What Is the Bowtie Method in Aviation SMS Risk Management?
Long story short, the Bowtie was developed in order to gain a clearer, more comprehensive handle on every angle of risk in a situation, be it a hypothetical or real one.
In terms of risk management, the Bowtie is split into three areas:
- Causes: the various primary reasons that gave rise to the Event;
- Event: the side effects of the Causes that lead to the single Event, and then eventually to Impacts; and
- Impact: the final consequences of the Event.
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The Bowtie is called thus for good reason, as its structure, of moving from a wide number of causes, upstream to the single event, and then downstream to a wide number of consequences, resembles a Bowtie. Unlike many other risk management methods in aviation SMS, this method is suited for many different and extremely effective uses in the aviation industry. Here are 4 best uses that you should know about.
1 – Teach What Risk Is in Safety Management
In many ways, the Bowtie has grown out of confusion about basic definitions of risk. I freely admit that my own definition of risk has undergone different revisions – which is a “pat myself on the back” way of saying that I have changed my mind about what risk management really is.
And I know for sure that I am not alone in this, judging by various meetings with other aviation SMS professionals when we are looking at the Risk Assessment Matrix, and trying to make sense of exactly what it means. Rarely do all people in the room agree and arrive at the same risk assessment. It’s one of those things that is used so often, and so freely, that we forget to actually form a solid understanding of why we use it and what it implies.
Enter the Bowtie, which visually clarifies what risk is, the purpose of risk management, and what the Risk Assessment Matrix actually means. We can easily grasp the Likelihood of various causes happening at once (left side of Bowtie), quickly assess the Severity (how big is the Impact on the right side of Bowtie), and thus have a clear idea of what the dot on the Risk Matrix entails.
Moreover, when you add your Risk Controls to the Bowtie, you see Risk Managements active role (i.e. purpose) in preventing Events, or mitigating an Event’s Impact.
2 – Preventative Analysis in Risk Management
Let’s explore the above point, “preventing Events” in a bit more detail. There is something about creating a visual flow chart of risk – which is essentially what the Bowtie is – that allows you to clearly analyze how well your controls are preventing [enter your safety scenario]. The difference between using and not using Bowtie for preventative analysis is dramatic. Having recently adopted the Bowtie, preventative risk analysis has felt like going from fishing with a cheap pole and worm-bait to shooting fish in a barrel.
Preventative analysis in aviation SMS can be past events, hypothetical situations, or issues that are currently being managed. The point with Bowtie preventative analysis is to look at risk controls (i.e., barriers) between the Causes and Event, and evaluate them for how effective they are, were, or are likely to be. Ideally, the different should be pretty obvious between:
- Poor risk controls;
- Decent risk controls; and
- Robust risk controls.
Moreover, preventative analysis in risk management with the Bowtie makes this process quick and easy.
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3 – Safety Incident Management
This one is pretty obvious – though I do have a tip or two that you may not have thought of if your area already using the Bowtie method. When you are managing safety incidents, this method is extremely useful for:
- Establishing root causes;
- Clarifying the main event;
- Understanding which risk controls mitigated or contributed to Impacts; and
- Seeing an overview of the event.
On the last point, a useful tip that you are probably not already doing is using the Bowtie as a summary of each managed safety issue. The nice thing about Bowtie “charts” is that, at a glance, they display all critical information about a reported safety issue, including:
- Root causes;
- Associated hazards;
- Existing controls;
- Corrective and Preventative Actions (CPAs) assigned or needed; and
- The Impact (if any) of the safety issue on the company.
In so many ways, Bowties accomplish in one page what a summary report might take several pages to communicate.
4 – Understand Your Risk Controls
As pointed out earlier, if you really want to see the how-when-where-why-what of risk controls in your aviation safety program, simply start looking at Bowties from your reported safety issues or hypothetical scenarios. Even better, if you have an aviation SMS software or database, information about risk controls will be much more readily available.
Nonetheless, there is a difference between know what your controls are/why they are there and how they actually function in many situations. Understanding risk controls is simply understanding the relationship between causes and events, and knowing how to “get in the way” so to speak.
When you are analyzing Bowties, as opposed to simply a text readout of the same information, you actively see what your risk control barriers are barring against. More to the point, with hundreds of risk controls in your organization, the Bowtie - frankly - simply makes totally comprehending those controls just a lot easier.
Final Thoughts on Using Bowtie in Aviation SMS
The Bowtie provides an excellent graphical representation of risk and existing risk controls. This representation covers a wide span, from detecting and preventing the hazard from manifesting, all the way to recovering from an event using corrective actions.
Not every operator will benefit from the Bowtie analysis. We see that the majority of aviation service providers who work in the oil and gas industries are most comfortable adopting the Bowtie. This is due to client influence.
The oil and gas industry conducts extensive audits on their contractors. When there are audit findings centering around proactively identifying hazards and managing associated risk, auditors from the oil and gas industries recommend the Bowtie.
If you are a smaller operator with fewer than 100 employees, there are simpler approaches than using the Bowtie. This holds particularly true if you do not know how to use the Bowtie. It can be easy for inexperienced safety professionals to get lost in the Bowtie analysis as they become confused as to how deep they should conduct the analysis.
Only the minority of aviation service providers use Bowtie in their aviation SMS. You may benefit from the Bowtie. If you don't have adequate risk analysis tools, consider the Bowtie. You may become one of the minority that benefit from using this visual tool.
If you are looking for aviation risk management tools to increase your capabilities, check out these short demo videos:
Published March 2019. Last updated in February 2021.