title: Organizing learning processes on risks by using the bow-tie representation.
abstract: The Aramis method proposes a complete and efficient way to manage risk analysis by using the bow-tie representation. This paper shows how the bow-tie representation can also be appropriate for experience learning. It describes how a pharmaceutical production plant uses bow-ties for incident and accident analysis. Two levels of bow-ties are constructed: standard bow-ties concern generic risks of the plant whereas local bow-ties represent accident scenarios specific to each workplace. When incidents or accidents are analyzed, knowledge that is gained is added to existing local bow-ties. Regularly, local bow-ties that have been updated are compared to standard bow-ties in order to revise them. Knowledge on safety at the global and at local levels is hence as accurate as possible and memorized in a real time framework. As it relies on the communication between safety experts and local operators, this use of the bow-ties contributes therefore to organizational learning for safety.
authors.affiliation: Ecole des Mines de Paris, 06904 Sophia-Antipolis, France. chevreau@cindy.ensmp.fr
authors.forename: F R
authors.initials: FR
authors.lastname: Chevreau
authors.forename: J L
authors.initials: JL
authors.lastname: Wybo
authors.forename: D
authors.initials: D
authors.lastname: Cauchois
mesh_terms: D000062:Accidents, Occupational / Q000517:prevention & control*; D015984:Causality; D002617:Chemical Industry / Q000458:organization & administration / Q000592:standards*; D003663:Decision Trees; D004345:Drug Industry; D004781:Environmental Exposure / Q000517:prevention & control; D004868:Equipment Failure; D005062:European Union; D005602:France; D017408:Guidelines as Topic; D015386:Hazardous Substances; D006801:Humans; D007318:Inservice Training; D017146:Models, Organizational; D018794:Problem-Based Learning; D018570:Risk Assessment / Q000379:methods*; D017751:Safety Management / Q000379:methods*
chemical_list: D015386:Hazardous Substances