Instructions for Completing a Hazardous Event Bowtie

Instructions for Completing a Hazardous Event BowTie

Safety cases are documented evidence that one has completely assessed potential hazards. They cross departmental boundaries as a way of tying together a system by which we control our organization.

The steps below will guide you through documenting this process.

1) Save the emailed documents to your computer. Do not forget to save your work as you go along. 2) Open the first hazardous event Excel form – notice there are two (2) tabs at the bottom of each Excel form. 3) Use the Word document risk assessment matrix to risk assess the event. This risk assessment is the Bristow standard probability vs. severity matrix. 4) Place the risk assessment score on the Excel sheet below the title. 5) Use the tabs to select the “right hand side”, and enter all possible consequences that could be face should that hazardous event occur. These should be potential but also realistic. These items will include single or multiple injuries/death, loss of assets, environmental harm, reputation, etc. 6) Use the tabs to select the “left hand side”, and begin to brainstorm all possible means (threats) that could cause that event to create a negative impact on the business. Be sure to leave 6-10 spaces between each of these threats, because there will be several controls for each threat and even more escalations for each control. They will expand like a tree. If severe weather is the hazardous event, then threats could be not being aware of its approach, loose items at the base, fueling ops ongoing, aircraft ops, untied aircraft, etc. 7) After you have entered every threat you can identify, return to each threat and brainstorm the number of existing controls for each of those threats. The column to the right of controls (and again seen in the final controls column) is for a document reference. If you say you have a control, there needs to be a reference for it. Some of these may be operations/maintenance manuals, base procedures, etc. 8) You may begin to see that you may need controls that are not yet in existence. This session is to identify those, enter them in, and put them into effect. The same is true for documentation. If you leave a base, how will the next manager know what controls you have active at your base? 9) Continue with the next column on the spreadsheet, entering in ways in which may cause each control to not work (escalations), such as non-compliance with procedures, equipment not available, not paying attention, etc. 10) The next column is for additional controls on those escalations, which may be supervision, monitoring, procedure reminders, etc. 11) The left hand side tab will be complete now. 12) Open the right hand side tab. 13) If none of the controls work and the hazardous event occurs, the right hand side tab is for reactive measures. For instance, if loss of passenger control occurs, set of recovery controls may be for someone to respond to that, attract attention, stop the operation, etc. 14) Next, escalations to those recoveries, and then backup controls if possible or necessary. 15) Consequences have already been entered. 16) For mitigation, this is assuming an accident has occurred with one of more of the consequences happening. The mitigation column is for how you react. In this column, emergency procedures are entered, base action plans, etc. 17) At this point, the BowTie for that hazardous event is complete.

The BowTie is a live document that should be used to guide you. The information you enter should be in place and actively practiced, as this is the comprehensive way you have stated your staff controls these events.