The pyramid of conclusions.
Figure 110 Example a Tripod Beta diagram.
Figure 111 Possible Tripod Beta appearances.
Figure 112 Example of a BFA diagram 1.
Figure 113 Example of a BFA diagram 2.
Figure 114 BFA core elements.
Figure 115 General structure of a BFA diagram.
Figure 116 Event chaining in BFA.
Figure 117 Defeated barriers are not BFA events.
Figure 118 Barrier identification in BFA.
Figure 119 Correct and incorrect barrier identification in BFA.
Figure 120 BFA analysis.
Figure 121 Events types in a BFA diagram.
Figure 122 Example of timeline developed for the Norman Atlantic investigation.
Figure 123 Timeline example.
Figure 124 The onion‐like structure between immediate causes and root causes.
Figure 125 Benefit of RCA.
Figure 126 RCA Process.
Figure 127 Levels of analysis.
Figure 128 The Bow‐Tie diagram.
Figure 129 Bow‐Tie risk assessment and incident analysis.
Figure 130 Bow‐Tie preparation workflow.
Figure 131 From organization to critical tasks.
Figure 132 Example of Barrier Criticality Assessment.
Figure 133 Steps to identify critical barriers.
Figure 134 Example of a barrier audit.
Figure 135 Traditional audit: one element of the management system is analyzed at a time.
Figure 136 Audit barrier‐based: all elements of the management system identified as relevant to a specific barrier are analyzed.
Figure 137 General workflow of LOPA.
Figure 138 The general workflow of a survey.
Figure 139 Incident barrier states and relation between barrier state and barrier lifecycle.
Figure 140 Recommendations development and review.
Figure 141 On the left: pier with a damaged downpipe; the concrete is wet and deteriorated. On the right: a similar pier with a safe downpipe; the concrete is in good condition.
Figure 142 Effects of ageing and humidity on the concrete. The reinforcement bars are corroded and there are signs of rust on the beams.
Figure 143 Concrete spalling on a Gerber support with a consequent capacity reduction. The cause of the damage has to be searched for on a damaged downpipe on the road joint (recently substituted).
Figure 144 The spalling of concrete caused the corrosion to progress. The reinforcement bars broken due to the limited cross‐section are causing a reduction of the capacity of the girder.
Figure 145 Bow‐Tie diagram for “Local reduction of the resisting capacity of a bridge due to ageing”.
Figure 146 Employee infected with COVID‐19 virus.
Figure 147 Fire in flight.
Figure 148 BFA on food contamination (near miss).
Figure 149 Web‐based software development – Bow‐Tie.
Figure 150 IT systems protection Bow‐Tie.
Figure 151 Satellite view of Matera.
Figure 152 Matera – Piazza Vittorio Veneto. On the right: steps. Source: Google LLC.
Figure 153 Developed Bow‐Tie to assess crowding‐related risks – zooming the threats and preventive barriers.
Figure 154 Developed Bow‐Tie to assess crowding‐related risks – zooming the consequences and mitigative barriers.
Figure 155 Map to develop simulated scenarios.
Figure 156 Different levels of service.
Figure 157 Piazza Vittorio Veneto and the bottleneck in Via San Biagio, Matera.
Figure 158 Impact of the soft obstacles on the pedestrian flow.
Figure 159 Bow‐Tie Risk assessment (whole picture).
Figure 160 Helicopter loss of control Bow‐Tie risk assessment.
Figure 161 Treatment of critically ill patients.
Figure 162 Treatment of patient with pain.
Figure 163 Preparing parenterals (excluding cytostatic drugs).
Figure 164 Administration of parenterals (excluding cytostatic drugs).
Figure 165 Medication verification in handoff during hospital admission.
Figure 166 Medication verification in handoff during hospital discharge (1of 2).
Figure 167 Medication verification in handoff during hospital discharge (2of 2).
Figure 168 Administration of medicines.
Figure 169 Treatment of patients with acute coronary syndrome.
Figure 170 Administering intravascular iodinated contrast media (excluding intensive care patients).
Figure 171 Applying a central venous catheter (CVC).
Figure 172 Operating on a patient.
Figure 173 Hospitalization of vulnerable elders (> 70 years) (1 of 4).
Figure 174 Hospitalization of vulnerable elders (> 70 years) (2 of 4).
Figure 175 Hospitalization of vulnerable elders (> 70 years) (3 of 4).
Figure 176 Hospitalization of vulnerable elders (> 70 years) (4 of 4).
Figure 177 Performing surgical procedures.
Figure 178 Elaboration of the threat “external corrosion” and main escalating factors and controls.
Figure 179 Link between controls and the company HSE management system procedures.
Figure 180 BFA of Flixborough (UK) incident.
Figure 181 BFA of Seveso (Italy) incident.
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