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Alchemy | Anatomy | Activity | Autonomy | Anarchy

July 25, 2018

When explaining bowties, I say that the Top Event (Loss of Control or Containment of the HAZARD) is 'What Keeps You Awake At Night" i.e. your (worst) fear that the Genie is now Out of the Bottle, Pandora's Box is now Open or The Gorilla is Out of the Cage (bit.ly/2OgP6Ez).

Dame Judith Hackett (bit.ly/25jrRMl) reminds us that:


"We need leaders who know what they don’t know and are willing to learn.

We need leaders who can live with a chronic sense of unease and who can spot the warning signs of complacency creeping in."

But what if you don't know what you don't know ? In this case, Ignorance is not Bliss !

The HSE investigation into Buncefield has spawned these, now famous, challenges:


  1. Do you understand what can go wrong?

  2. Do you know what your systems are to prevent this from happening?

  3. Do you have information to assure they are working effectively?

The EPC has long gone and the drawings & documents are out of date. You are new to the role and your most experienced (knowledgeable) staff have moved on or retired.


Do you really understand the:


  • ALCHEMY = Processes: Materials (Chemicals)

  • ANATOMY = Plant: Machines (Equipment & Structures)

  • ACTIVITY = People: Manpower (Competence & Capability)

  • AUTONOMY = Procedures: Methods (Automation)

If you really don't understand (or believe you understand and have to communicate that knowledge to others) how your facility functions and malfunctions then bowties offer a clear, concise visualisation of hazard scenarios with potential negative consequences on People, Planet, Plant, Production, Product & Profile due to Design, Deviation, Degradation, Discipline, Damage & Digital threats.


The text book definition of Anarchy is "a state of disorder due to absence or non-recognition of authority or other controlling system" and derives from a word which originally meant leaderlessness.

Without leadership (commitment) and controlling systems (risk management) you are likely to remain or end up in a state of disorder.

To learn more about barrier-based risk management, scenario visualisation, valuation & validation, please consider attending the CGE Network Event.
A host of industry speakers will share their experience & ideas on how to make (and keep)risk understandable and how to tackle the persistent technical & commercial hazards & challenges we face, since (to quote an obscure German patent clerk):

"We cannot solve our problems with the same thinking we used when we created them"

It's OK to fear the unknown, but better to Know Thine Enemy (bit.ly/2LpiRFm) or as Sun Tzu quotes in "The Art of War":

“If you know the enemy and know yourself, you need not fear the result of a hundred battles.
If you know yourself but not the enemy, for every victory gained you will also suffer a defeat.
If you know neither the enemy nor yourself, you will succumb in every battle.”

If you can't make the Network Event and want to know more, please contact me directly.

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