Construct a bowtie diagram identifying threats, a top event, consequences and controlling barriers.
Occupational Health & Safety
Critical Control Management and Bowtie Analysis for Fatal Risks
Build bowtie diagrams for fatal risk scenarios, identify genuinely critical controls, write verification criteria and report barrier health in a way that drives corrective action.
🗓️Duration5 training days
📚Content4 modules · 8 sessions
🎓On completionAccredited attendance certificate
About the programme
Course Overview
Standard risk matrices treat a fatality and a minor injury from the same activity as different points on the same scale, which is exactly why organisations with fatal risks increasingly separate them out and manage them through critical control management and bowtie analysis instead. This course teaches participants to build a bowtie diagram for a material unwanted event, working outward from the top event to credible threats on one side and realistic consequences on the other, then identifying the preventive and mitigative barriers that sit between them. Participants learn to test whether a barrier is genuinely critical, meaning its failure would materially increase the chance of the top event or its consequences, and to write verification criteria that check a barrier is present, functioning and effective rather than just documented. Sessions cover building a fatal risk register from bowtie outputs, designing critical control verification schedules that fit into existing inspection routines, and reporting barrier health to leadership in a way that drives action rather than producing another chart. Case material is drawn from generic fatal risk scenarios such as working at height, isolation of stored energy and vehicle-pedestrian interaction.
Expected Learning Outcomes
Test whether a proposed barrier meets the criteria to be classed as a critical control.
Write verification criteria that confirm a critical control is present, functioning and effective.
Build a fatal risk register from bowtie analysis outputs across multiple material unwanted events.
Design a critical control verification schedule that fits within existing inspection routines.
Distinguish a preventive barrier from a mitigative barrier when placing it on a bowtie diagram.
Report critical control performance to leadership in a way that prompts corrective action.
Who Should Attend
Health and safety professionals managing fatal or catastrophic risk exposures.
Operations and asset managers responsible for barriers that prevent major incidents.
Risk engineers building bowtie models for high-consequence activities.
Senior leaders who need to understand critical control reports to govern fatal risk.
Auditors and inspectors verifying critical controls during site visits.
Process safety and technical safety specialists in high-hazard industries.
Course Modules
Select any module to see its sessions and points.
01From Fatal Risk to Bowtie Structure
2 sessions · 8 points
Session 1Defining the Material Unwanted Event
- Select a top event specific enough to analyse, rather than a broad category like falls.
- Separate a material unwanted event from routine incidents that carry much lower consequence.
- Confirm a top event represents loss of control of a hazard rather than a consequence itself.
- Agree the boundary of a bowtie so threats and consequences do not overlap with another diagram.
Session 2Mapping Threats and Consequences
- Identify credible threats that could independently lead to the top event occurring.
- Rule out threats that are theoretically possible but not realistic for this operation.
- Map consequences ranging from contained near misses through to worst-case outcomes.
- Check that each threat and consequence pathway is distinct rather than a restated duplicate.
02Identifying and Testing Critical Controls
2 sessions · 8 points
Session 1Placing Barriers on the Bowtie
- Place preventive barriers between each threat and the top event in the order they would act.
- Place mitigative barriers between the top event and each consequence to limit its severity.
- Avoid listing a procedure or a piece of PPE as a barrier when it cannot reliably stop the event.
- Test each barrier for independence so one failure does not silently disable another.
Session 2Distinguishing Critical From Supporting Controls
- Apply criteria that classify a barrier as critical based on its effect on the top event if it fails.
- Separate a critical control from a supporting control that helps but is not decisive on its own.
- Limit the critical control list to a manageable number that an organisation can actually verify.
- Assign ownership of each critical control to a specific role accountable for its performance.
03Verifying That Controls Actually Work
2 sessions · 8 points
Session 1Writing Verification Criteria
- Write a verification statement that checks presence, functionality and effectiveness separately.
- Define objective evidence a verifier can check rather than relying on a self-reported checklist.
- Set a verification frequency that matches how quickly a barrier could realistically degrade.
- Align verification criteria with existing inspection or maintenance routines to avoid duplication.
Session 2Running Verification and Recording Barrier Health
- Conduct a critical control verification check against the written criteria on site.
- Record a barrier as healthy, degraded or failed using consistent, defined criteria.
- Escalate a degraded or failed critical control immediately rather than at the next scheduled review.
- Track barrier health trends over time to spot controls that repeatedly underperform.
04Governing Fatal Risk With Bowtie Outputs
2 sessions · 8 points
Session 1Building and Maintaining a Fatal Risk Register
- Consolidate bowtie outputs from multiple material unwanted events into a single fatal risk register.
- Prioritise fatal risks in the register using consequence severity rather than combined risk score alone.
- Update the register when a bowtie is revised after an incident, audit or process change.
- Link fatal risk register entries to the specific critical controls that manage each one.
Session 2Reporting to Leadership for Action
- Report critical control performance using barrier health status rather than lagging injury statistics.
- Present bowtie-based reporting in a format leadership can use to direct resources and attention.
- Escalate a pattern of critical control failures to a level with authority to change the underlying design.
- Close the loop by confirming leadership decisions on fatal risk are implemented and re-verified.
What the participant receives
4 course modules
A structured syllabus
8 training sessions
across 5 days
32 detailed points
Applied, detailed content
Accredited attendance certificate
On completing the programme
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