Both the bowtie method as well as human factors have become increasingly popular topics in risk management. The challenge remains, however, to discover the best way to include human factors in the bowtie method. CGE has written a white paper on human factors and bowties. In this blog, we will give you a taste of what’s in that white paper.

Research questions

Why should human factors be included in the bowtie method, and if they should, how should they be included? These are the questions we try to address. To properly answer these, we draw inspiration from ideas from Shewart and Borman, later popularized by Hollnagel in his Safety- I and Safety-II thinking:

Vision 1

“A Safety-I approach presumes that things go wrong because of identifiable failures or malfunctions of specific components: technology, procedures, the human workers and the organizations in which they are embedded. Humans—acting alone or collectively—are therefore viewed predominantly as a liability or hazard, principally because they are the most variable of these components” (Hollnagel, 2015)

Vision 2

Hollnagel believes safety management should move from “ensuring that ‘as few things as possible go wrong’ to ensuring that ‘as many things as possible go right’. We call this perspective Safety-II; it relates to the system’s ability to succeed under varying conditions. A Safety-II approach assumes that everyday performance variability provides the adaptations that are needed to respond to varying conditions, and hence is the reason why things go right. Humans are consequently seen as a resource necessary for system flexibility and resilience” (Hollnagel, 2015)

Vision 3?

This dichotomy in thinking is also prevalent within bowtie and human factors thinking. The question is not, should we include human factors in bowties, but where should human factors be included within the bowtie framework. The debate is primarily about whether human factors can appear as ‘threats’ and/or ‘escalation factors’ in the bowtie methodology. Proponents of including human factors in bowtie as both a threat and escalation factors are associated to Safety- I thinking. Proponents of including human factors in bowtie only as escalation factors are associated to
Safety- II thinking.


Find out more about vision 3 on Human Factors

In our paper we will argue that both these visions (related to Safety- I and Safety-II thinking) are lacking and instead a third vision should be adopted. How we get to that third vision is explained in detail in the full white paper. What are your ideas, what do you think the 3rd vision should be? Please let us know in the comments below!

Fill out the form below and find the white paper immediately in your inbox. Have you downloaded the paper and want to learn more about Bowties, Risk Management & Human Factors? Check out our Risk Management Master Class in November 2020.