1. Presentation Layout - Tripod-BETA
Where it fits in the HSE MS structure.
Accident mechanism using Bow-tie concept (What happened.)
Tripod Causation Path (Why it happened.)
Illustrations using Trees of recent incidents.
Benefits of Tripod-BETA methodology.
Next Steps for Managers.
Tripod-BETA Project Schedule.
List of Trained Persons.

2. Structure of the HSE Management System
Leadership and Commitment
Tripod Beta
Policy and Strategic Objectives
Organisation, Responsibilities
Resources, Standards & Doc.
Hazard and Effects Management
Corrective
Action
Planning & Procedures
Implementation
Monitoring
Audit
Corrective Action & Improvement
Corrective Action & Improvement
Management Review

3. An Accident through the Bow-tie Concept
Event Tree
Fault Tree
Harm to people ,assets
reputation or environment
BARRIERS
HAZARD
CONSEQUENCES
The ‘bow tie’ is a pictorial representation of how a hazard can be hypothetically released and further developed into a number of consequences.
The left hand side of the diagram is constructed from the fault tree (causal) analysis and involve those threats associated with the hazard and the barriers associated with each threat.
The right hand side of the diagram is constructed from the hazard event tree (consequence) analysis and involves recovery preparedness measures.
The centre of the bow tie is commonly referred to as the ‘top event’ (or first hazardous event).
Definitions:
hazard: the intrinsic property to cause harm or damage
threat: a possible cause that will potentially releases a hazard
barrier: a measure (hardware or software)put in place to prevent the release of a hazard
top event: the release of a hazard. The undesired event at the end of the fault tree and the beginning of the event tree.
recovery preparedness measure:measures that limit the chain of consequences from the first hazardous or top event. These can reduce the likelihood that the first hazardous event will further develop into consequences or provide life saving or environmental mitigation capabilities should the hazardous or top event develop further.
The bow tie is just one method of analysing hazards - it is not a mandatory requirement to use this method, but many companies find it useful.
When an incident occures it can be seen as a path through the bow tie with the barriers that have failed
Undesirable event with
potential for harm or damage
Engineering activities
Maintenance activities
Operations activities

4. Tripod Causation Path The Tripod causation path shows where to look.
by Top level decision makers
by Line management, designers, planners
by Line managers, supervisors
by Operators, maintenance crews
Fallible decisions
Latent failures
Pre- conditions
Unsafe acts
System defences
Leiden research 1988 to date
Based on study of Shell (EP) fatal accidents
Incidents are multi-causal
Decisions may be right at the time they are made, based on info available.
Circumstances within or outside mgt control can invalidate decisions
Change control often implicated
Investigation path
Accident

5. Event (Operator gets burnt)
Tripod-BETA tree
Target e.g. operator
Hazard e.g. hot pipework
Event (Operator gets burnt)
Active Failure
Precondition
Latent Failure
Failed Defence
Failed Control

6. Galfar Fatality from Loading Pipes at Marmul, Oman.

7. Galfar Fatality from Loading Pipes at Marmul - Cont’d.

8. Food Poisoning Incident at TOCO Camp in Saih Rawl

9. Food Poisoning Incident at TOCO Camp in Saih Rawl

10. Tripod-BETA Brings a structure to investigation
Helps distinguish relevent facts
Makes causes and effects explicit
Encourages team discussion
Reduces the report writing task
Helps Increase quality of corrective actions
Next Steps for Managers
Insist on Tripod for High Risk Incidents
Nominate key staff for the Sept. 15th course

11. Line Personnel Trained on Tripod-BETA
Peter Jongens OIE/2
Yaqoob Al-Kiyumi OQO/11
Khalid Al-Zeedi OQO/13
Hamoud Al-Habsi OQO/19
Mohsin Al-Amri OQO191
Mark Crowther OIT/5
Mohamed Al-Harthy XGP/15
Xavier Shelton Jeganathan OBE/1
Kamil Siad Al-Dhamri OBE/55
Sami R. Baqi Al-Lawati OBE/5
Fareed Ali Said Al-Hinai OYS
Shukry Al-Suleimany OYO/15
Said Hamed Al-Hinai OFO/1L
Abdullah Al-Khanjary OQO/14
Hanif Qadir OQO/141
Saleh Al-Hammad OBE/35B
Ali Al-Harrasi OYO/1
Saif Al-Sumry OIE/34
Gerard Flanagan GGO
Mahmood Al-Shaqsy HES6
Suleiman Al-Wardy OFS/1F
Alan Busby
Arjan Ros
Richard Kraak OIP/4