Abstract Incident investigation can lead to organizational learning to prevent future recurrences. There are many published investigation methods, with most driving to the management system root cause and some applying newer methods. However, these methods either do not link tightly to the facility risk assessment or are very difficult to apply, and lessons from incidents that might reveal weaknesses can be missed. This presentation explains a novel method for incident investigation (BSCAT) that combines the ideas of barrier-based risk assessment with a well-established systems-based root cause analysis method (SCAT). The method described is efficient and can be applied by a properly trained workforce, and this potentially allows every incident or near-miss event to be assessed in a consistent risk-based format. The method clearly establishes links back to the facility risk assessment and thus identifies risk pathways that are potentially too optimistic (i.e. the risk is greater than predicted), which can be due to initial optimism or degradation of safety barriers (human or hardware). Introduction to Bowtie Methodology A prerequisite for discussing barrier-based risk assessment, e.g. BSCAT, is to understand the basic concepts which underpin Bowtie barrier methodology. Bowtie or barrier-based analysis is a widely used risk assessment technique with a particular focus on assessing barrier strength and effectiveness for prevention and control of hazards from being realized. Bowtie diagrams serve as excellent communication tools and demonstrate the crucial connection between risk controls and the management system for assuring their ongoing effectiveness.

Application of barrier-based approach to enhance incident investigation

251st National Meeting (2016)

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