Shailesh Purohit Hitchhikers Guide To Bowties

Hitchhiker's Guide to Bow Tie Risk
Analysis for the new comers to Major

Accident Hazard Industries
Shailesh Purohit: CMIOSH/ AMIChemE
Process Safety Engineer CLH Pipeline System Limited
Acknowledgments
• I wish to thank CLH-PS Limited for permitting me to conduct this

workshop.
• I with to thank Risktec and CGE for their permission to use some of their
training materials. Further information is available from their websites:
• http://www.risktec.co.uk/
• http://www.cgerisk.com/
• Last but not the least, I wish to thank the Hazardous Industries Group
(HIG)Committee and IOSH Staff for their help and guidance in presenting
this BowTie workshop.
160429 Hitchhiker's Guide to Bow Ties r0.pptx Hitchhiker's Guide to Bow Ties 2
Who are we?
• CLH Pipeline System (CLH-PS) Ltd is an oil product logistics

company wholly owned by CLH that carries out its activities in the
United Kingdom.
• CLH-PS provides its services to several military facilities and some
of the main airports in the United Kingdom. It is the main fuel
pipeline and storage facility network in that country.
• Its infrastructures consist of a pipeline network of 2,000
kilometres, which represents 50% of the British pipeline network,
and 14 storage facilities with a total capacity of over one million
cubic metres.
• CLH-PS supplies 35% of the demand for aviation fuel in the United
Kingdom. Heathrow, Gatwick, Stansted and Manchester are
among the main airports it supplies, in addition to other 10
regional airports that are supplied by road tanker.
• CLH Pipeline System is currently carrying out a major
modernisation programme in its infrastructures with the aim of
improving safety and efficiency and reducing costs.
Introduction
• This presentation is to provide a brief overview of a “Bow Tie” Method”

of Analysis of HSE Risks for your Organisation for threats that may lead
to loss in terms of major accidents occurring.
• It is your expertise that will drive the workshop and achieve the goal of
identifying risks and coming up with potential ways of minimising or
even eliminating these risks.
• So…. let this not be a death by power point presentation but a lively
interactive session with lots of interruptions and fun 
Outguess me
Some definitions/ terms that will be used
• What is a Hazard?
• Top Event?
• Threats?
• Consequences?
• Barriers (Controls)
• Escalation Factors
11
160429 Hitchhiker's Guide to Bow Ties r0.pptx Hitchhiker's Guide to Bow Ties
Hazard
• Hazards are shown as per the

figure in the right hand side in a
Yellow/ Black Box
• An example for this BowTie
Workshop is “Product Storage”
Top Event
• Release of a “Hazard” leads to a

“Top Event” which is usually a loss
of control event.
• For your BowTie, it is shown in the
right hand side in a Red/ Yellow/
Orange Circle
Threats
• Typical HSE Threats are:

 Internal Corrosion
 Overfilling
 Lack of Maintenance
 Asset Impact by vehicles
 And so on….
 These are shown on the BowTie
within Blue Border boxes
Controls or Barriers
• Controls or Barriers are designed to neutralise the “Threats” and stop

the Top Event (Loss of control) leading to a Consequence.
• Barriers may be colour coded (for example “green” for good/ effective
control that does not rely on procedures alone) as shown in next slide
Barrier (Control) Effectiveness
Control (Barrier) Effectiveness Key
Effectiveness Is it used? Does it work/ is it effective/ human Bow Tie Control
Is it in place? dependency? Colour
Controls is very likely to work when required,

Good Always
little human involvement
Control is likely to work when required, active

OK Mainly
human involvement
Control is either non-existent or has a low

chance of working when required, continuous
Poor Rarely
human involvement, very complex. Actions are
raised for all barriers where effectiveness is poor
Escalation Factors: Shown inside Yellow Box
Consequences
• Examples of a consequence of the

Hazard being related due to loss of
control could be:
 Pollution
 Fire
 Prosecution by Competent Authority
 Serious Injury
• Consequences are shown inside
Red Boxes
Summary: A Completed Bow Tie looks like this
QUESTIONS?
Warm Up Exercise for the Bow Tie Workshop – 5 minutes to set the scene
Car Journey from home to work
• Consider a car journey from home to work

• Here the hazard is “driving”
• Top Event is losing control of your car whilst driving
• Threats can be listed as………
• Consequences can be listed as ……..
• What are your risk control barriers on each side – preventive and
mitigatory? ...............
• Are there any escalation factors?
Case Study/ 1
Hypothetical Site Description
1. The site is a Liquid Chemicals bulk storage and blending facility located by the side of a major Estuary
and has a series of 2 x 4 above ground Mild steel tanks within 2 separate concrete bunds. Each tank has
a working capacity of 5000 M3 and the bunds are adequately sized to EA Containment Policy Score Card
guidance. The chemicals are compatible and will not react if mixed accidentally in both the bunds.
2. Bulk chemicals are supplied and stored in these tanks via road tankers from the Humber Terminal and
have a flashpoint of 30 C ( ) and are environmentally toxic ( ). These would cause severe
pollution if released to the waters. They are not toxic or corrosive according to the CLP Classification
criteria. These properties bring the site into the scope of COMAH 2015 as an Upper Tier installation.
3. Site drains are split into surface drains which go to the estuary via an interceptor and foul drains which
go to the on-site sewage treatment plant and then into Water Authority sewers under a consent to
discharge permit.
4. There is no fire fighting provision on the bulk tanks or the bunds and the site relies on Fire Rescue
Service attendance. Site operates from 6 AM to 10 PM in two shift patterns Monday to Friday and no on
site security presence. There is CCTV monitoring by external Party who would call out On Call Duty
Manager.
Case Study/ 2
Bow Tie Construction Steps
• Various steps in conducting the Bow Tie analysis are:

1. Identify the hazard, top event, threats, barriers (controls) and
consequences. (It is suggested that storage of bulk hazardous chemicals
is the hazard to consider for this case study.
2. Secondly, loss of containment is the Top Event for this study.
3. Threats & consequences are identified in the next slide. What you have
to discuss amongst your groups are the possible preventive barriers &
escalation factors for prevention on the LHS and the recovery or
mitigatory barriers & escalation factors on the RHS
Case Study/3
Threats & Consequences to consider
• Threats
1. Internal corrosion
2. Overfilling
3. Lack of Maintenance
4. Asset Impact by site vehicle
• Consequences
1. Major Accident to the Environment (MATTE)
2. Reputation loss and/ or Regulatory action
3. Claims/ increase in insurance costs
4. Serious accident to person(s)
Completed Bow Tie (After the workshop)
This will be sent out to all attendees after the event based
on the workshop findings.

Shailesh Purohit Hitchhikers Guide To Bowties

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Hitchhiker's Guide to Bow Tie Risk

Analysis for the new comers to Major

• I wish to thank CLH-PS Limited for permitting me to conduct this

• CLH Pipeline System (CLH-PS) Ltd is an oil product logistics

• This presentation is to provide a brief overview of a “Bow Tie” Method”

• Hazards are shown as per the

• Release of a “Hazard” leads to a

• Typical HSE Threats are:

• Controls or Barriers are designed to neutralise the “Threats” and stop

Controls is very likely to work when required,

Control is likely to work when required, active

Control is either non-existent or has a low

• Examples of a consequence of the

• Consider a car journey from home to work

• Various steps in conducting the Bow Tie analysis are:

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