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Barrier 2
Barrier 3
Causes
Consequences
Harm /
Loss
Cause
Barrier
Barrier
Event
Cause
Barrier
Barrier
Barrier
Barrier
Cause
Barrier
(Processes, procedures to
maintain and assure / verify that
barriers are in place and
effective)
Medium
High
High
High
Medium
Medium
High
High
Low
Medium
Medium
High
One in a thousand to
one in ten thousand per
patient year
Low
Low
Medium
Medium
High
Reduced Risk
3
Low
Low
Low
Medium
Medium
One in a hundred
thousand to one in a
million per patient year
Likelihood
Risk Management
Activities and Actions
High
Initial Risk
High
High
Reduce
Likelihood
Reduce
Consequence
Severity
Low
Low
Low
Low
Medium
Low
Low
Low
Low
Low
Negligible /
Very Low
Low
(Minimal
Harm)
Barrier
Moderate
Severe
(Short Term
(Long
Harm)
Term/Perm.
Harm)
Consequence
E
Fatality
(one or
more)
Consequence
Consequence
Consequence
Few barriers
/ controls
Repeating barrier
/ control
Defined
Responsibilities
Direct link to
procedures
and requirements
This is a simple BSCATTM BowTie that presents the investigation of the root causes for failures of barriers in
an event on the cause side of a BowTie using SCAT (Systematic Causal Analysis Technique). Why barriers
on the consequence side failed are yet to be investigated. Note that only one branch on the causal side is
shown, as this was the path that lead to the event. For each barrier / control the immediate cause (green
text), root cause (red text) and the management system element that failed (blue text) are shown. This can
now be used to explain to those not undertaking the accident investigation what happened. It illustrates that
two areas of their safety management system need to be addressed, namely safety hazard identification
and evaluation and process safety leadership.
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Any or all consequences / impacts could result (multiple routes from the event)
Barriers / Controls:
- Should be independent of each other
- Stop occurrence of the risk event
- Should be equipment or activities (pieces of paper are not barriers!)
- Stop a cause or consequence of the risk event
- Reduce the magnitude of the consequence on the risk event
- Can appear more than once on the bowtie diagram, however they:
- Should appear on one side of the bowtie only (generally)
- Should appear only once on any branch in the bowtie diagram
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Workshop
Hazard
Cause
Cause
Cause
Instructions:
Place on the diagram barriers that
help prevent or mitigate the event
Consequence
Event
Consequence
Consequence
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