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Can We Stop a Black Swan Breeding? Advances in Bowties and Critical Control Management


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Author R Mills, M Andrew and H Reynolds


As the global mining industry continues to grapple with ‘black swans’ (high consequence / low frequency events) for health, safety and environmental losses, the focus is shifting from risk assessment of these events to risk management using selected purposeful controls that reduce the risk.

Fundamental to critical control management (CCM) is a soundly based rationale for selecting the right controls for each and every risk. The approach should be based on a thorough understanding of the dynamics of the event: What causes it? How frequently will it occur? How likely is the consequence to be realised? This is typically done through a bowtie and methodical numerical risk analysis. Core to this step, then, is the structure and content of the bowtie; specifically, the analytic architecture that is used to construct the bowtie. Different architectures yield different constructions, and bowties are no different.

Although bowties for operational health and safety (OHS) hazards appear to have a common architecture, they are not generic. It is important to stress that they contain site specific information, are prepared by site based operational teams, and vary from site to site to reflect each site’s operational conditions. They are often a product of the knowledge and understanding of the operational teams involved, may be prone to human error, and potentially miss latent hazards that may have been embedded early in the planning, design or construction phase of a mine or facility, or within the mining equipment. Overcoming these deficiencies through constant re-evaluation of the risks, and challenging the content on the bowtie will help to minimise the chance that something will be missed.

This paper will cover key themes in bowtie architecture, introduce the concept of barrier models for high consequence event (HCE) bowties and present a relevant case study to illustrate the issues that determine quality in bowtie construction and critical control (barrier) selection and management.


Mills, R, Andrew, M and Reynolds, H, 2016. Can we stop a black swan breeding? Advances in bowties and critical control management, in Proceedings International Mine Management Conference, pp 105-114 (The Australasian Institute of Mining and Metallurgy: Melbourne).