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Driver loss of attention (due to phone, controlling radio, fatigue, eating etc.

These are Threats, they cause the central Top Event

The Hazard is the potentially dangerous aspect in your organisation

Unwanted scenarios
These are Consequences, they are the different scenarios that can result from the Top Event

Driving a car Intoxicated driving

BowTies give you an overview of all the scenarios that you do not want to happen, centered around the Top Event

Crash into other car or motionless object resulting in injury

Blowout (tire) Crash into deep water resulting in confined space

Unexpected manoeuvre from nearby car

Losing control over the car

Hitting a pedestrian/cycli st Slippery road conditions Vehicle roll-over

Uneven road surface

Poor visibility (external)

Controls can be proactive, preventing or stopping a scenario before it develops into an uncontrolled state Escalation factors weaken the integrity of a Control
Driver needs to communicate urgently

Controlling those scenarios


Controls can also be reactive. They get you back to a controlled situation once control is lost.

Driver loss of attention (due to phone, controlling radio, fatigue, eating etc.)

Limit mobile phone use in car

Regular driving breaks

Escalation Factor Controls control Escalation Factors


Driving a car

Provide hands free set

Head rest adjusted to appropriate height

Wearing a seatbelt

Crumple zone

Airbag

Crash into other car or motionless object resulting in injury

Intoxicated driving

Periodic medical examination for professional drivers

Breath alcohol ignition interlock device

Agreeing on a designated driver

Forgetting/refus ing to wear seatbelt

Blowout (tire) Tyre integrity system Defensive driving

Losing control over the car

Competence in confined space rescue

Crash into deep water resulting in confined space

Unexpected manoeuvre from nearby car Adjust car mirrors Defensive driving ABS

Impact knocks driver unconscious

Slippery road conditions

Listen to weather report and adjust driving schedule accordingly

Hitting a pedestrian/cycli st ABS External airbag

Vehicle roll-over Uneven road surface Pre-journey planning ABS Roll-over protection

Poor visibility (external) Car lights are turned on Defensive driving

Driver loss of attention (due to phone, controlling radio, fatigue, eating etc.)

Adding extra information


Limit mobile phone use in car DR Driver PE People Regular driving breaks DR Driver PE People

Driver needs to communicate urgently

Provide hands free set DR Driver PR Process

Control effectiveness can be assessed and visualised using colors.


Head rest adjusted to appropriate height DR Driver PE People Wearing a seatbelt DR Driver PE People Crumple zone EN Engineer HW Hardware Airbag EN Engineer HW Hardware

Crash into other car or motionless object resulting in injury

Intoxicated driving

Periodic medical examination for professional drivers DR Doctor PR Process

Breath alcohol ignition interlock device EN Engineer HW Hardware

Agreeing on a designated driver DR Driver PE People

Driving a car

Forgetting/refus ing to wear seatbelt

Blowout (tire) Tyre integrity system MM Maintenance Manager PR Process Defensive driving DR Driver PE People Losing control over the car Competence in confined space rescue DR Driver PE People

Crash into deep water resulting in confined space

Unexpected manoeuvre from nearby car Adjust car mirrors DR Driver PE People Defensive driving DR Driver PE People ABS EN Engineer HW Hardware

Impact knocks driver unconscious

Control types help to analyse where potential common mode failures in the organisation are
External airbag EN Engineer HW Hardware

Hitting a pedestrian/cycli st

Slippery road conditions

Listen to weather report and adjust driving schedule accordingly DR Driver PE People

ABS EN Engineer HW Hardware

Vehicle roll-over Roll-over protection EN Engineer

Uneven road surface Pre-journey planning DR Driver PR Process ABS EN Engineer HW Hardware

HW Hardware

Poor visibility (external) Car lights are turned on DR Driver PE People

People can be made responsible for Controls, and see why they are important for a safe organsiation

Defensive driving DR Driver PE People

Mapping Safety Management Systems Risk assessing Consequences


Driver loss of attention (due to phone, controlling radio, fatigue, eating etc.) Limit mobile phone use in car DR Driver PE People Activity: SCA-08 Schedule driving breaks Responsible: DR Driver PE People DR Driver Regular driving breaks

Activities & document links allow you to define how controls are put and kept in place

Driver needs to communicate urgently Provide hands free set DR Driver PR Process Activity: SCA-04 Maintain internal car safety devices Responsible: EN Engineer

Head rest adjusted to appropriate height DR Driver PE People Agreeing on a designated driver DR Driver PE People

