Оглавление
Luca Fiorentini. Bow-Tie Industrial Risk Management Across Sectors
Table of Contents
List of Tables
List of Illustrations
Guide
Pages
Bow‐Tie Industrial Risk Management Across Sectors. A Barrier‐Based Approach
List of Figures
List of Tables
List of Acronyms
Preface 1
Preface 2
Preface 3
Preface 4
Preface 5
Preface 6
Preface 7
Preface 8
Author Preface
Acknowledgements
1 Introduction to Risk and Risk Management
1.1 Risk Is Everywhere, and Risk Management Became a Critical Issue in Several Sectors
1.2 ISO 31000 Standard
1.2.1 The Principles of RM
First Principle – Integrated
Second Principle – Structured and Comprehensive
Third Principle – Customized
Fourth Principle – Inclusive
Fifth Principle – Dynamic
Sixth Principle – Best Available Information
Seventh Principle – Human and Cultural Factors
Eighth Principle – Continous Improvement
1.3 ISO 31000 Risk Management Workflow
1.3.1 Leadership and Commitment
1.3.2 Understanding the Organization and Its Context
1.3.3 Implementation of the RM Framework
1.3.4 The Risk Management Process
1.3.5 Relationship between the RM Principles, Framework, and Process
1.3.6 Evaluating and Improving the RM Framework
1.3.7 The Risk Assessment Phase
1.3.8 Risk Identification
1.3.9 Risk Analysis
1.3.10 Analysis of Control Barriers
1.3.11 Consequences Analysis
1.3.12 Frequency Analysis and Probability Estimation
1.3.13 Preliminary Analysis
1.3.14 Uncertainty and Sensitivity of the Analysis
1.3.15 Risk Evaluation
1.3.16 Acceptability and Tolerability Criteria of the Risk
1.3.17 The Risk Matrix
1.3.18 The ALARP Study
1.3.19 Risk Management over Time
1.3.20 Risk Treatment
1.3.21 Monitoring and Review
1.3.22 Audit Activities
1.3.23 The System Performance Review
1.4 Uncertainty and the Human Factor
1.4.1 Performance‐Shaping Factors
1.5 Enterprise Complexity and (Advanced) Risk Management (ERM)
1.6 Proactive and Reactive Culture of Organizations Dealing with Risk Management. 1.6.1 Risk Management between Fulfilment and Opportunity
1.6.2 Quality of Risk Management
1.6.3 The Pathological Condition
1.6.4 The Reactive Condition
1.6.5 The Bureaucratic Condition
1.6.6 The Proactive Condition
1.6.7 The Generative Condition
1.7 A Systems Approach to Risk Management
1.7.1 ISO 9001 (Quality) / ISO 45001 (Occupational health and safety) / ISO 14001 (Environment)
1.7.2 Industrial Safety (Major Accidents)
1.7.3 Functional Safety and RAGAGEP Standards
1.7.4 ISO 55000 (Asset Management and Integrity)
1.7.5 ISO 22301 (Business Continuity)
1.7.6 ISO IEC 27001 (Information Security)
1.7.7 ISO 19011 (Audit)
1.7.8 ISO 39001 (Road Traffic Safety)
1.7.9 ISO 19600 (Compliance Management Systems)
2 Bow‐Tie Model. 2.1 Hazards and Risks
2.2 Methods of Risk Management
2.2.1 Risk Identification
Brainstorming
Checklists
What‐if
HAZOP
HAZID
FMEA/FMEDA/FMECA
2.2.2 Risk Analysis
Fault Tree Analysis (FTA)
Event Tree Analysis
2.2.3 Barrier‐Based Methods
Bow‐Tie
2.2.4 Risk Evaluation
FN Curves
Risk Indices
Risk Matrices
Calibrated Risk Graph
Cost‐Benefit Analysis
2.3 The Bow‐Tie Method
2.4 The Bow‐Tie Method and the Risk Management Workflow from ISO 31000
2.5 Application of Bow‐Ties
Project: Disposal of a Data Center. Project description
Objectives
Project limits
Recruitment
Constraints
Operating Modes
2.6 Level of Abstraction
2.7 Building a Bow‐Tie
2.8 Hazards
2.9 Top Events
2.10 Threats
2.11 Consequences
2.12 Barriers
2.12.1 Primary Barriers
2.13 Escalation Factors and Associated Barriers
2.13.1 Secondary Barriers
2.14 Layer of Protection Analysis (LOPA): A Quantified Bow‐Tie to Measure Risks
2.14.1 How to Build a LOPA Assessment
2.14.2 AIChE CCPS Guidelines
Specificity of the Elements
Danger
Top Event
Causes
Consequences
Independence of Causes
Differentiation between Causes and Failed Barriers
Definition of Barrier Types
Definition of Criteria for the Validity of a Barrier
Correct Use of Escalation Factors and Secondary Barriers
Using Bow‐Tie as a Barrier Management Tool
2.14.3 Conditional Modifiers and Enabling Factors
