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Organizing learning processes on risks by using the bow-tie representation

Abstract : The Aramis method proposes a complete and efficient way to manage risk analysis by using the bow-tie representation. This paper shows how the bow-tie representation can also be appropriate for experience learning. It describes how a pharmaceutical production plant uses bow-ties for incident and accident analysis. Two levels of bow-ties are constructed: standard bow-ties concern generic risks of the plant whereas local bow-ties represent accident scenarios specific to each workplace. When incidents or accidents are analyzed, knowledge that is gained is added to existing local bow-ties. Regularly, local bow-ties that have been updated are compared to standard bow-ties in order to revise them. Knowledge on safety at the global and at local levels is hence as accurate as possible and memorized in a real time framework. As it relies on the communication between safety experts and local operators, this use of the bow-ties contributes therefore to organizational learning for safety.
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https://hal-mines-paristech.archives-ouvertes.fr/hal-00546972
Contributor : Magalie Prudon <>
Submitted on : Wednesday, December 15, 2010 - 11:27:49 AM
Last modification on : Friday, April 9, 2021 - 4:30:06 PM

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François-Régis Chevreau, Jean-Luc Wybo. Organizing learning processes on risks by using the bow-tie representation. Journal of Hazardous Materials, Elsevier, 2006, 130 (3), pp.276-283. ⟨10.1016/j.jhazmat.2005.07.018⟩. ⟨hal-00546972⟩

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