Success in the face of uncertainty: human resilience and the accident risk bow-tie


The problem addressed

An accident bow-tie is a scenario-based cause-consequence model used for risk analysis. The bow-tie is a linear model with a focus on the negative, accidents which have already occurred. Resilience modelling is a mirror of this in being proactive rather than reactive in the face of unanticipated scenarios. It is unclear how these two ways of thinking about safety can be combined, integrating resilience concepts with classical bow-tie scenario tools.

Keywords: risk analysis resilience bow-tie

Research questions

The project aims to:
  • Identify through interviews at operational and managerial levels the characteristics of mental models of resilient people who have to manage high consequence risks on a daily basis and turn these into inspiring case studies and components for the bow-tie.
  • Incorporate resilience into the bow-tie based on the research on mental models, knowledge within the consortium and developed modelling principles, identifying the key steps.
  • Run a set of accidents through the new model to create a showcase of lessons learned to stimulate resilience-thinking in organisations.
Specific research questions:
  • How can the bow-tie model and resilience be integrated to extract additional information from accidents?
  • What Human and Organisational Factor (HOF) elements are involved?
  • What can be learned from the integration by inputting new scenarios?
  • How can safety be improved in practice by adopting the resilience approach?
  • Can resilience concepts be integrated into the classical bow-tie approaches to risk assessment, in particular to improve the characterization of the management system’s performance and the impact of human and organization factors of safety and loss of control?

Keywords: resilience HOFS

Scientific disciplines: psychology, political science

Expected outputs

The innovative (success not failure) experience-based modelling of people’s handling of uncertainty in high risk situations and incorporation into bow-tie modelling will provide a better and deeper understanding of the meaning and use of resilience to enhance success in the face of uncertainty. Inspiring cases and scenarios made from resilience interviews and lessons learned scenarios will be transformed into success models for improving policy and for industry to invest the value of human high-risk handling experience in their human capital. Resilience webinars, a workshop and a dedicated project website for will be provided for participants and associated sector organisations.

Workplan

The following activities will be undertaken:
  • Coordination meetings of the researchers in the consortium.
  • Functional specifications of the required modelling outcomes.
  • Consolidation of consortium knowledge on mental modelling and resilience engineering.
  • Development of a resilience questionnaire to support interviewing for the specific modelling requirements of the project.
  • Interviews with Safety, Health & Environment (SHE) management and operations personnel.
  • Evaluating and consolidating the interview results in order to describe mental models of risk awareness and control and to provide case studies of resilience in handling uncertainty.
  • Defining uncertainty and resilience in the bow-tie and development of the success modes of the safety barriers into the human part of the system leading to the first iteration of bow-tie success in the Storybuilder tool (this process will be carried out in parallel with the interviewing).
  • Attaching the mental modelling to success barriers in Storybuilder resulting in the second iteration.
  • Modelling accidents (25-50) in the new model to identify lessons learned
  • Various dissemination activities including developing a project website, delivering webinars, a workshop, writing journal papers and spreading a compendium of resilience cases from interview studies via participants and their sector organisations.
The approach will utilise modelling experience of a multi-disciplinary team which brings together psychology, engineering, reliability modelling, crisis management and policy development as well as expertise in practical implementation in the business processes.

