What is Bowtie Analysis in Aviation SMS
Bowtie analysis in aviation SMS is an effective risk management tool for investigating serious aviation safety incidents. Bowtie analysis is useful for:
Using the bowtie will expose all of these elements in one way or another, and it does so in a single, concise visual chart.
Purpose of Bowtie in Risk Management
The purpose of the bowtie is to gather data about a reported safety issue, including establishing
- Root causes;
- Top Event (i.e., the main issue that arises);
- Impacts on an organization; and
- The relevant risk controls to the threat/event/impact.
When a bowtie is conducted in full, it gives a visual picture of the entire issue, from root causes to impacts, including the risk control holes along the way.
Step Process for Creating a Bowtie in Aviation SMS
Creating bowties is simple with SMS Pro
1 - Choose what the Top Event "loss of control incident" is
The Top Event is integrated with identified risks from the Proactive Hazard Analysis Tool (PHAT). You simply select it from a drop-down menu.
2 – Identify root causes
It’s extremely important to make sure your root causes are accurate, because the root causes are the threats around which you will create risk controls. Too often people confuse weak controls (e.g. “lack of training” which is actually a weak control) with root causes (better would be “Human Error”).
You can enter in as many root causes as is relevant.
3 – Identify consequences
Consequences are the final result and damages associated with the issue. You can list as many as necessary
4 – Identify Controls for each root cause/consequence
Finally, for each root cause you identified, and for each consequence, you document the risk control that controls the root cause/consequence. These root causes populate based on documented controls in the PHAT module – you simply needed to select it from the drop-down menu.