21/01/2016
Risk Management Process
Establish Context
Identify Risks
risk management and assessment for business
Communicate
& Consult
When is Enough, Enough? Using Bowties to
Achieve ALARP
Andy Lidstone, Principal Consultant, Risktec Solutions, UK
CGE User Group: Bowties and ALARP , Slide 1
www.risktec.com
Risk
Assessment
Analyse Risks
Evaluate Risks
Terminate
Transfer
Treat
Risk assessment should
be an input into a
decision making process
NOT a justification for a
decision
already
CGE
User Group:
Bowties made
and ALARP , Slide 2
Risk Understanding
Tolerate
– Reactively, for what we have
– Proactively, for audit and review
What is really there, rather than what
we wish is there
Risk
Treatment
ALARP
When is enough, enough?
Basic Bowtie
Prevention
The better we understand, the better
we manage
Monitor &
Review
Threat
Threat
Mitigation
Hazard
Consequence
Top Event
Consequence
Consequence
Threat
Barriers
CGE User Group: Bowties and ALARP , Slide 3
Bowtie Method - Advantages
Graphical format encourages
–
–
–
–
Participation
Ownership
Use
Understanding
Clear identification of roles and
responsibilities
Can vary level of detail specific to the
analysis
CGE User Group: Bowties and ALARP , Slide 5
CGE User Group: Bowties and ALARP , Slide 4
Bowtie Method - Pitfalls
Can be difficult to do well
Need to ensure:
–
–
–
–
Consistency of approach
Pitching at the right level
Involving the right people
Avoiding wish fulfilment
Control dependencies
Doesn’t replace QRA
CGE User Group: Bowties and ALARP , Slide 6
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21/01/2016
Key Points
Case Law
Principle of Reasonable Practicability
“A computation must be made in which the quantum of risk is placed
on one scale and the sacrifice, whether in money, time or trouble,
involved in the measures necessary to avert the risk is placed in the
other; and that, if it be shown that there is a gross disproportion
between them, the risk being insignificant in relation to the sacrifice,
the person upon whom the duty is laid discharges the burden of
proving that compliance was not reasonably practicable”
Asquith LJ in Edwards v. The National Coal Board (1949) 1 All ER 743C
Health and Safety at Work etc. Act 1974
“It shall be the duty of every employer to ensure, so far as is
reasonably practicable, the health, safety and welfare at work of
his/her employees.”
SFAIRP and ALARP are
generally treated as
interchangeable terms
CGE User Group: Bowties and ALARP , Slide 7
‘Reasonably practicable’ is a narrower term
than ‘possible’
There is no absolute safety, accepting a risk
requires weighing the risk against the
sacrifice necessary to reduce it further
Any risk based decision should be weighted
in favour of health and safety i.e.
presumption of implementation
The burden of proving the risk is ALARP lies
with the duty-holder (“the owner”)
Measures should be adopted unless they
involve grossly disproportionate sacrifices
CGE User Group: Bowties and ALARP , Slide 8
ALARP Fundamental Questions
The better we understand what we have, the better
we can answer the questions...
Is there anything more we can do?
Is it reasonably practicable?
Risk levels – may be quantitative and/or
qualitative
Number, type and quality of controls
Further risk
reduction
Have we done the
basics?
Acceptance Criteria
Good Practice
Company Standards
Risk Levels (quantitative and/or qualitative)
Legislative Requirements
CGE User Group: Bowties and ALARP , Slide 9
– Need to consider what supports the barrier,
e.g. people, equipment, documentation
– The likelihood of the event
– Suitability of the controls
– Independence of the controls
– Defeating factors
CGE User Group: Bowties and ALARP , Slide 10
Acceptance Criteria – effective
barriers
Simple
ALARP Assessment
Identify potential risk reduction measures
– e.g. three independent and effective
Improvements on existing controls
Additional controls
Compare Benefit and Sacrifice
Depth of assessment should be proportional (Owner
decides)
Semi-complex
Complex
–
–
–
– Numerical
criteria
– SIL
Qualitative
Semi-quantitative
Cost Benefit Analysis
Rigour will depend on e.g.
Threat
Score
Well Test
Threat
Overpressure of seperator
0
Internal Corrosion
0
Failure of piping / small connections
0
Dropped Objects
2
CGE Error
User Group: Bowties and ALARP , Slide
Human
0 11
–
–
1
4
4
2
4
4
Barrier Scores
2
3
4
2
3
2
4
4
3
4
2
4
6
3
Total
5
5
3
16
12
5
12
20
–
–
–
Nature of hazard
Extent of risk
Societal concerns etc.
The more systematic the approach, the more rigorous
and transparent it is to stakeholders
CGE User Group: Bowties and ALARP , Slide 12
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Choice of approach
Approach vs Risk Level
After: Guidance on Risk Assessment for Offshore Industries HSE 3/2006
Semi-Quantitative
Risk Level
ALARP
Region
Broadly
Acceptable
t
en
em
dg
u
J
g
in
sis
er
aly
ne
gi
An BA
n
d
E
se A, C
a
B R
sk Q
Ri e.g.
Verification
Peer Review
Benchmarking
Qualitative
Internal Stakeholder
Consultation
Complexity
Low complexity
Solution is obvious
Situation covered by
codes and standards
High complexity
Difficult solution
One-off situation
No relevant standards/guidance
External Stakeholder
Consultation
Start simple. Is this adequate
Y/N?