Wearing a seatbelt DR Driver PE People

Crumple zone EN Engineer HW Hardware

Airbag EN Engineer HW Hardware

Crash into other car or motionless object resulting in injury


D4 D2 D0 D1

Intoxicated driving Periodic medical examination for professional drivers DR Doctor PR Process Activity: SCA-06 Medical examination driver Responsible: DR Doctor Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager HW Hardware EN Engineer Breath alcohol ignition interlock device

Activity: SCA-09 General car safety training Responsible: TM Training Manager

Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager

Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager

Forgetting/refus ing to wear seatbelt

Blowout (tire) Tyre integrity system Defensive driving DR Driver PE People Activity: SCA-03 Defensive driving training Responsible: TM Training Manager MM Maintenance Manager PR Process Activity: SCA-01 Inspection of car tires Responsible: MM Maintenance Manager Activity: SCA-02 Tyre pressure check Responsible: DR Driver Driving a car

Crash into deep water resulting in confined space Competence in confined space rescue DR Driver PE People Activity: SCA-05 Confined space training Responsible: TM Training Manager Losing control over the car Activity: SCA-04 Maintain internal car safety devices Responsible: EN Engineer
C4 C2 C0 C1

Unexpected manoeuvre from nearby car Adjust car mirrors DR Driver PE People DR Driver PE People Defensive driving ABS EN Engineer HW Hardware

Impact knocks driver unconscious

Hitting a pedestrian/cycli st Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager External airbag EN Engineer HW Hardware
C4 C1 C0 C2

Activity: SCA-09 General car safety training Responsible: TM Training Manager

Activity: SCA-03 Defensive driving training Responsible: TM Training Manager

Slippery road conditions

Listen to weather report and adjust driving schedule accordingly DR Driver PE People

ABS EN Engineer HW Hardware

Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager

Consequences can be risk assessed using risk matrices and then displayed on the diagram
Vehicle roll-over Roll-over protection EN Engineer HW Hardware Uneven road surface Pre-journey planning DR Driver PR Process Activity: SCA-10 Pre-journey planning Responsible: DR Driver ABS EN Engineer HW Hardware Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager
C4 C2 C0 C1

Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager

Poor visibility (external) Car lights are turned on DR Driver PE People Activity: SCA-07 General car maintenance Responsible: MM Maintenance Manager Defensive driving DR Driver PE People Activity: SCA-03 Defensive driving training Responsible: TM Training Manager

Driver loss of attention (due to phone, controlling radio, fatigue, eating etc.)

Research complian ce Limit mobile phone use in car DR Driver PE People Regular driving breaks DR Driver PE People SCA-08 (DR)

Making recommendations
Actions allow you to make risk based recommendations on how to improve safety.
Head rest adjusted to appropriate height Wearing a seatbelt DR Driver PE People SCA-07 (MM) Crumple zone EN Engineer HW Hardware Airbag EN Engineer HW Hardware SCA-07 (MM) Crash into other car or motionless object resulting in injury
D4 D2 D0 D1

Driver needs to communicate urgently

Provide hands free set DR Driver PR Process SCA-04 (EN) Improve reliability Periodic medical examination for professional drivers DR Doctor PR Process SCA-06 (DR) Breath alcohol ignition interlock device EN Engineer HW Hardware SCA-07 (MM) Agreeing on a designated driver DR Driver PE People

DR Driver PE People SCA-09 (TM)

Intoxicated driving

Driving a car

Add Forgetting/refus control ing to wear seatbelt

Blowout (tire) Tyre integrity system MM Maintenance Manager PR Process SCA-01 (MM) SCA-02 (DR) Defensive driving DR Driver PE People SCA-03 (TM) Losing control over the car Competence in confined space rescue DR Driver PE People SCA-05 (TM) SCA-04 (EN)

Crash into deep water resulting in confined space


C4 C2 C0 C1

Unexpected manoeuvre from nearby car Adjust car mirrors DR Driver PE People SCA-09 (TM) Defensive driving DR Driver PE People SCA-03 (TM) ABS EN Engineer HW Hardware SCA-07 (MM) External airbag Slippery road conditions EN Engineer Listen to weather report and adjust driving schedule accordingly DR Driver PE People ABS EN Engineer HW Hardware SCA-07 (MM) Roll-over protection Uneven road surface Pre-journey planning DR Driver PR Process SCA-10 (DR) ABS EN Engineer HW Hardware SCA-07 (MM) EN Engineer HW Hardware SCA-07 (MM) HW Hardware SCA-07 (MM)

Impact knocks driver unconscious

Hitting a pedestrian/cycli st
C4 C1 C0 C2

Vehicle roll-over
C4 C2 C0 C1

Poor visibility (external) Car lights are turned on DR Driver PE People SCA-07 (MM) Defensive driving DR Driver PE People SCA-03 (TM)

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