Famous Barriers within the Bowtie Levels Analysis: Creating Middle and Senior Management Understanding about the Relative Importance of Management Activities

摘要

The paper discusses extending the use of the Frequency Adjusted Measured Effectiveness (FAME) methodology (SPE-190633) to the operational, organisational and cultural levels in bowties. The method enables risk management functions to steer senior management toward effective management actions at the middle management level, allows greater understanding of the cultural and regulatory factors impacting those management activities, and provides a clearer understanding of where the most important impact can be achieved through organisational change. This paper develops Bowtie concepts by applying FAME (SPE-190633) to the bowtie ‘levels analysis’ (SPE 127180). The ‘levels analysis’ defines the barriers at the levels of a bowtie as the workplace (Level 1, L1), organisational (Level 2, L2), and cultural and regulatory factors (Level 3, L3). FAME quantifies the relative importance of barriers within bowtie systems as a whole. The paper uses these concepts to provide simple ways of providing middle and senior managers with understanding about how well their risks are being managed. The disconnect between what management does and what actually needs to be done has been shown to contribute strongly to accidents. Without the support of analytical tools to steer decision-making, management activities are generally prioritised on an ad-hoc basis, usually guided by an individual manager's experience as well as senior management pressures. This can lead to important management activities not being conducted as rigorously as they require. The Levels Analysis improves understanding of the middle and senior management roles involved in the management of the risks of the operation, while the FAME methodology supports the understanding of the relative importance of those activities, allowing prioritisation. When applied this allows risk-based decision-making to be applied not only to frontline tasks but also to higher-level management functions. This approach, by looking at all the management functions controlling barriers, allows risk managers to communicate clearly the priority safety critical management functions require to senior managers. This allows the conversation to change from "why wasn't he wearing his gloves?" to "how did we not have a start-up audit on this contract?" The emphasis is moved from immediate causes that are hard to control to factors that are within the span of control of middle and senior managers. This paper introduces a method for clearly communicating to middle and senior management what their own critical management functions are, which are most important and what they can and should be held accountable for.