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ComplianceOctober 02, 2019

ISO 31000 blog series – Monitoring and review – Learning from incidents with bowties

In the previous ISO 31000 blog, we saw the inherent difficulties in incident analysis and learning from incidents.

In this software blog, we focus on how IncidentXP helps tackle these difficulties. IncidentXP guides you through the process of incident investigation.

7 steps

Notably, IncidentXP supports you in the following 7 steps:

  1. Fact-finding
  2. Timeline
  3. Event chaining
  4. Identifying barriers
  5. Assessing barrier state
  6. Causation analysis & categories
  7. Recommendations and Reporting/linking to bowtie diagram

The details on each of these steps can be found in other blogs. For the purposes of this blog, we are primarily interested in how we can improve learning from incidents, the last step.

Link incident analysis to bowties

In order to really improve learning from incidents, IncidentXP has been built to be able to be integrated with BowTieXP. That means that any incident analyses can be related back to the barriers in your bowties, giving you key performance indicators for your barriers. Here’s how it works:

Before you do any incident analysis, make sure to have created a few bowties. For instance, a bowtie about driving a vehicle:

Figure 1: Bowtie diagram driving a car, click here for a full version of the image
Carry out your incident analyses using one of 5 available incident techniques (BSCAT, BFA, Tripod Beta, RCA or Kelvin TOP-SET RCA). For instance, explaining the loss of control over a vehicle with the help of Barrier Failure Analysis:
Figure 2: BFA losing control over a vehicle, click here for a full version of the image
The astute observer will have noticed that the reported incident is similar to a specific leg of the bowtie, this allows us to link the barriers from the incident to the barriers in the bowtie.
Figure 3: Learning from incidents, click here for a full version of the image

Time to open up your software

In the software, it works like this: hover over an incident barrier and click the small pencil icon in the bottom right corner.

Figure 4: Pencil icon on the incident barrier
This will open a pop-up window. Go to the barriers tab. Here you will be presented with a list of bowties with their related barriers, available for you to choose one. In this case, we choose the ‘lane departure warning system’.
Figure 5: Edit window incident barrier
The software has now been told that the incident barrier is related to the bowtie barrier. Press OK, and right-click on the barrier, select the green arrow “go to barrier lane departure warning system”.
Figure 6: Link incident barrier to barrier in bowtie
This will take you to the bowtie where you can now select the Incident filter to get incident data reflected on your bowtie barriers.
Figure 7: Incident filter, click here for a full version of the image

As you can see, our barrier ‘Lane departure warning system’ has been called upon and analyzed in two incidents. One time it failed and the other time it was effective, a ‘near-miss’. Using this link between barriers, you can maximize learning from your incidents.

Next step, next ISO blog…

In the next and final ISO 31000 blog, we will look at how barrier-based auditing can be combined with bowties for the Monitoring and Review of the barriers.

In the meantime, we are always happy to provide an online product demonstration of the product(s) of your interest. Whether you want to know more about learning from incidents or you are curious about how to monitor barrier performance with the help of AuditXP. Request an online demonstration!

© CGE Risk. 2019 – The copyright of the content of this blog belongs to CGE Risk Management Solutions B.V.

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