2.15 Bow‐Tie as a Quantitative Method to Measure Risks and Develop a Dynamic Quantified Risk Register
2.15.1 LOPA Analysis in Bow‐Tie
2.16 Advanced Bow‐Ties: Chaining and Combination
Note
3 Barrier Failure Analysis. 3.1 Accidents, Near‐Misses, and Non‐Conformities in Risk Management
3.2 The Importance of Operational Experience
3.3 Principles of Accident Investigation
3.4 The Barrier Failure Analysis (BFA)
3.4.1 Event
3.4.2 Timeline
3.4.3 Barriers
3.4.4 Causation Path and Multi‐Level Causes
3.5 From Root Cause Analysis (RCA) to BFA
3.5.1 Introduction to RCA
3.6 BFA from Bow‐Ties
4 Workflows and Case Studies
4.1 Bow‐Tie Construction Workflow with a Step‐by‐Step Guide
4.1.1 Case Study Anatomy
4.1.2 Case Study Taxonomy
4.1.3 Acceptability Criteria
4.1.4 Definition of Risk Matrices
4.1.5 Diagram Construction
4.1.6 Versioning Activities and Track Changes
4.1.7 Terminology
4.1.8 Using Colors
4.1.9 Attach Documentation
4.1.10 Definition of Organizational Structure and Responsible Stakeholders
4.1.11 Defining Tasks
4.1.12 LOPA Analysis
4.1.13 Other Data
4.1.14 Extraction of Critical Barriers and Performance Standard Register
Barrier Criticality Assessment
4.1.15 Bow‐Tie Audit Activity
4.1.16 Work Organizational Schemes for Multi‐Site Operations
“Top‐Down” Approach
“Bottom‐Up” Approach
Hybrid Approach
4.2 LOPA Construction Workflow with a Step‐by‐Step Guide. 4.2.1 Identification of Objectives
4.2.2 Identify the Consequence to Screen the Scenarios
4.2.3 Select an Accident Scenario
4.2.4 Identify the Initiating Event of the Scenario and Determine the Initiating Event Frequency
4.2.5 Identify the Independent Protection Layers
4.2.6 Characterize the IPLs in Terms of Probability of Failure on Demand
4.2.7 Estimate the Risk
4.2.8 Evaluate the Risk and Make Risk‐Based Decisions
4.2.9 Consideration of Results
4.3 BFA Construction Workflow with a Step‐by‐Step Guide
4.3.1 Fact‐Finding
4.3.2 Event Chaining
4.3.3 Identifying Barriers
4.3.4 Assessing Barrier State
4.3.5 Causation Analysis and Categories
4.3.6 Recommendations
4.3.7 Reporting
4.4 Worked Examples
4.4.1 Local Reduction of the Resisting Capacity of a Bridge due to Ageing – Bow‐Tie Risk Assessment
4.4.2 COVID‐19 infection – Bow‐Tie Risk Assessment
4.4.3 Fire in Flight – Bow‐Tie Risk Assessment
4.4.4 Food Contamination – Barrier Failure Analysis
4.4.5 Web‐Based Software Development – Bow‐Tie Risk Assessment
Threats
Preventive Barriers
4.4.6 IT Operations – Bow‐Tie Risk Assessment
Threats
Preventive Barriers
Recovery Barriers
4.4.7 Crowding Bow‐Tie Risk Assessment
Methodology
Results
The Risk Assessment Phase Using the Bow‐Tie method
Computational Modelling of the Exodus
Conclusion
4.4.8 Military Helicopter Operations Bow‐Tie Risk Assessment
4.4.9 Patient Safety Bow‐Ties
4.4.10 Process Safety Bow‐Tie
Conclusion
4.4.11 Famous Process Industry Incidents Analyzed with BFA
4.4.12 Drug Administration Bow‐Ties
4.4.13 ThyssenKrupp Fire Investigation and Bow‐Tie
Incident Dynamics
Why It Happened
Findings
Lessons Learned and Recommendations
Forensic Engineering Highlights
Bow‐Tie Diagram
4.4.14 Twente Stadium Roof Collapse Tripod Beta Analysis
4.4.15 Water Treatment Bow‐Tie Analysis
4.4.16 Operational Experience Analysis Using BFA. Deadly Explosion in a Cold Room
The Facts
Initial Survey
Evidence Collection
Incident Analysis
4.4.17 Fire Risk Assessment for Companies Managing Multiple Assets
4.4.18 Fire Risk Assessment for Companies Managing Multiple PV Plants
Step 1
Step 2
Step 3
Step 4
Step 5
Dangerousness (P)
Vulnerability (V)
Exposure (E)
Step 6
Step 7
Conclusions
Appendix 1 Bow‐Tie Easy Guide
Appendix 2 BFA Easy Guide
Appendix 3 Human Error and Reliability Assessment (HRA) Human Errors and Violations
The Rasmussen Skills‐Rules‐Knowledge Model of Human Error
Slips and Lapses
Mistakes
Violations
Reducing the Risk of Human Error
Probability of Error and Evaluation Techniques
The SPAR‐H Method
The SLIM Method
References and Further Reading. References
Further Reading
Index. a
b
c
d
e
f
g
h
i
j
k
l
m
n
o
p
q
r
s
t
u
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