Bowtie Diagrams began circulating as far back as the 1970s, but did not become widely used until the 1990s. Today, they are an invaluable tool across a wide range of industries including Oil and Gas, Petrochemical, Aviation and even Cyber Security. They are a lens through which to visualise risk. They focus our attention on the barriers we put in place to prevent incidents from occurring, or limiting the consequences if they do.
An accident scenario is described from left to right with the ‘knot’ of the Bowtie depicting the ‘Top Event’, the point at which control of a hazard is lost. Let’s introduce the elements of a Bowtie Diagram.
A Hazard is a source of potential harm and is shown top and centre of the Bowtie Diagram. It may be an operation, activity or a material. Examples of hazards may be an object stored at height, hydrocarbons under pressure or valuable data being stored on a server.
The Top Event is the point at which control of the hazard is lost, but no consequences have been realised yet. Examples of a top event may be, object is dropped, flammable hydrocarbons release to atmosphere, or data excursion.
Consequences, the undesirable outcomes of the top event, are located on the right-hand side of the Bowtie Diagram.
Threats are the causes of an incident and are to the left of the Bowtie Diagram. Threats themselves can be the cause of a failure, an external influence or operational issues.
Barriers are the steps taken to prevent an accident scenario from occurring. These may be physical equipment or actions carried out by people. The barriers along the line are the steps we put in place to prevent a threat from leading to the top event, or to prevent or limit the consequences of the top event.
No barrier is 100% reliable. Escalation factors allow us to visualise what can make a barrier’s performance degrade or make it fail. They do not directly cause an incident but may mean that a barrier may not function when called upon. For example, if a Barrier is ‘Emergency Exits’, an escalation factor may be ‘Emergency Exits blocked’.
Escalation barriers prevent an escalation factor from causing a barrier to fail. From the above example, Escalation barriers may be ‘Inspections to ensure that Emergency Exits are not blocked’ or ‘Training for all staff not to leave items near emergency exits’
Bowtie Diagrams can be far easier to understand than a tabular risk assessment and are a fantastic tool in the toolbox for understanding, communicating and managing risks.