BT
Bowtie InvestigationBarrier-based incident analysis
01

Describe the incident or hazardous scenario

Use facts: what happened, where, during which task, and which controls were present or failed.

Threats0
Preventive barriers0
Top eventNot defined
Mitigating barriers0
Consequences0
BOWTIE MAP

Controls before and after loss of control

Threat Barrier needs attention Effective barrier Consequence
PREVENTION
HAZARD
TOP EVENT · LOSS OF CONTROL
RECOVERY & MITIGATION
BARRIER HEALTH

Escalation factors

Conditions that could weaken or defeat a barrier, with a control for each one.

FOLLOW-THROUGH

Recommended actions

Prioritized improvements based on missing, weak, or dependent barriers.

QUALITY CHECK

Is this Bowtie defensible?

0%
BOWTIE INCIDENT ANALYSIS

Bowtie Analysis

THREATSPREVENTIVE BARRIERS
HAZARD
TOP EVENT
MITIGATING BARRIERSCONSEQUENCES
Barrier status: Effective Needs attention Missing
TECHNICAL INCIDENT INVESTIGATION REPORT

Barrier analysis findings

1. Executive summary

2. Incident description

3. Bowtie analysis

4. Root cause(s)

5. Contributing factors

6. Failed or missing barriers

7. Recommendations

8. Corrective action plan

9. Conclusion

This report is generated from the Bowtie information entered by the investigation team and should be validated against evidence, interviews, procedures, and field conditions before final approval.

SAVED ON THIS DEVICE

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