Bow-tie diagram: Difference between revisions
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{{Short description|Symbolic representation of accident path and safety barriers}} |
{{Short description|Symbolic representation of accident path and safety barriers}} |
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A '''bow-tie diagram''' is a [[Diagram|graphic tool]] used to describe an [[Accident|accidental event]] in terms of its initial causes, ultimate negative consequences, and safety barriers designed to prevent or control the associated hazards. The diagram visualizes an unintended event, usually one with the potential to escalate to undesired consequences, with all its credible initiating causes and ultimate outcomes |
A '''bow-tie diagram''' is a [[Diagram|graphic tool]] used to describe an [[Accident|accidental event]] in terms of its initial causes, ultimate negative consequences, and safety barriers designed to prevent or control the associated hazards. The diagram visualizes an unintended event, usually one with the potential to escalate to undesired consequences, with all its credible initiating causes on the left of the event and its ultimate outcomes (such as injury, loss of property, damage to the environment, etc.) on the right. A number of barriers, either hard/engineered or administrative/procedural, are placed on the path from the initiators to the final outcomes. The shape of the diagram recalls that of a [[bow tie]], after which it is named.<ref name=":1">{{Cite book |last=[[Center for Chemical Process Safety]] in association with [[Energy Institute]] |title=Bow Ties in Risk Management |publisher=[[John Wiley & Sons]] |year=2018 |isbn=9781119490388 |location=Hoboken, N.J.}}</ref> |
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Bow-tie diagrams are used to analyze and manage risk in several industries, such as oil and gas production, the [[Process manufacturing|process industries]], [[aviation]], and [[finance]].<ref name=":1" /><ref>{{Cite web |title=Introduction to Bowtie |url=https://www.caa.co.uk/Safety-initiatives-and-resources/Working-with-industry/Bowtie/About-Bowtie/Introduction-to-bowtie/ |url-status=live |access-date=2023-07-14 |website=[[UK Civil Aviation Authority]]}}</ref> |
Bow-tie diagrams are used to analyze and manage risk in several industries, such as oil and gas production, the [[Process manufacturing|process industries]], [[aviation]], and [[finance]].<ref name=":1" /><ref>{{Cite web |title=Introduction to Bowtie |url=https://www.caa.co.uk/Safety-initiatives-and-resources/Working-with-industry/Bowtie/About-Bowtie/Introduction-to-bowtie/ |url-status=live |access-date=2023-07-14 |website=[[UK Civil Aviation Authority]]}}</ref> |
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== History == |
== History == |
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It is generally accepted that the earliest mention of the bow-tie methodology appeared in the [[Imperial Chemical Industries]] (ICI) course notes of a lecture on [[hazard analysis]] given at the [[University of Queensland]], Australia in 1979.<ref name=":1" /><ref>{{Cite web |title=Bowties - History |url=https://www.bowtiepro.com/bowtie_history.asp |url-status=dead |archive-url=https://web.archive.org/web/20160617213121/https://www.bowtiepro.com/bowtie_history.asp |archive-date=2007-11-04 |website=BowTie Pro}}</ref> Other sources point to Derek Viner of the Ballarat College of Advanced Education (now the [[Federation University Australia|Federation University]]), who used it as an aid to explain aspects of his Generalised Time Sequence Model (GTSM) for accidental events.<ref>{{Cite journal |last=Donaldson |first=Craig |date=2016 |title=Time for OHS to Understand the Science of Risk |journal=OHS Professional |issue=December 2016 |pages=18-22}}</ref><ref name="Viner">{{cite book |author=Viner |first=Derek |title=Occupational Risk Control: Predicting and Preventing the Unwanted |publisher=[[Routledge]] |year=2015 |isbn=978-1-4724-1970-5 |location=}}</ref> As noted by Viner, risk analysis tools such as [[fault tree analysis]] and [[event tree analysis]], as well as relevant concepts in [[Nuclear safety and security|nuclear safety]] (like [[Defense in depth (nuclear engineering)|defense-in-depth]]) were introduced separately but at similar times. |
