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Introduction to Bowtie and Model Thinking

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Introduction to Bowtie and Model Thinking Risk Management Modeling and Information Sharing Beyond Maintenance Introduction to bowties and model thinking Bowtie as a framework to measure performance and share information Marko Krnjić| CGE Risk Management Solutions We make Market 80-90 Started in barrier based risk management leader Events 2004 software. In 12 industries each year 2000+ 20-30% 200+ annual growth in the last 6 clients years partners in 83 countries around the world What are we managing? Challenges Sharing data and information Speaking a common and understandable language Analyze differences and make well-founded decisions Maintain all information streams and keep data updated Are you in control? Do you understand what can go Plan wrong? Do you know what your systems are to prevent this from happening? Act Do Do you have information to assure they are working effectively? Check Reality Representation on map Risk Register Bowtie Risk Analysis Bowtie in 8 steps Scenario based story telling Use as framework and provide structure Easier to see relations and weak spots VS ! The next step Identify weak links and blind spots ✔ Improve initial decision making ✔ Take away borders – Communicate in the same language Get the right information to the right person Receive relevant information 1. All information in one place 2. Analyze and compare 3. Barrier Performance - Organizational map - Audit data - BowTie registers - Incident data - Hazard register - Maintenance data - Barrier register - Permit data - Barrier history - Hazid Module - Action Tracking - WorkBowTies - Wiki documents 4. Generate valuable information and facilitate awareness Update or alter decision based on new information ! ! ! Learn from incidents Learn proactively Aeroporto di Verona E.N.I. Servizi Aerei SpA Nayak Aircraft Services Aerolíneas Argentinas ERA Helicopters Noordzee Helikopters Vlaanderen Afriqiyah Airways FAA Norwegian Air Air New Zealand Finnair Norwegian Air Shuttle ASA Air France Finnish Commuter Airlines Norwich Airport Airways New Zealand Finnish Transport Safety Agency Oman Air Air Service Gabon Flair Air Pegasus Airlines AirTanker Services Limited Flight Safety Foundation Pellissier Helicopter Alba Servizi Aerotrasporti SpA Freebird Airlines Perth airport Alidaunia srl Genova Airport Petrobras Aviation American Airlines Hainan Air Group Praxair Amsterdam Schiphol Airport Heathrow airport Qantas ArkeFly Helibarra Taxi Aéreo Royal Australian Air Force Australia Ascent Flight Training Helicópteros Marinos S.A. Royal Air Force UK Avinor Hong Kong Civil Aviation Department Royal Netherlands Aeronautical Association Belfast City Airport HOP Brit Air Ryanair Bergamo airport Italfly SFS Aviation Bizjet Aircraft and Helicopters Management Irish Aviation Authority Shell Aircraft International Boeing Defense UK Japan Airlines Singapore Air Transport Training College Bristow Helicopter Jayrow Helicopters Sirio SpA Britair France Jazeera Airways Skyline Helicopters British Airways JetStar SkyWest Airlines Canadian Base Operators Kelowna Flightcraft SmartLynx Airlines Caverton Helicopters KLM Royal Dutch Airlines Taxi Aéreo - Lider Aviação Changi Airport Group KLM UK TFC Civil Aviation Authority UK Leonardo Helicopters Torino Airport Civil Aviation Authority Singapore Liverpool Airport Toscana Airport CASA - Civil Aviation Safety Authority London City Airport Turin Airport CHC Helicopter Luchtverkeersleiding Nederland Turkish Airlines Christchurch International Airport Malaysian Airlines UK Air Accident Investigation Board Corendon Dutch Airlines Manchester Airport Urzad Lotnictwa Cywilnego - CAA Poland COCESNA MHS Aviation Vancouver Island Helicopters Delta Air Lines Milano airport Venice Airport DGAC Military Aviation Authority UK Verona airport Emirates Airline National Helicopter Services Trinidad & Tobago World Food Programme Military Aviation Authority UK A 6 year journey towards learning from incidents and (occurrences) - First a proof of concept for LFI (1 BowTie, 72 incidents plotted) - Implementing structured Learning from incidents - (200+ Bowties, 15000 occurrences yearly) Structured analysis of occurrences in BowTieServer Single reporting system ASIMS Circa 15,000 reports per year Data is imported into BowTieServer using SIR Occurences are analysed and linked to 200+ BowTies © Crown Copyright 2016 Scenario-based Inicdent Registration Civil Aviation Authority UK Specialist Aviation Regulator providing a framework to the industry using bowtie Created the “Significant 7” – Set of bowties identifying 7 significant risks which can be used as a starting point by the players in the industry. https://www.caa.co.uk/Safety-Initiatives-and-Resources/Working-with-industry/Bowtie/ Conclusion Start small – Try to speak the same language through (a part of) the organization by adapting certain models like bowtie. Create buy in – Fit processes and structures from the organization into the model. Quantify and enrich – Collect additional data sources and combine them all together. Reach the right person – Use the available tools to reach the right person in the organization and work efficiently by providing and gathering valuable information. Continuously improve – Use information of today to be safer tomorrow. Find weak spots and fix them! Questions? Please feel free to visit our stand to elaborate and see the tools in action..
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