Bowtie Analysis – An Effective Risk Management
Hindustan Petroleum Corporation Limited
Corporate HSE Department
By
Murthy V S S Malyala
Manager –HSE
Contents
Risk analysis –background
Incidents in Oil Industry
Bowtie – a visual risk evaluation tool
Terminology
Development of Bowtie
Case study – Gas fired Pipe heater explosion modelling
Barriers for controlling incidents
Barrier Effectiveness
End users of Bowtie
Better than other Hazard identification Techniques
Risk Analysis
Risk = Probability X Consequence
3
Decades of learning from disasters
3000 fatalities
MIC Release
500 fatalities and terminal destroyed
Rupture of 8 inch LPG pipeline
167 fatalities and platform destroyed.
28 fatalities and 36 injured Leakage from pump discharge
Bhopal Gas Incident- 1984
Vapor cloud explosion ( Explosion
relief valve
Loss – Human & Property
during start up)
Mexico (1984)
18 fatalities and 81 injured
LPG Leakage – Flixborough (1974)
Sampling/ water Piper Alpha 1988
draining
Feyzin, France
- 1966 Emergency Preparedness
MOC
Staffing Work permit system
Operating Assert
Management Of Change Multiple Failures Hazard communication
Procedure Integrity
Years of learning
Decades of learning from disasters
Leakage occurred during
maint. work on valve . overfilling of a large
storage tank
Fatalities 23. Over 130 injured
Loss – Human & Property
Over filling of column .
Fatalities 15. Over 170 injured Jaipur
Terminal
Pasadena 1989 (2009)
Catastrophic failure of heat exchangers Buncefield (2005)
2 fatalities and 8 injured
BP Texas (2005)
Esso Longford (1998)
Operating Discipline
Maintenance practices Contractor Safety Operating Discipline
Hazard Analysis
Assert Integrity
Years of learning
5
Bowtie Analysis
The Bow-tie Diagram is a user-friendly, graphical illustration of how
hazards are controlled.
Bowtie …. A simplified fusion of
Fault Tree Analysis and Even Tree Analysis
FTA + ETA = Bowtie
Effective risk management is only possible if people are assigned
responsibilities for controls via HSE-Critical Tasks
Visible links are made to HSE-critical systems and competencies
Bowtie methodology demonstrates not only what controls are in
place today and their effectiveness
Used in Oil & gas , Aerospace, Railways
6
Bowtie analysis for high risk Activities
ALARP
Bowtie Analysis
8
Bowtie Analysis
9
Terminology
Top event - no catastrophe yet but the first event in a chain of
unwanted events.
Threats - The top event can be caused by (sufficient or necessary
causes).
Consequences - The top event has the potential to lead to
unwanted consequences.
Barriers - Preventive or mitigate measures taken to prevent
threats from resulting into the top event.
Escalation factor - a condition that defeats or reduc
es the effectiveness of a barrier.
10
Bowtie analysis – Development
Describe unwanted event for the Bowtie Knot
Determine scope of analysis – operational boundries
Identify threats that could cause the event
Identify possible consequence of the event
Select the optimum set of control to manage the
causes and consequence of the event
Identify failure mode for important control
Determine items for control assurance management
Case Study - Simple Pipe still Heater
12
Case Study – Gas fired Pipe Heater Explosion
Threats
Consequence
13
Threats Preventive Barriers Unwanted Event
14
Threats Preventive Barriers Unwanted Event
15
Threats Preventive Barriers Unwanted Event
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Threats Preventive Barriers Unwanted Event
17
Top event Mitigation barriers Consequence
18
Complete Bowtie Diagram
19
Swiss cheese model –Hazard -Barriers– Incident
Barriers in accident prevention
The Hierarchy of Hazard Control Methodology
Barrier system
1. Accountability
Increased reliability
2. Detect – Decide - Act
3. Safety Critical Task
4. Safety Critical Equipment
Simple application - Bowtie - Car Incident
Swiss cheese model
- Organisations manage risk using ‘barriers’
Why incidents happen
- Barriers – use of equipment, design of plant (redundancy, overflows, etc.),
following rules, procedures, standards …… usually barriers are people doing a
job
- Barriers are ‘functions’
Why do barriers fail? & Weakness in Incident causation path
Underlying Preconditions Immediate
causes causes
Creates That influences the person To take That causes That Accidents, incidents
action or barriers to fail result in and business upsets
inaction
Error /
violation
promoting
An organisation conditions
• SMS • Performance • Human action or inaction
• Leadership influencing factors • slips, lapses,
• Culture (PIFs) mistakes, violations
- Competence
- Fatigue
- Environment
- Supervision
- Task
- Etc.
Types of Barrier in Bowtie
1. Detect – Decide - Act
2. Safety Critical Equipment
3. Safety Critical Task
4. Accountability
End users of Bowtie Analysis
Bow tie is Visual risk depiction tool for a failure mode situation
Technician – Look for Hardware controls –active & passive
Supervisor – Look for administrative controls - Health of
controls
Manager - Identify weak links in controls & monitor
Sustained Operational discipline & timely
maintenance & Skill development.
Thanks
29
Questions?
30
31
HAZARD IDENTIFICATION Techniques
Commonly used :
HAZOP- Identifies “process plant” type incidents(time consuming)
What If Analysis- Possible outcomes of change(high dependency of skills)
FMEA/FMECA-Equipment failure causes (Extremely time consuming)
Task Analysis-(JSA ) Maintenance etc, incidents (Does not address process
deviations
Fault Tree Analysis-Combinations of failures(identified the incident first&
difficult to update )
Checklists-questions to assist in hazard identification(no new hazard types are
identified)
HAZAN -Risk ranking tools are used Dow index OR MOND index