It is generally accepted that the earliest mention of the bow-tie methodology appeared in the [[Imperial Chemical Industries]] (ICI) course notes of a lecture on [[hazard analysis]] given at the [[University of Queensland]], Australia in 1979.<ref name=":1" /><ref>{{Cite web |title=Bowties - History |url=https://www.bowtiepro.com/bowtie_history.asp |url-status=dead |archive-url=https://web.archive.org/web/20160617213121/https://www.bowtiepro.com/bowtie_history.asp |archive-date=2007-11-04 |website=BowTie Pro}}</ref> Other sources point to Derek Viner of the Ballarat College of Advanced Education (now the [[Federation University Australia|Federation University]]), who used it as an aid to explain aspects of his Generalised Time Sequence Model (GTSM) for accidental events.<ref>{{Cite journal |last=Donaldson |first=Craig |date=2016 |title=Time for OHS to Understand the Science of Risk |journal=OHS Professional |issue=December 2016 |pages=18-22}}</ref><ref name="Viner">{{cite book |author=Viner |first=Derek |title=Occupational Risk Control: Predicting and Preventing the Unwanted |publisher=[[Routledge]] |year=2015 |isbn=978-1-4724-1970-5 |location=}}</ref> As noted by Viner, risk analysis tools such as [[fault tree analysis]] and [[event tree analysis]], as well as relevant concepts in [[Nuclear safety and security|nuclear safety]] (like [[Defense in depth (nuclear engineering)|defense-in-depth]]) were introduced separately but at similar times. The bow-tie diagram builds on some elements of those approaches and introduces the concept of a central event (the "bow tie knot") which frees the energy available to escalate to the final undesired consequences.<ref name="Viner" /> |
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[[Royal Dutch Shell]] is considered to be the first major company to successfully integrate bow-tie diagrams into their business practices, at least since the early 1990s.<ref name=":1" /><ref name=":0">{{Cite web |last=Sneddon |first=James |title=Practical Application of Bowtie Analysis |url=https://www.cheminst.ca/wp-content/uploads/2019/04/509-Application-of-Bowtie-CSChE2017.pdf |url-status=live |access-date=2023-07-14 |website=[[Chemical Institute of Canada]]}}</ref><ref name=":2">{{Cite book |last=Rausand |first=Marvin |title=Risk Assessment: Theory, Methods, and Applications |publisher=[[John Wiley & Sons]] |year=2011 |isbn=978-0-470-63764-7 |location=Hoboken, N.J.}}</ref> |
[[Royal Dutch Shell]] is considered to be the first major company to successfully integrate bow-tie diagrams into their business practices, at least since the early 1990s.<ref name=":1" /><ref name=":0">{{Cite web |last=Sneddon |first=James |title=Practical Application of Bowtie Analysis |url=https://www.cheminst.ca/wp-content/uploads/2019/04/509-Application-of-Bowtie-CSChE2017.pdf |url-status=live |access-date=2023-07-14 |website=[[Chemical Institute of Canada]]}}</ref><ref name=":2">{{Cite book |last=Rausand |first=Marvin |title=Risk Assessment: Theory, Methods, and Applications |publisher=[[John Wiley & Sons]] |year=2011 |isbn=978-0-470-63764-7 |location=Hoboken, N.J.}}</ref> |
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[[File:Bow-tie diagram.jpg|thumb|420x420px|Layout of a bow-tie diagram<ref name=":2" />]] |
[[File:Bow-tie diagram.jpg|thumb|420x420px|Layout of a bow-tie diagram<ref name=":2" />]] |
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Bow-tie diagrams contribute to the identification, description and understanding of the different types of hazards that can arise in a given situation, facility or production process. |
Bow-tie diagrams contribute to the identification, description and understanding of the different types of hazards that can arise in a given situation, facility or production process. They also help identify the relevant risk control measures (barriers) for a given hazard. |
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The fact that scientific effort benefits greatly from a focus on "process" is well known in |
The fact that scientific effort benefits greatly from a focus on "process" is well known in several scientific domains as was noted by Haddon.<ref name=":3">{{Cite journal |last=Haddon, Jr. |first=William |date=1973 |title=Energy Damage and the Ten Countermeasure Strategies |journal=[[Human Factors (journal)|Human Factors]] |volume=15 |issue=4 |pages=355-366 |doi=10.1177/001872087301500407}}</ref> The Generalised Time Sequence Model (GTSM) was developed as a process model of which bow-tie diagrams are a simplified extract. |
