ROOT CAUSE ANALYSIS (BOWTIE METHODOLOGY)

INTRODUCTION FOR ROOT CAUSE ANALYSIS (BOWTIE METHODOLOGY)

This one-day training course introduces participants to Bowtie Analysis—a powerful risk assessment and management tool used to visualize the pathways of risk from causes to consequences. Participants will learn how Bowtie Diagrams help identify, analyze, and manage barriers that prevent incidents and mitigate their impacts.

The course also provides a brief overview of complementary root cause analysis tools—Tripod Beta and Why-Why Analysis—to help participants understand the broader context of incident analysis and prevention.

LEARNING OBJECTIVE

This program is designed to enable participants to learn the 

Here are the learning objectives for the two days training program; after completing this program, participants will be able to:

• Understand the structure and principles of Bowtie Analysis.
• Develop and interpret Bowtie Diagrams.
• Identify threats, consequences, barriers, and escalation factors.
• Understand how Bowtie Analysis supports risk management and safety culture.
• Gain a basic understanding of Tripod Beta and Why-Why Analysis.
• Compare Bowtie Analysis with other causal analysis methods.

WHO SHOULD  ATTEND

 Senior Management Executive.

COURSE OUTLINE

INTRODUCTION TO RISK MANAGEMENT AND BOWTIE ANALYSIS 

1. Risk management
2. Traditional vs. barrier-based risk analysis
3. Overview of Bowtie Methodology
4. Applications in industries (oil & gas, aviation, manufacturing, etc.)

COMPONENTS OF A BOWTIE DIAGRAM (1.5 HOURS)

1. Hazard: The source of potential harm
2. Top Event: The moment control is lost
3.  Threats and Consequences
4.  Preventive and Mitigative Barriers
5.  Escalation Factors and their controls
6.  Visualizing the bowtie structure
7.  Activity: Deconstruct a simple incident using Bowtie structure

BUILDING A BOWTIE DIAGRAM 

1.     Step-by-step development of a Bowtie Diagram
2.     Using checklists and team-based brainstorming
3.     Validating barriers (effectiveness, independence, auditability)
4.     Introduction to software tools (optional)
5.     Exercise: Team-based creation of a Bowtie for a case study scenario

BARRIER MANAGEMENT AND USE IN OPERATIONS 

1.     Barrier performance monitoring
2.     Linking Bowtie to Safety Management Systems
3.     Human and Organizational Factors (HOFs)
4.     Integration into daily operations and audits

COMPARATIVE ROOT CAUSE TOOLS – TRIPOD BETA & WHY-WHY 

1. 1. Tripod Beta 
      1. Philosophy: Incidents are symptoms of failed controls
      2.     Underlying concepts: General Failure Types, Basic Risk Factors
      3.     How it complements Bowtie (barrier failure vs. root causes)
   2. Why-Why Analysis 
      1.     Simplicity and clarity for identifying root causes
      2.     How to perform it effectively (iteration, evidence-based)
      3.     Use cases and limitations
      4.     Activity: Mini Why-Why exercise on a simple incident