Bow Tie Analysis
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School
Lambton College *
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Course
2193
Subject
Industrial Engineering
Date
Apr 3, 2024
Type
docx
Pages
10
Uploaded by GeneralKnowledgePolarBear28
Faculty of Business, Health & Technology Program: Quality Engineering management (QEMT)
Course Number
1402_2
Section Number
Course Title
Workplace Health and Safety
Semester/Year
1/2023
Instructor
Meisam Salahi
ASSIGNMENT No. 2
Assignment Title
Bow-Tie Analysis
Submission Date
05 Dec 2023
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Table of Contents
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Abstract
The Humboldt Broncos tragedy held on April 6 of 2018 at the intersection of highway 35 and 335, was one of the heartbreaking tragedies that had deeply wounded the hearts of many. It was a terrible accident that also shook the entire hockey community that took the life of 16 and 13 where injured. A northbound coach bus carrying a junior ice hockey team struck a westbound semi-truck that failed to stop near Armely, Saskatchewan, Canada. In order to prevent such future occurrences from happening, a Bow tie analysis methodology is been used to analyse the threats, barriers, mitigating control and consequences.
A bow tie analysis is risk assessment methodology used to visualize and analyse possible risks and its consequences and there by taking corresponding preventive and mitigative measures. this methodology is used in areas where risks and safety measures are critical. Its visual nature makes it more
easy to, identify and rectify risks, communicate complex risk scenarios to decision-makers. This methodology is capable of finding root cause of this incident and its possible solutions, so that tragedies like this never be repeated. There are human made errors, lack of safety precautions, engineering failures and lack of planning may be reflected in this issue.
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Introduction Road accidents in Canada represents a significant concern and risk to public safety and cause potencial economic impacts. With diverse landscapes, varying weather conditions, failing in traffic regulations such as speeding, distracting driving and road frustrations may induces accidents. Canadian authorities fortifying road safety through stringent traffic rules and public awareness programmes.despite these efforts, it is still a on going challenge to reduce road accidents. One of such accident was the Humboldt Broncos hockey tragedy. The collision between the Humboldt Broncos hockey teams bus and semi-truck on April 6, 2018 near Armley Saskatchewan, Canada
, was one of the heart aching tragedies in the history of Canada as well as hockey community. This incident claimed 16 lives and 13 were severely injured.
Utilizing Bow tie analysis, it will be easy visualise and analyse the root cause of this incident prevent such incidents further from happening. By analysing the factors causing the collision, assessing its aftermath and providing potential preventive measures which can be used to avoid potential tragedies in the future. The Humboldt Broncos hockey tragedy remains as one of the remainder to fortify safety of lives of many.
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Discussion
The bow tie approach is very easy to comprehend complex risks as it is a visual way of analysing effects of risks, precaution, and the mitigations that need to be implemented. Since it is a visual analysis, complex risk can be communicated more easily by the decision makers to use and train people.
The Humboldt Broncos hockey tragedy held on April 6, 2018 near Armley Saskatchewan, stealing the lives of 16 with 13 fatalities
occurred at the intersection of highways 35 and 335 consist of several reasons. One of the prominent reason is trees on the south-east side of the intersection which was vailing the view of the westbound semi-truck as well as the southbound bus. Removing the trees on the south-east side of intersection may increase the field of vision of both the drivers, as it is a more accident-prone area. Based on the bow tie analysis, it is much clear that the terrain was also a crucial factor as the roads were gravelled. Since the road were gravelled, the stopping distance of both
the vehicles has been considerably increased. Both the vehicles were equipped with anti-locking breaking system, which was ineffective in gravelled terrain. The accident was occurred at 5pm CST, and
the semi-truck was moving westbound at a speed of 100 km/h had a chance of missing the blinking red light as sun glare was directly falling on to the semi-truck drivers’ eye as it was recorded as a sunny
day. The possible way to prevent this is to provide sun protecting glasses for vehicles. Since it was winter, the overall illumination comparatively greater. Climate is also contributed a roll in this incident,
as the gravelled roads were further slippery. Modifying the roads with German anti-slippery roads fortifying with hot water sprinklers on roads as like in Japan may reduce slippery ice which enhances the grip. Over speeding and negligence is an another factor which contributed this tragedy. To prevent this from happening, installation of traffic lights, rumble strips as well as stop or stop ahead sign can be installed. Providing a dedicated trail can reduce congestion and improve field of vision.
In the below given bow tie diagram (Fig.1) demonstrates the qualitative analysis of the tragedy
with several causes , threats and preventive measure to tackle the situation further from happening in the future. 5
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Figure 1 The bow tie diagram for
The Humboldt Broncos hockey tragedy
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Conclusion
This article utilizes the bow tie analysis and its visual illustration to comprehend the qualitative analysis of the The Humboldt Broncos hockey tragedy . This gives us an idea about the events causes, preventive measures, and resulting outcomes through structural and visual representation. After the analysis it is clear that there were a lot of factors contributed the tragedy such as gravelled road, sun glare, lack of field viion, over speeding and negligence.
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References
8 Steps to using Bow Tie Analysis for Risk Management
. (2020, 07 26). Retrieved from MAny Caps Consulting: https://www.manycaps.com/blog/8-steps-to-bow-tie-analysis.html
Safely Transporting Dangerous Goods
. (2023). Retrieved from Railway Association of Canada: https://www.railcan.ca/101/safely-transporting-dangerous-goods/
Valiante, G. (2019). Lac-Mégantic Rail Disaster
. Retrieved from The Canadian Encyclopedia: https://www.thecanadianencyclopedia.ca/en/article/lac-megantic-rail-disaster
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