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Bow-tie diagrams pivot around a central event releasing the energy necessary to bring about the ultimate undesired consequences. This central event is sometimes referred to as the ''top event''.<ref name=":1" /> This mirrors the significance of energy sources in the accident process, as previously mentioned by Deblois as early as |
Bow-tie diagrams pivot around a central event releasing the energy necessary to bring about the ultimate undesired consequences. This central event is sometimes referred to as the ''top event''.<ref name=":1" /> This mirrors the significance of energy sources in the accident process, as previously mentioned by Deblois as early as 1926,<ref>{{Cite book |last=DeBlois |first=Lewis Amory |title=Industrial Safety Organization for Executive and Engineer |publisher=[[McGraw-Hill|McGraw-Hill Book Company]] |year=1926}}</ref> Gibson,<ref name="Gibson">{{cite book |author=Gibson |first=J. |title=Behavioral Approaches to Accident Research |publisher=[[Foundation for Child Development|Association for the Aid of Crippled Children]] |year=1961 |editor-last=Jacobs |editor-first=Herbert J. |location=New York, N.Y. |chapter=The Contribution of Experimental Psychology to the Formulation of the Problem of Safety – A Letter for Basic Research}}</ref> and Haddon.<ref name=":3" /> Further insight into the structure of the processes leading to damage is given by Rowe’s seminal work,<ref name="Rowe">{{cite book |author=Rowe |first=William D. |title=An Anatomy of Risk |publisher=[[John Wiley & Sons]] |year=1977 |location=}}</ref> where the central event is defined as "the point in time when control was lost of the potentially damaging properties of the energy source of interest". |
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Credible initiating causes are shown on the left of the top event and its ultimate outcomes (such as injury, loss of property, damage to the environment, etc.) on the right. Control barriers, either hard/engineered or administrative/procedural, are placed on the path from the initiators to the final outcomes. |
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⚫ | For example, |
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⚫ | For example, pressure in a process vessel is a form of energy that can be released if containment is breached (the central event). The results/outcomes of the release may be noise, blast overpressure propagation, possible flying debris, loss of fluid, etc. These outcomes are shown at the right-hand side of the diagram. Causes for breach of containment are shown at the left-hand side of the diagram, as arising from such mechanisms as structural degradation ([[Abrasion (mechanical)|abrasion]], [[corrosion]], [[Fatigue (material)|fatigue]], external impact, application of other forces and the like), spurious pressurization above design limits, inadvertent opening, etc. When initiating causes and outcomes are understood, the analyst can ensure that control measures (barriers) exist to intervene in these possible parts of the processes. Left-hand side barriers are, in this example, external and internal surface [[Coating|coatings]], vessel inspection (internal and external), wall thickness measurements, [[Safety valve|pressure safety valves]], etc. While some are relevant to design and commissioning, others are to [[maintenance]] and [[condition monitoring]]. A right-hand side barrier, in this example, are nearby structures designed to withstand modelled blast overpressure. |
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Bow-tie diagrams are very similar to, and often used to support the [[Swiss cheese model]] of accident causation.<ref name=":1" /> |
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== Use in various disciplines == |
== Use in various disciplines == |
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[[File:"Bow-tie" diagram of components in a directed network.svg|thumb|A simplified bow-tie for [[network theory in risk assessment]] |
[[File:"Bow-tie" diagram of components in a directed network.svg|thumb|A simplified bow-tie for [[network theory in risk assessment]]]]Bow-tie diagrams are used in various disciplines and domains, including for example: |
