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Adding information that examines how the controls may be degraded is an area where the bowtie
excels. It allows for the inclusion of a level of detail entirely appropriate to the management of
controls. In bowtie these are known as escalation factors.
In our driving a car on a busy motorway example, an escalation factor would be the driver
lacking the knowledge of how to counteract the tyre blow out, therefore the driver not appreciating
the need to steer into the skid to keep control.
A condition that
leads to increased risk by defeating or reducing the effectiveness of controls
(a control decay mechanism).
Controls are seldom
100% effective and history teaches us that they do fail. We need to give
consideration and understand the factors that cause this to happen.
factor is a condition that leads to increased risk by reducing the
effectiveness of controls. An escalation factor cannot directly cause the top
event or consequence rather it increases the likelihood that the scenario will
progress because the associated control will be degraded or fail.
Escalation factors need to be credible and significant.
Incorporate lessons learned from incidents and accidents. Safety occurrence reports normally
identify ‘contributory factors’.
Escalation factors should not cause the top event (in this case they would be threats).
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