Introduction
Barrier Failure Analysis (BFA) is a pragmatic, un-opinionated, general-purpose incident analysis method. BFA is a way to structure incidents and to categorize certain parts of an incident taxonomy. The structure consists of events, barriers and causation paths. Events are used to describe a causal sequence of events that we want to prevent from cascading. This means that each event causes the occurrence of a next event. There can also be parallel events that, combined, cause the next event to happen.
The barriers in a BFA are designed to stop a chain of events. They are not necessarily independent or sufficient, as would be the case in the bowtie risk analysis tool. Since a barrier failure is presumed in this technique, causation paths are determined to explain why the barriers did not perform according to function.
The causation consists of three steps, which are respectively called Primary, Secondary and Tertiary level. These labels can be customized. Each level in the causation path can additionally be categorized to your own fit. This allows you as the flexibility to create relevant, custom categories specific to your own organizational context.
Any organization should go through an initial period of testing and iterating these categories. At some point a steady state should emerge that will capture most incidents and provide relevant insights. Whenever diversions from this structure were to occur more often, it is possible to keep this learning process alive and reconsider the initial categorization.
This 4 half-days course is designed for participants to learn how to build a timeline of events leading to incidents, then use the BFA technique to analyze the barrier states at the time of the incident. The course is highly interactive, switching regularly between input sessions using a presentation style and group work where participants will be involved in a variety of different activities (discussing, analyzing, applying, comparing, categorizing, etc.).
The course also aims to equip participants with the skills to analyze failed barriers, and to employ IncidentXP software as a platform on which to practice these skills. The software will be provided to each user to install on his/her own laptop, on a 30-day free trial basis. Bowtie diagrams will be introduced, and participants are to be introduced to the technique of linking incidents to proactive risk models, in order to improve understanding of the management of risks through learning from past incidents.
Learning Outcomes
By the end of the course, the delegate will be able to:
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Objectives
- Obtain an overview of the incident fact finding process;
- Be able to construct an incident timeline or storyboardin advance of analysis;
- Understand and apply the BFA technique;
- Be able to analyse causation for barrier failures;
- Be competent in building BFA diagrams using theIncidentXP software;
- Understand the basics of Bowtie theory;
- Be able to link BFA barrier failures to Bowties;
- Produce recommendations and reporting.
1. Incident Fact Finding and Building Incident Timelines
- Investigation and Fact Finding
- Defining the Scope
- Building the Incident Timeline
- Demo of the Incident XP – creating timeline stamps and actors
- Exercise – creating a timeline using the IncidentXP
2. The Barrier Failure Analysis Technique
- Event chaining
- Identifying barriers
- Assessing barrier state
- Causation analysis & categories
- Recommendations
- Reporting
- Step by step BFA diagram building using examples
3. Linking BFA with Bowtie – Learning from Incidents
Linking BFA diagrams with Bowties using the IncidentXPsoftware
4. Syndicate Exercises
Building incident timelines and BFA diagrams with actions / recommendations.
Who Should Attend?
This course is designed for accident investigation team leaders and team members, line managers and supervisors, contract holders, reliability and maintenance managers, HSE advisors, safety officers and supervisors, quality assurance managers, insurance assessors, regulatory officers
Training Pre-requisite
It is assumed that participants to this course are already familiar with the incident investigation process (evidence gathering, etc.) so as to enable the course to fully focus on the Barrier Failure Analysis technique to establish the underlying causes of incidents. A basic understanding of the Bowtie methodology will be useful, but not essential.