Bowtie analysis in aviation safety management systems (SMS) databases is a fairly new tool that is catching on with great success in aviation risk management programs. There are not many SMS databases that have the bowtie, but if you want a great risk management tool seamlessly incorporated into your hazard and risk register, then getting an SMS database with the bowtie is a great choice.
Simply put, the bowtie is one of the most effective risk management tools currently available to aviation safety managers. It ties together previously distinct risk philosophies and tools into a single purpose.
A few critical risk management items that the bowtie incorporates are:
Using the bowtie will expose all of these elements in one way or another, and it does so in a single, concise visual chart. The bowtie relies on 4 elements to do this (explained more below) which are:
The bowtie will appear different from organization to organization as companies will create bowties that functionally and visually suit their needs best. Some organizations will use a simplified version of the bowtie, and others will use much more complex verbose bowties. They may even appear different each time you use them depending on what your goals are.
The explicit purpose of the bowtie is to show the flow of a safety event including:
When a bowtie is conducted in full, it gives a visual picture of the entire issue, from root causes to impacts, including the risk control holes along the way.
The implicit purpose of the bowtie is to expose the important elements of your system, namely key risk indicators, which may also be your key performance indicators (KPIs), and weak controls. Without the bowtie, piecing all of these elements together in a way that shows how they function in context can be difficult and error-prone.
Perhaps I am zealous about its potential uses, but I have seen it successfully employed for:
The list goes on, but you get the idea. It is versatile and suited for many uses. Aviation service providers that adopt the bowtie tend to – if they use it right – employ the bowtie with different goals for different uses.
To this end – though I have not seen it done in practice yet – I strongly advise that when you perform a bowtie analysis you should write a “purpose” or “goal” at the top of the bowtie. I recommend this for three reasons:
You could establish ahead of time, for example, 3 or 4 different goals you might have when using bowties. For example, “Hypothetical safety case analysis,” “Safety incident analysis,” “Financial Impact Analysis,” and so on.
Creating bowties is actually fairly simple as long as you follow the basic process and understand why you are performing it. It goes like this. You have some kind of scenario, real or hypothetical. You need to:
This top-level event will be the main “risk” or worst credible "risk scenario" related to:
For example, this would be the point at which “The driver loses control of the car,” or “The aircraft suddenly loses altitude.”
It’s important not to confuse the Top Event with downstream events or Impacts. Just remember that your Top Event is the point or "incident" at which loss of control occurs.
It’s extremely important to make sure your root causes are accurate because the root causes are the threats around which you will create risk controls. Too often people confuse weak controls (e.g. “lack of training” which is actually a weak control) with root causes (better would be “Human Error”).
The best indication that you have arrived at a root cause is that the threat is an ACTIVE verb as opposed to a static, negative “lack of X” or “no Y” noun. Moreover, when you get to a spot where your answer to “But why?” is simply “Because it is,” then you have probably found one root cause. For example, the car lost control. But why? Flat tire. But why? Nail in the road – and there is no answer to this. We found one good root cause: “Road debris.”
To get from your Top Event to impacts, you will want to see the interim events that culminated in the impact. To do this simply ask “And then” about your Top Event and subsequent events. The impacts should be clear when you get there because they are the outcome and “output” of the issue.
We spent a lot of time here already, so here are a few tips when conducting bowtie analysis in your aviation SMS:
A common data management problem for most aviation SMS under one thousand employees is that their data is scattered across multiple systems, whether they are:
SMS Pro has all the tools necessary to manage a compliant SMS. Furthermore, you can use the bowtie analysis tools as well as:
To see this aviation SMS database in action, please watch these short demo videos to determine whether we are a good fit for your company.
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Last updated November 2024.