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

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. (C) 2005 Elsevier B.V. All rights reserved.