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* [[Occupational safety and health]] (OSH)<ref name=":1" /> |
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⚫ | |||
* [[Process safety]]<ref name=":1" /> |
* [[Process safety]]<ref name=":1" /> |
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* [[Aviation safety]]<ref>{{Cite web |title=Introduction to bowtie {{!}} UK Civil Aviation Authority |url=https://www.caa.co.uk/Safety-initiatives-and-resources/Working-with-industry/Bowtie/About-Bowtie/Introduction-to-bowtie/ |access-date=2021-09-20 |website=www.caa.co.uk}}</ref> |
* [[Aviation safety]]<ref>{{Cite web |title=Introduction to bowtie {{!}} UK Civil Aviation Authority |url=https://www.caa.co.uk/Safety-initiatives-and-resources/Working-with-industry/Bowtie/About-Bowtie/Introduction-to-bowtie/ |access-date=2021-09-20 |website=www.caa.co.uk}}</ref> |
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* [[Information security]] and [[Computer security|cyber security]] risks |
* [[Information security]] and [[Computer security|cyber security]] risks<ref>{{Cite book |last=Bernsmed |first=K. |title=Graphical Models for Security. 4th International Workshop, GraMSec 2017, Santa Barbara, CA, USA, August 21, 2017, Revised Selected Papers |last2=Frøystad |first2=C. |last3=Meland |first3=P.H. |last4=Nesheim |first4=D.A. |last5=Rødseth |first5=Ø.J. |publisher=[[Springer Science+Business Media|Springer, Cham]] |year=2018 |isbn=978-3-319-74860-3 |editor-last=Liu |editor-first=P. |chapter=Visualizing Cyber Security Risks with Bow-Tie Diagrams |editor-last2=Mauw |editor-first2=S. |editor-last3=Stolen |editor-first3=K.}}</ref> |
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⚫ | |||
* [[Finance]]<ref name=":1" /> |
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⚫ | Bow-tie diagrams are often compared to and used in conjunction with the [[Swiss cheese model]] of accident causation.<ref name=":1" /> Several software packages are available in the market for bow-tie diagram creation and management. Bowtie Master (cloud-based)<ref>{{Cite web |last= |first= |title=Understand, Communicate and Visualise Your Risk |url=http://bowtiemaster.com/ |url-status=live |access-date=2023-07-14 |website=Bowtie Master}}</ref> and BowtieXP (local only)<ref>{{Cite web |last= |first= |title=BowTieXP Feature Overview |url=http://www.wolterskluwer.com/en-gb/solutions/enablon/bowtie/bowtiexp?utm_term=bowtiexp&utm_campaign=BowTieXP.com/uk&utm_source=adwords&utm_medium=ppc&hsa_acc=1345887116&hsa_cam=962542048&hsa_grp=48007645175&hsa_ad=231408532932&hsa_src=g&hsa_tgt=aud-458181053730:kwd-351663829812&hsa_kw=bowtiexp&hsa_mt=b&hsa_net=adwords&hsa_ver=3&gclid=EAIaIQobChMIoc_w2NnV-wIVFu3tCh1gCA17EAAYASAAEgI89fD_BwE |url-status=live |access-date=2023-07-14 |website=Wolters Kluwer}}</ref> are two examples. |
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== Criticism == |
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{{Section expansion needed|date=July 2023}} |
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A common criticism made of models of the process leading to damage is that they are linear.<ref>{{Cite web |last=Leveson |first=Prof. Nancy G. |author-link=Nancy Leveson |title=Shortcomings of the Bow Tie and Other Safety Tools Based on Linear Causality |url=http://sunnyday.mit.edu/Bow-tie-final.pdf |url-status=live |website=[[Massachusetts Institute of Technology]]}}</ref> |
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== Software for bow-tie diagrams == |
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⚫ | Several software packages are available in the market for bow-tie diagram creation and management. Bowtie Master (cloud-based)<ref>{{Cite web |last= |
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== References == |
== References == |
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{{reflist}} |
{{reflist}} |
Revision as of 15:26, 14 July 2023