Before
moving
to , next
CGE User
Group: Bowties
and ALARP
Slide 13 level
Company
Values
Context
• Nothing new or unusual
• Well understood risks
A • Established practice
• No major stakeholder implications
• Lifecycle implications
- offs/transfers
risk trade
B•• Some
Uncertainty/deviation from standard, best practice
• Significant economic implications
• Very novel or challenging
Societal
Values
Strong stakeholder views and perceptions
C •• Significant
risk trade
-offs or risk transfers
• Large uncertainties
• Perceived lowering of safety standards
UKOOA - A Framework For Risk Related Decision Support
CGE User Group: Bowties and ALARP , Slide 14
Semi-Quantitative - Matrices
High Impact / Low Cost
Risks and Sacrifices
High Impact / High Cost
Risks
All reasonably foreseeable risks (on and offsite effects)
External events where can mitigate consequences
Effects to most exposed person
Benefits
Reduction in harm to workers, public
Sacrifice
Sacrifice (time, cost, effort)
Implement Immediately
Risk Control Impact
Codes &
Standards
G
oo
d
Codes & Standards
Pr
ac
tic
e
Use in Decision
Making Process
Methods
Quantitative
Intolerable
Low
Implement if Practicable*
Benefit (risk
reduction)
Implement as part of
Continuous Improvement
Don't Implement
Low Impact / Low Cost
Medium
Consider, if
risk high
High
Do not
implement
Consider, if
risk high
Low
Consider
Medium
Implement
Consider
High
Implement
Implement
Consider
Low Impact / High Cost
Allows for
consistent and
transparent
decision making
Cost of Risk Control
Risk Reduction
Level
Value
HIGH
1
MEDIUM 2
LOW
3
Cost
Level
LOW
MEDIUM
HIGH
Effort
Effort
Level
Level
LOW
LOW
Value
1
2
3
Risk Matrix Value
Risk reduction from High to Low
Risk reduction from High to Medium
Risk reduction from Medium to Low
Money, time, trouble e.g.
–
Need to calibrate
axes
$ Cost of implementation
<50k
50k – 500k
>500k
–
–
–
Effort
Value Effort
Value
QuickFix,
Fix,simple
simpletotoachieve,
achieve,
e.g.
install
new
valve
Quick
e.g.
install
new
valve
11
conducttraining
training
ororconduct
Simplefix,
fix,relatively
relatively
easy
achieve,
e.g.
replace
Simple
easy
toto
achieve,
e.g.
replace
itemofofequipment
equipmentoror
revise
simple
layouts
item
revise
simple
layouts
Complexfix,
fix,technically
technically
feasible
easy
Complex
feasible
butbut
notnot
easy
to to
33
achieve,e.g.
e.g.major
majorequipment
equipment
layout
changes
achieve,
oror
layout
changes
Transfer of risk e.g. new/altered hazards
MEDIUM 2 2
MEDIUM
HIGH
CGE User Group: Bowties and ALARP ,HIGH
Slide 15
CGE User Group: Bowties and ALARP , Slide 16
ALARP Process Assessment
Is
RRM ‘easy’ to
implement?
YES
Implement RRM
NO
NO
ALARP Process Summary
Develop the Bowtie
NO
Does RRM?
Assess benefit and
sacrifice for RRM
Identify and question the barriers
Follow recognized industry good
practice for hazard management?
or
Matrix Assessment for
Have significant impact on
Implementation of RRM
reducing potential for multiple
based on Benefit vs Sacrifice
fatality events?
or
Result in inherently safer design?
Sacrifice (time, cost, effort)
YES
Low
Benefit (risk
reduction)
CGE User Group: Bowties and ALARP , Slide 17
Cost of installation, operation, maintenance, future
productivity losses
Temporary shutdown costs for installation where required
Offset any costs, benefits that may occur
To duty holder only and no gold-plating
Medium
Consider, if
risk high
Low
Consider
Medium
Implement
Consider
High
Implement
Implement
High
Do not
implement
Consider, if
risk high
Consider
How good are the barriers?
Could we do more?
- Plant
- People
- Procedures
- Are there enough?
- Of the right quality?
- Improve existing?
- Add more?
Sacrifice (time, cost, effort)
Low
Benefit (risk
reduction)
Medium
Consider, if
risk high
Low
Consider
Medium
Implement
Consider
High
Implement
Implement
High
Do not
implement
Consider, if
risk high
Consider
Is it reasonably practicable?
Implement in good time
Document the process
CGE User Group: Bowties and ALARP , Slide 18
- Monitor/Audit
- Review
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21/01/2016
Example Case
19 major hazard bowties developed with crew
Possible additional measures identified
Later review meetings to discuss, perform further reviews
Conclusions
To improve, we need a clear understanding of
where our weaknesses are
Each bowtie/barrier is an opportunity to ask
questions
ALARP reviews need to question
– Have we done enough?
– Could we do more?
– Is it reasonably practicable to do so?
A simple matrix can aid clarity and
transparency of decision making
CGE User Group: Bowties and ALARP , Slide 19
CGE User Group: Bowties and ALARP , Slide 20
Thank you for your attention
Questions?
[email protected]
CGE User Group: Bowties and ALARP , Slide 21
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