scenario “Oxygen sent to blow down, d...Figure 234 The Swiss Cheese Model by James Reason.Figure 235 Level 1: Unsafe acts.Figure 236 Level 2: Preconditions.Figure 237 Level 3: Supervision Issues.Figure 238 Level 4: Organizational Issues.

      Guide

      1  Cover Page

      2  Title Page

      3  Copyright Page

      4  Dedication Page

      5  List of Figures

      6  List of Tables

      7  List of Acronyms

      8  Preface 1

      9