1690 control effectiveness and/or the probability of the control to fail under demand. ● Obtain information on the incident that describes what happened ● If recurring event (rather than novel event), identify the material unwanted event using taxonomy of material unwanted events. Table 1 shows the taxonomy collected by the author over the past 15 years of analysing high-risk industrial accidents. ● If recurring event, obtain the bowtie for the related material unwanted event. If novel event, build a bowtie that identifies all relevant causes and consequences as well as the suite of controls that should be implemented to prevent and mitigate the event to ALARP levels. ● Analyse the incident information to identify which of the controls listed on the bowtie were o Present and effective. o Present but ineffective and if available the reasons for it being ineffective. o Absent and if available the reasons for the absence. Understanding the reasons for ineffective and absent controls can help to define key components of performance specifications. ● Collate results to highlight the percentage of incidents that were attributable to the failure of the control (i.e the control being ineffective or absent). ● If analysis involves high potential incidents (HPIs) – collate results to highlight the percentage of incidents that were arrest with controls that prevented worst outcomes and those where luck prevented the worst outcomes. Also highlight the percentage contributions of those controls that were effective in preventing the incident from being worse. ● Review analysis to identify from the evidence which controls are crucial in preventing fatalities and have this analysis critiqued but local experts and subject matter experts to inform local critical control selection as it is important to not overlook critical controls that are effectively working and thereby preventing events as these will not show up in incident data. Table 1 – Taxonomy of Fatal Mining Events Hazard/ Risk Major unwanted event (bowties should focus on these) Subordinate unwanted event scenarios Mobile plant/ vehicles Unsafe operation of land transport vehicle/mobile plant Vehicle-vehicle collision Vehicle-pedestrian collision Vehicle-infrastructure collision Vehicle-environment collision Single vehicle crashes over edge Single vehicle fire Unsafe operation or interaction with aircraft Plane crash - in air Plane crash - on ground Unsafe interaction with manned plane/drone Unsafe operation or interaction associated with watercraft Watercraft crash with other craft/object Single watercraft overturn/sinking Unsafe interaction with manned watercraft/UAV Unsafe operation or interaction with rail track vehicles Train/track vehicle crash with other vehicle Train/track vehicle crash with pedestrian Train/track vehicle crash with animal/object Single vehicle derailment Elevated work Person and/or object exposed to falling from height Person falling from height Person falling over edge/into void
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