case for safety - bowtie analysis
DESCRIPTION
Bowtie Analysis - case studyTRANSCRIPT
Case for Safety
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RUSSEL A REBELLO
FIIRSM-RSP WSO CSS-CSM GIFireE
• Cases for Safety are used for the Control ofMajor Accident Hazards ( COMAH )
• Applicable to sites where activities have thepotential to cause multiple fatalities orsignificant environmental damage.
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Case for Safety
• They are a mechanism to demonstrate thatall major accident hazards (MAH) relating tothe operation have been identified.
• They help to ensure that arrangements arein place to reduce the risks to a level that isAs Low As is Reasonably Practicable (ALARP).
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Case for Safety
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Case for Safety
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Part 1:The Introduction describes the scope, objectives and structureof the Case.
Part 2:Is a comprehensive description of the facilities, the equipmentand an inventory of hazardous materials.Most of these descriptions were written by offshore operationspersonnel and can be used as a reference document to guidepersonnel unfamiliar with the installations.
Part 3:Provides a description of the HSE system in place.
Case for Safety
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Part 4:
Details the audit process that systematically reviews theeffectiveness of its Health and Safety Management Systems,Standards and Procedures.
It also tracks actions arising from internal and external auditsto completion.
Note: Action tracking register to be developed to ensuremonitoring & tracking for completion.
This will include review verification audits of the Safety CriticalElements performance Standards
Case for Safety
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Part 5:
Hazard Assessment.
It provides a demonstration that:
• All potential major hazards have been identified.
• The risk from the hazards evaluated and understood.
• The controls to manage the cause and consequences are inplace.
Case for Safety
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Part 6:
Details HSE-Critical Task Catalogue & Emergency Response:
• The identification of the barriers and controls in the hazard
bow-tie diagrams is to be linked to those HSE-critical tasks
carried out prior to, or during, operations.
• It is only by conducting these tasks (design, inspection and
maintenance, operational or administrative ) that assurance
is provided that the major accident hazards will be managed.
Case for Safety
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The Emergency response plan is established as part of
identified controls to prevent the consequence/ reduce effect
of consequence.
Part 7:
Remedial action plan.
• Established to resolve any outstanding actions.
• Records improvements or shortfalls identified.
• Ensures improvements to the operations are made.
• It is the responsibility of the Case Custodian to ensure that
these actions are satisfactorily completed.
5 Hazard Assessment Process
• Step 1: Identification of major accident hazardsthrough HAZID. A HAZID is a structured brainstormingtechnique using personnel from a variety ofbackgrounds to identify and provide initial scoping ofhazards present within an operation or process
• Step 2: Bowtie Analysis - This analysis took the form ofstructured, specialist brainstorming sessions to developthe hazard “bow-tie” diagrams, which identify thecontrols to be put in place for the identified hazards.
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Bow Ties - MAH and Top Event (from HAZID)
• From the results of the HAZID, credible ‘Top Events’are identified for each major accident hazard.
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Bow-tie - Threats
• The threats that might cause the ‘top event to be realised areidentified like so:
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Bow-tie - Barriers to ThreatsThe systems in place as barriers against each threat are inserted into thethreat branch.
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Bow-tie – Escalation Factors
• Some barriers are weakened by current circumstances.
• This is termed an ‘escalation factor’.
• In this case the fact that no Responsible Electrical Person (REP)is appointed ‘weakens’ the maintenance barrier.
• However, the E&I Supervisor’s role in electrical maintenancebecomes a control against the escalation factor.
• AS DETAILED OVERLEAF:
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Bow-tie – Escalation Factors
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Bow-tie – Escalation Factors (cont’d)
• When there are no controls against escalation factors thebarrier remains weakened.
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CONTROLS INTOLERABLE
RISK HAZARDS
ALARP ZONE
HAZARDS
LOW RISK
HAZARDS
Threat Barriers Minimum of 3 Independent
effective barriers to be in
place for each identified
threat
Minimum of 2 independent
effective barriers to be in
place for each identified
threat
No acceptance criterion
because outside of scope of
hazard analysis
Recovery Preparedness
Barriers
Minimum of 3 independent
effective recovery measures
required for each identified
consequence (including one
to detect automatically
occurrence of top
event, and one other to
prevent automatically
further escalation)
Minimum of 2 independent
effective recovery measures
required for each identified
consequence (one to detect
occurrence of top event and
other to prevent further
escalation)
No acceptance criterion
because outside of scope of
hazard analysis
Escalation Factor Controls Minimum of 1 independent
effective recovery measure
for each identified escalation
factor
Minimum of 1 independent
effective recovery measure
for each identified escalation
factor
No acceptance criterion
because outside of scope of
hazard
analysis
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Bow-tie – Remedial Action Plan
• The absence of a formal verificationscheme weakens the Safety Critical statusof electrical equipment in that nobody isverifying that we maintain it to assurecontinued fitness for purpose.
• This escalation factor becomes an item inPart 7 of the case, the Remedial ActionPlan.
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Case for Safety - ConsequencesSimilarly the consequences of the ‘top event’ should it be realised areevaluated.
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Safety Critical Elements
• Systems and equipment identified in thebowties as being able to cause orcontribute to, or prevent, detect ormitigate a MAH are given SAFETYCRITICAL status.
• A list of Safety Critical Elements has beendeveloped and Technical AuthoritiesAppointed.
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Case for Safety - Conclusions
• The Case for Safety is a tool used to assure aCompany that personnel working on the offshoreassets are not subject to intolerable risks.
• Tool that helps to manage continual improvement.
• It was prepared on behalf of the offshoreworkforce and is a living document that will beupdated as changes occur.
• Please use it and share the knowledge with otherpersonnel who may not be aware of its existence.
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References:
BowTieXP v5.2–CGE Risk Management Solutionshttp://www.cgerisk.com/support-a-downloads/support/bowtie-method-support/56-the-bowtie-method
Offshore Installation Regulations ( Safety Case) 2005http://www.legislation.gov.uk/uksi/2005/3117/pdfs/uksi_20053117_en.pdf
COMAH - Safety Report Assessment Manual (V2)http://www.hse.gov.uk/comah/sram/index.htm
GAS SAFETY (SAFETY CASE) REGULATIONS 2008http://www.austlii.edu.au/au/legis/vic/consol_reg/gscr2008318/
Review of Safety Case contents at least every three years.http://www.legislation.gov.uk/uksi/1996/551/regulation/4/made