Visualization of risk through bowtie
Paul de Kock
What will I cover?
• Risk and critical control management
• Where does bowtie assessment fit in?
• Technology and risk data integration – demonstrate
an Integrated Bowtie Assessment (IBTA) in
IsoMetrix
Risk and Critical Control Management - A Well
Known Example
The top or material unwanted
event
• Low wall failed and toppled
into the pit
Consequence
• Falling material partially
engulfed an excavator and
haul truck
Source: Queensland Mining Industry
Conference 2014
Causes and Contributing Factors
Causes
• Complex full-face slope
failure
• Geotechnical Issues
• Mining activities that
progressively removed
support for the pit wall
• Communication
Source: Queensland Mining Industry
Conference 2014
Failed Critical Controls
Investigation revealed a
fundamental failure in
managing critical controls
over the long term
Failed Critical controls:
• The slope stability radar
• Monitoring the top of the
pit wall for cracks
• No hard barrier was put in
place at the toe of the pit
• Verbal advice on
managing the risks
associated with mining
Source: Queensland Mining Industry
Conference 2014
Risk and Critical Control Management
Source: ICMM
Risk and Critical Control Effectiveness
• The Critical Control Effectiveness
Monitoring (CCEM) process is dependent
on the following processes:
Full site or baseline risk assessment
Project / change / issue based RA
• A comprehensive ‘baseline’ risk assessment
conducted across the site
Routine/non-routine task based RA
• Identification of ‘Priority Unwanted Events’ or
events that could lead to multiple fatalities
Continuous RA
• Controls required for the management of
Priority Unwanted Events have been identified
and their effectiveness assessed via
comprehensive risk assessment exercises (best
practice: ‘bowtie’ analyses)
• Process of monitoring effectiveness of critical
controls
• Ongoing and visible reporting and
accountability
The Bowtie Diagram Concept
The Bowtie in Reality
Bowtie – The Link Between Risk and Management
Systems
Unlike traditional risk evaluation tools, the bowtie method makes the direct
link between risk, controls and the management system to implement these:
HSE Management System is a structured framework for managing HSE risk
and controls in a business:
Effective Control Management
Source: ICMM
The following flow from a single identified critical
control
Action plans are created to ensure the control is implemented and effective. These are
tracked through to completion
Ongoing control self assessments – scheduled, tracked, actioned
Specific checks (inspections) are scheduled – tracked and implemented
Specific behaviours are encouraged checked and reinforced (BBS or VFL)
Key (performance) indicators are measured tracked and actioned (data from multiple
sources such SCADA, smart meters, drones, GIS, or a spatial information platform)
Procedures are reviewed and communicated
Incidents, near hits, non-conformances are recorded, investigated, actioned
Audits are conducted and findings tracked, actioned and closed out
Etc.
The Bowtie in IsoMetrix
Bowtie – the link between risk and management
systems
• Because performance information can be linked to individual bowties and
individual critical controls and because they exist in real or near real time
the Bowtie can become a living document showing the current state of all
critical controls at any point in time.
• Example Critical Control – site specific performance
Preventative control
Slope Stability Radar
CRITICAL
L
Actionss
Indicator
Findings
Incidents
Demonstrate Bowtie in IsoMetrix