I'd like to share what we had learnt at work last week - part of our Learning From Incidents monthly series. But instead of focusing on a particular incident, this month we looked back to basics - How do we prevent incidents from happening, and if they do happen, how do we prevent them from getting worst.
We were introduced to a tool called Bow-Tie. Not to put on our tuxedo though :-) Normally Bow-Tie is used by companies involved with high risks activities to manage their Major Accident Hazards (MAH), where occurrence could likely result in multiple fatalities, significant assets loss, serious environmental issues and really affect your company's reputation.
Basic Bow Tie Diagram
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The blue box is the incident we are trying to avoid from happening - the red box on the left is the threat that could cause the incident to happen and the green box on the left is the barrier that we need to beef up to ensure the incident doesn't occur. But if it does occur, we need to prevent it from getting worst (red box on the right), so we have to make sure the green box on the right is effective.
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Bow-Tie Diagram - in simpler terms
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| Same thing, but in much simpler terms to help any layman like you and me. |
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| We used the example of road accident as the thing that can go wrong. What could cause it to go wrong, well one of it could be road conditions. The barriers can be endless but we picked up three main ones. For example we have to ensure the tires are in great condition, we follow the speed limit and we are trained to drive safely. If we have 'holes' in these barriers e.g. tires are bald, we speed and are not competent, the likelihood of an accident is high or... inevitable. |
Example of Recovery (right hand side)
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| OK... the incident actually happened, but it could get worst. In this example, Na'uzubillah (I seek protection from Allah), it could result in death. How we can avoid it from getting worst is to make sure the barriers actually work: airbags, seat belts and cars with |
The presenter, a scouser with great sense of humor offered an example where the top event is "achieving just average year end appraisal". Now, working backwards, what can we do to make sure it won't happen? Deliver more than target, be visible, more structured in our work? But when it does happen, average appraisal = lower salary increment / lower bonus and the worst that could happen is the iPad or the iPhone that we've dreamed of purchasing hedged against the potential bonus, may remain a dream. How do we prepare for that? Plan B perhaps?... that Nokia still looks useful and it's only a tenth the price of an iPhone.....
You can use whatever top event you'd like, and it can help prepare you for the worst OR better still, avoid them from happening by strengthening your barriers. Practice makes perfect. I am still working on it myself.
I hope this is of help. And Mike S, I hope your google search for bowtie will lead you here :-)
Salaam
Azmi