Associated deliverables

Annex C: Lessons learned, near misses and unsafe conditions
Annex of final report CC BY-NC-ND published on 2015-05-12
Annex D: Success model event checklist
Annex of final report CC BY-NC-ND published on 2015-05-12
Annex E: Glossary of terms
Annex of final report CC BY-NC-ND published on 2015-05-12
Annex: resilience questionnaire
Annex of final report CC BY-NC-ND published on 2015-05-12
Annex: Storybuilder Success Bow-tie Database
Storybuilder database file CC BY-NC-ND published on 2015-05-12
Dealing with uncertainty in practice: Strengths and traps in human intervention
Intermediate report: resilience case studies Creative Commons BY-SA published on 2015-02-09
In a world where growing complexity and uncertainty are the norm, there is a need to become more resilient in handling the potential for serious accidents from industrial operations. Resilience stands for being able to successfully sustain (safe) operations in response to variation and change for both foreseen risks and the unexpected. This is different from simply being robust - being able to withstand demands - in that resilience is more about renewal and regeneration. Many current risk management systems focus on permanent designed-in measures, standard procedures and rules to avoid incidents and things going wrong. These procedures, rules and permanent measures are generally designed to cope with foreseeable risks. Interview case studies with professional mountaineers, rope access workers and people dealing with risk in the high hazard industry (e.g. supervisors, plant managers and HSE leaders) were used to better understand which mental characteristics foster human resilient intervention. Information about functioning in teams and organisational processes contributing to human resilience was also identified. The interviews were based on the four cornerstones of resilience: anticipation, learning, monitoring and knowing how to respond. In aiming for success, the case studies show that there are certain cognitive traps involved, especially when there are pressures such as time restraints and competing goals. It was found that resilient intervention needs a human mind that is ‘vigilant’, ‘aware’ and ‘switched on’. In many current industries the level of automation is high and the number of accidents is low, which does not promote these characteristics. As well as being switched on and having the ability to make good decisions and responses when the pressure is on, resilient intervention also needs time and resources for reflection when dealing with uncertainties, including hold points, second opinions and thinking together. This helps in counteracting cognitive biases in decision-making - these being unconscious automatic influences affecting thinking about possible outcomes and their chances of occurrence. Cognitive biases circumvent making judgements in a thorough, methodological way and therefore can lead to erroneous interventions. The characteristics of the resilient human mind are described using citations from the interviews. These characteristics could be used in selection, training and coaching of people that have to deal with unforeseen risks or to enhance the resilient mind in the context of teams and organisational processes. Furthermore suggestions are given on how to avoid some of the typical cognitive traps in decision making. This study can provide a basis for a shared understanding and vocabulary in which the strengths and traps of human intervention can be discussed and managed, starting from the mental frameworks of people that handle risks on a daily basis.

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Human resilience and the accident risk bow-tie: final report
Final report CC BY-NC-ND published on 2015-05-12
This research concentrates on the way professional people in operational and management roles deliver success in handling the unexpected and the organisational contexts which foster resilient behaviour. It is particularly concerned with decision making when faced with the uncertainties of managing major accident hazards. In the (petro)chemical industry major accident hazards are the potential for “...a major emission, fire, or explosion resulting from uncontrolled developments in the course of the operation involving dangerous substances... and leading to serious danger to human health and/or the environment...”.(EC 1996). Risk is defined as “the likelihood of a specific effect occurring within a specified period or in specified circumstances”. However, the risk of having a major accident is not static because the possible consequences and associated likelihoods can change from moment to moment depending, amongst others, on such factors as activities being undertaken, the presence of people, their state of awareness, environmental conditions, the condition of the controls for hazard containment and the organizational context within which the activities take place. How do people manage the uncertainty of such a changing environment?

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Participating researchers

Hans Baksteen (White Queen BV, The Netherlands)

Arthur Dijkstra (White Queen BV, The Netherlands)

Nijs Jan Duijm (Department of Management Engineering, Technical University of Denmark, Denmark)

Anne van Galen (Anne van Galen Consultancy, France)

Olga Aneziris (Institute of Nuclear Technology – Radiation Protection, N.C.S.R. “DEMOKRITOS”, Greece)

Ioannis Papazoglou (Institute of Nuclear Technology -- Radiation Protection, N.C.S.R. “DEMOKRITOS”, Greece)

Linda Bellamy (White Queen BV, The Netherlands) — project coordinator

Kirsten Jørgensen (Department of Management Engineering, Technical University of Denmark, Denmark)

Funding organizations

FonCSI (France)

RIVM (The Netherlands)

More details

Duration 2014-05 to 2015-03
Contact email
More information http://www.resiliencesuccessconsortium.com/

Information last updated on 2014-10-01.

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