A bow-tie diagram is a graphic tool used to describe an accidental event in terms of its initial causes, ultimate negative consequences, and safety barriers designed to prevent or control the associated hazards. The diagram visualizes an unintended event, usually one with the potential to escalate to undesired consequences, with all its credible initiating causes on the left of the event and its ultimate outcomes (such as injury, loss of property, damage to the environment, etc.) on the right. A number of barriers, either hard/engineered or administrative/procedural, are placed on the path from the initiators to the final outcomes. The shape of the diagram recalls that of a bow tie, after which it is named.[1]
Bow-tie diagrams are used to analyze and manage risk in several industries, such as oil and gas production, the process industries, aviation, and finance.[1][2]
History
It is generally accepted that the earliest mention of the bow-tie methodology appeared in the Imperial Chemical Industries (ICI) course notes of a lecture on hazard analysis given at the University of Queensland, Australia in 1979.[1][3] Other sources point to Derek Viner of the Ballarat College of Advanced Education (now the Federation University), who used it as an aid to explain aspects of his Generalised Time Sequence Model (GTSM) for accidental events.[4][5] As noted by Viner, risk analysis tools such as fault tree analysis and event tree analysis, as well as relevant concepts in nuclear safety (like defense-in-depth) were introduced separately but at similar times. The bow-tie diagram builds on some elements of those approaches and introduces the concept of a central event (the "bow tie knot") which frees the energy available to escalate to the final undesired consequences.[5]
Royal Dutch Shell is considered to be the first major company to successfully integrate bow-tie diagrams into their business practices, at least since the early 1990s.[1][6][7]
Structure of the diagrams
Bow-tie diagrams contribute to the identification, description and understanding of the different types of hazards that can arise in a given situation, facility or production process. They also help identify the relevant risk control measures (barriers) for a given hazard.
The fact that scientific effort benefits greatly from a focus on "process" is well known in several scientific domains as was noted by Haddon.[8] The Generalised Time Sequence Model (GTSM) was developed as a process model of which bow-tie diagrams are a simplified extract.
Bow-tie diagrams pivot around a central event releasing the energy necessary to bring about the ultimate undesired consequences. This central event is sometimes referred to as the top event.[1] This mirrors the significance of energy sources in the accident process, as previously mentioned by Deblois as early as 1926,[9] Gibson,[10] and Haddon.[8] Further insight into the structure of the processes leading to damage is given by Rowe’s seminal work,[11] where the central event is defined as "the point in time when control was lost of the potentially damaging properties of the energy source of interest".
Credible initiating causes are shown on the left of the top event and its ultimate outcomes (such as injury, loss of property, damage to the environment, etc.) on the right. Control barriers, either hard/engineered or administrative/procedural, are placed on the path from the initiators to the final outcomes.
For example, pressure in a process vessel is a form of energy that can be released if containment is breached (the central event). The results/outcomes of the release may be noise, blast overpressure propagation, possible flying debris, loss of fluid, etc. These outcomes are shown at the right-hand side of the diagram. Causes for breach of containment are shown at the left-hand side of the diagram, as arising from such mechanisms as structural degradation (abrasion, corrosion, fatigue, external impact, application of other forces and the like), spurious pressurization above design limits, inadvertent opening, etc. When initiating causes and outcomes are understood, the analyst can ensure that control measures (barriers) exist to intervene in these possible parts of the processes. Left-hand side barriers are, in this example, external and internal surface coatings, vessel inspection (internal and external), wall thickness measurements, pressure safety valves, etc. While some are relevant to design and commissioning, others are to maintenance and condition monitoring. A right-hand side barrier, in this example, are nearby structures designed to withstand modelled blast overpressure.
