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The Bowtie method in safety management system: A literature review

Seyed Shamseddin Alizadeh, Parisa Moshashaei


The Bowtie method is a qualitative incorporating management system technique. The theory behind the bow tie approach can be found in the “Swiss cheese model” of Reason. The Royal Dutch/Shell Group was the first major company to integrate fully the total bow-tie methodology into its business practices and then the bowtie has become popular as a structured method to assess risk where a quantitative approach is not possible or desirable. Its essence is to establish how many safety barriers there are available to prevent, control or mitigate the identified scenarios, and the quality of those barriers.


Burgess-Limerick, R., Horberry, T., Steiner, L., 2014.Bow-tie analysis of a fatal underground coal mine collision.Ergonomics Australia.10(2).

Chevreau, F.R., Wybo J.L., Cauchois, D., 2006. Organizing learning processes on risks by using the bow-tie representation.Journal of Hazardous Materials.130, 276-283.

Couronneau, J.C., Tripathi, A., 2003. Transoft International, Implementation of the New Approach of Risk Analysis in France. 41st International Petroleum Conference, Bratislava.

Duijim, N.J., 2009. Safety-barrier diagrams as a safety management tool.Reliability Engineering and System Safety.94, 332-341.

De Dianous, V.,Fievez, C., 2006. ARAMIS project: a more explicit demonstration of risk control through the use of bow-tie diagrams and the evaluation of safety barrier performance.Journal of Hazardous Materials.130, 20-33.

December 2008. Asset Integrity - the Key to Managing Major Incident Risks.The International Association of Oil and Gas Producers (OGP).

Environmental Management Systems.,1996. BS EN ISO 14001.

Gower-Jones, A.D., van der Graaf, G.C., Milne, D.J., 1996.Application of Hazard and Effects Management Tools and Links to the HSE Case. Shell International Exploration and Production B.V.

Gifford, M., Giltert, S., Bernes, I., 2003.Bow-Tie Analysis.Equipment Safety Assurance Symposium (ESAS).

Gifford, M.J., Gilbert, S.M., 2003.The Use of Bow-tie Analysis in OME Safety Cases.Atkins Defence Systems, Barnes, I. Ministry of Defense.

Guidelines for the Development and Application of Health, Safety and Environmental Management Systems., July 1994. E&P Forum.

Guide to Business Continuity Management., 2003. BSI PAS 56:2003.

Jacinto, S., Silva, C., 2010.A semi-quantitative assessment of occupational risks using bow-tie representation.Safety Science. 48(8), 973-979.

July 2007. Active Bow Tie.A tool for displaying and improving hazard analysis and energizing safety management Risk Support, Risk Management Consultants.

July 1994. Guidelines for the Development and Application of Health, Safety and Environmental Management Systems. E&P Forum(6.36/210).

June 2004. Review of the South Island Rail Coal Route. Kellogg Brown and Root for the Land Transport Safety Authority of New Zealand, MET351-X-REP-001, Rev 1,

Kandola, B., Sullivan,M., 2003. The Use of Bow-tie Model and THESIS in the Control of Major Accident Hazards.FABIG Technical Meeting.

Lidstone, A., 1998. THESIS: The Health Environment and Safety Information System - Keeping the Management System ‘Live’ and Reaching the Workforc. EQE International Ltd, IChemE Hazards XIV, Cost Effective Safety.

Lewis, S., Smith, K., 2010.Lessons Learned from Real World Application of the Bow-tie Method.Prepared for Presentation at American Institute of Chemical Engineers - 6th Global Congress on Process Safety San Antonio.

McConnell, P., Davies, M., 2004.Safety first - scenario analysis under Basel II.Retrieved from on 02/02/2011.

March 2009. Safety Management System and Safety Culture Working Group (SMS WG) - Guidance on Hazards Identification.ECAST European Strategic Safety Initiative.

Nordgård, D.E., 2008. Quantitative Risk Assessment in Distribution System Maintenance Management using Bow-Tie Modeling.16th PSCC Conference, Glasgow, Scotland.

October2006. Health, Safety and Environment Case Guideline for Mobile Offshore Drilling Units.International Association of Drilling Contractors, 3(2).

Occupational Health and Safety Management Systems – Specification., 1999. BSI-OHSAS 18001.

Primrose, M.J., Bentley, P.D., van der Graaf, G.C., 1996.Thesis - Keeping the Management System “Live” and Reaching the Workforce. Shell International Exploration and Production B.V.

Primrose, M.J., et al., 1996.The HSE Management System in Practice-Implementation. Shell International Exploration and Production B.V.

Reason, J., 1990.Human Error.Cambridge University Press.

Sullivan, M., Kandola, B., October 2003. The Use of Bow-tie Model and THESIS in the Control of Major Accident Hazards.FABIG Technical Meeting.

Trbojevic, D.V.M., 1999. The Use of Risk Assessment to Improve Safety Management Systems in Ports. Journal of The Dock and HarbourAuthority., EQE International Ltd. 79, Nos. 889-892.

The UK Financial Reporting Council Combined Code on Corporate Governance., 2003.

Weaver, R.A., Acfield, A.P., 2012. Integrating Safety Management through the Bowtie Concept A move away from the Safety Case focus Air services Australia GPO Box 367, Canberra 2601, 145.

Zuijderduijn, C., 2000. Risk Management by Shell Refinery/Chemicals at Pernis, The Netherlands.EU Joint Research Centre Conference on Seveso II Safety Cases, Athens.

Guidelines on Tools and Techniques for Hazard Identification and Risk Assessment. Petroleum and Natural Gas Industries - Offshore Production Installations- ISO 17776.

Victorian Work Cover Authority, Major Hazards Division, Major Hazards Facilities Regulations Guidance Note 14. Safety Assessment under the Occupational Health and Safety (Major Hazard Facilities) Regulations,

Demonstrating How Hazards Are Being Properly Managed. RISKworld, The Newsletter of Risktec Solutions Ltd(1).

Generic Safety Assessment for ATC Surveillance using Wide Area Multilateration., EUROCONTROL. EATMP Infocentre: BrusselsRetrieved from ,0Generic%20WAM%20Surveillance%20Safety%20Assessment%20v6-0.pdf on 02/02/2011.

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