Abstract
Many high hazard industries use bowties to analyze and assess risks. In the bowtie risk analysis model, barriers are identified which aim to prevent, control or mitigate unwanted scenarios.
However, despite best effort risks assessments, incidents and near misses may still occur. When they do, organizations typically conduct investigations to come up with recommendations to avoid similar situations in the future. Unfortunately, in many cases these investigation reports end up as a collection of largely unstructured documents. They are often treated as single events, making it difficult to clearly identify trends over multiple events.
Scenario-based Incident Registration (SIR) aims to provide a more structured process. A user selects a specific scenario from a set of bowties and assesses the effectiveness of the barriers identified on the original bowtie. Specific questions are asked per barrier about the reasons of the failure. These findings are stored on a barrier level. If this process is repeated, the bowtie will accumulate barrier failure data of multiple incidents in a single diagram. This information helps the organization to identify the strength of their barriers, which in turn facilitates risk-based decision-making.
Some incidents require in-depth investigations and a registration only is not enough. However, this registration can be used as a starting point for the incident analysis. Doing barrier-based incident analysis allows you to learn from barrier failures and improve their performances in order to prevent similar incidents from happening. This incident data together with the SIR data can be linked back to the bowtie diagram in order to spot the strengths and weaknesses of your visual risk assessment.
SIR is a continuous process which is more than a reporting system. The reporter does not require knowledge about the bowtie methodology, while incident managers receive valuable insight to their pro-active risk assessment.