Use in various disciplines
Bow-tie diagrams are used in various disciplines and domains, including for example:
- Occupational safety and health (OSH)[1]
- Process safety[1]
- Aviation safety[12]
- Information security and cyber security risks[13]
- Risk assessment based on network theory[citation needed]
- Finance[1]
Bow-tie diagrams are often compared to and used in conjunction with the Swiss cheese model of accident causation.[1] Several software packages are available in the market for bow-tie diagram creation and management. Bowtie Master (cloud-based)[14] and BowtieXP (local only)[15] are two examples.
References
- ^ a b c d e f g h i Center for Chemical Process Safety in association with Energy Institute (2018). Bow Ties in Risk Management. Hoboken, N.J.: John Wiley & Sons. ISBN 9781119490388.
- ^ "Introduction to Bowtie". UK Civil Aviation Authority. Retrieved 2023-07-14.
{{cite web}}
: CS1 maint: url-status (link) - ^ "Bowties - History". BowTie Pro. Archived from the original on 2007-11-04.
{{cite web}}
:|archive-date=
/|archive-url=
timestamp mismatch; 2016-06-17 suggested (help) - ^ Donaldson, Craig (2016). "Time for OHS to Understand the Science of Risk". OHS Professional (December 2016): 18–22.
- ^ a b Viner, Derek (2015). Occupational Risk Control: Predicting and Preventing the Unwanted. Routledge. ISBN 978-1-4724-1970-5.
- ^ Sneddon, James. "Practical Application of Bowtie Analysis" (PDF). Chemical Institute of Canada. Retrieved 2023-07-14.
{{cite web}}
: CS1 maint: url-status (link) - ^ a b Rausand, Marvin (2011). Risk Assessment: Theory, Methods, and Applications. Hoboken, N.J.: John Wiley & Sons. ISBN 978-0-470-63764-7.
- ^ a b Haddon, Jr., William (1973). "Energy Damage and the Ten Countermeasure Strategies". Human Factors. 15 (4): 355–366. doi:10.1177/001872087301500407.
- ^ DeBlois, Lewis Amory (1926). Industrial Safety Organization for Executive and Engineer. McGraw-Hill Book Company.
- ^ Gibson, J. (1961). "The Contribution of Experimental Psychology to the Formulation of the Problem of Safety – A Letter for Basic Research". In Jacobs, Herbert J. (ed.). Behavioral Approaches to Accident Research. New York, N.Y.: Association for the Aid of Crippled Children.
- ^ Rowe, William D. (1977). An Anatomy of Risk. John Wiley & Sons.
- ^ "Introduction to bowtie | UK Civil Aviation Authority". www.caa.co.uk. Retrieved 2021-09-20.
- ^ Bernsmed, K.; Frøystad, C.; Meland, P.H.; Nesheim, D.A.; Rødseth, Ø.J. (2018). "Visualizing Cyber Security Risks with Bow-Tie Diagrams". In Liu, P.; Mauw, S.; Stolen, K. (eds.). Graphical Models for Security. 4th International Workshop, GraMSec 2017, Santa Barbara, CA, USA, August 21, 2017, Revised Selected Papers. Springer, Cham. ISBN 978-3-319-74860-3.
- ^ "Understand, Communicate and Visualise Your Risk". Bowtie Master. Retrieved 2023-07-14.
{{cite web}}
: CS1 maint: url-status (link) - ^ "BowTieXP Feature Overview". Wolters Kluwer. Retrieved 2023-07-14.
{{cite web}}
: CS1 maint: url-status (link)