case for safety - bowtie analysis

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Case for Safety 1 RUSSEL A REBELLO FIIRSM-RSP WSO CSS-CSM GIFireE

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Bowtie Analysis - case study

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Page 1: Case for Safety - Bowtie Analysis

Case for Safety

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RUSSEL A REBELLO

FIIRSM-RSP WSO CSS-CSM GIFireE

Page 2: Case for Safety - Bowtie Analysis

• 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

Page 3: Case for Safety - Bowtie Analysis

• 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

Page 4: Case for Safety - Bowtie Analysis

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Page 5: Case for Safety - Bowtie Analysis

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.

Page 6: Case for Safety - Bowtie Analysis

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

Page 7: Case for Safety - Bowtie Analysis

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.

Page 8: Case for Safety - Bowtie Analysis

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.

Page 9: Case for Safety - Bowtie Analysis

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.

Page 10: Case for Safety - Bowtie Analysis

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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Page 12: Case for Safety - Bowtie Analysis

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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Page 13: Case for Safety - Bowtie Analysis

Bow-tie - Threats

• The threats that might cause the ‘top event to be realised areidentified like so:

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Page 14: Case for Safety - Bowtie Analysis

Bow-tie - Barriers to ThreatsThe systems in place as barriers against each threat are inserted into thethreat branch.

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Page 15: Case for Safety - Bowtie Analysis

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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Page 16: Case for Safety - Bowtie Analysis

Bow-tie – Escalation Factors

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Page 17: Case for Safety - Bowtie Analysis

Bow-tie – Escalation Factors (cont’d)

• When there are no controls against escalation factors thebarrier remains weakened.

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Page 18: Case for Safety - Bowtie Analysis

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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Page 19: Case for Safety - Bowtie Analysis

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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Page 20: Case for Safety - Bowtie Analysis

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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Page 22: Case for Safety - Bowtie Analysis

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