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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters

Put a bow on it

MARK OGILVIE describes how teaching all staff a simplified version of bow tie analysis has promoted a common understanding of risk.

Perhaps you think bow tie analysis is something of a black art, best left for the use of big oil companies, engineers or health and safety professionals. If so, then you’re probably where we were until 18 months ago.

Following three fatal accidents on our farms in a year, Pāmu Farms of New Zealand (the brand name for Landcorp) radically re-thought every aspect of our safety culture. Part of that process saw us adopt the bow tie methodology, not just as a positive tool for health and safety risks but also for use in general business planning.

The catalyst for this adoption was the safety leadership training provided to all staff in 2017, delivered in conjunction with Wilson Consulting Ltd and the Pāmu Academy, This training focused on risk management and the role of controls in making safety decisions. Significantly, the training simplified the bow tie process to a level that was appropriate and understandable for all employees, regardless of where they sit in the organisation.

This allowed line managers and their teams to have a common language and understanding around cause, effect and controls.

Pāmu’s work with Wilson Consulting also focused the company on eight critical risks.

For each of these we held bow tie workshops which established the causes and the preventative and mitigating controls around these risks. This provided managers and staff with a better understanding of the controls needed to reduce harm around the use of vehicles, plant and animal handling that accounted for 78% of the company’s recorded incidents and near misses. Pāmu has since completed other bow ties for the use of shared roads and exposure to chemicals – all risks that were highlighted by staff through Pāmu’s worker safety forum.


Key to the success of these bow ties is their simplicity. We have not adopted the sophisticated software approach of recording and collating controls. While that is a comprehensive way of maintaining information around risks and controls, we have adopted an abridged approach which enables line managers to easily identify causes and risk control management for their own operations (without affecting the overall integrity or value of the bow tie methodology).

The demystification of the bow tie model has led to an acceptance of the method as a useful tool at each level of the company. For example, Pāmu now has three levels of safety investigation, depending on the severity of the incident or near miss. Each of these uses a bow-tie appropriate to the incident.

At the highest level is the Business Investigation, used for notifiable events or high potential near miss incidents, and reflects an ICAM analysis. These are normally completed by the health and safety team or senior managers and include bow ties in the conventional sense to identify which controls failed and which ones worked.

At the next level down, line managers use a simplified investigation format to look at injuries and medium potential near miss incidents. The bow tie in this case is a simple diagram that records two or three key controls to illustrate lessons that may be applicable for other farms.

At the lowest level, farm managers use only the simplified bow tie diagram itself to examine first-aid type injuries and low potential near misses with their farm staff. This investigation technique is particularly effective in discussing incidents at team toolbox meetings.

Additionally, we have used the results of the critical risk bow ties to give our executive team members “cheat sheets” to support their observations when visiting farms, providing the visitor with an awareness of the controls applicable to the respective risk along with a series of questions they can ask to identify how people are managing these risks.


An unexpected but pleasing consequence of the formal introduction of bow ties has been the adaption of the methodology by line managers as a general planning tool. Some farms have created white-boards with the bow tie template for problem-solving operational issues. For example, a number of farms used bow ties prior to the peak activity period in July. By using the bow tie diagram they are able to identify how fatigue could lead to work-place accidents. They then discuss subjects like nutrition and energy levels at work and how to help staff cope with stress which comes with the busy period.

Feedback from managers and staff indicates the bow tie diagram is providing a simple, clear visual planning tool for this exercise. The key advantage is that all staff can contribute to the development of the bow tie and increase their understanding of safe work practices as part of the cause and effect discussion. Their awareness is maintained when the diagram is kept in team rooms and referred to during the course of the activity.


Two key lessons stand out from our experience with the adoption of the bow tie methodology. The first is to simplify the process to make it accessible to managers and staff alike. The second is the key role bow ties can play in raising the awareness of risk management and controls at all levels of the organisation.

From Pāmu’s experience, it became clear that big, multi-layered bow ties can intimidate the users, whether they be executives or general hands. Keeping it simple means everyone can understand the concept and use it.

Mark Ogilvie is acting health and safety manager with Landcorp Farming Ltd.

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