Challenge
The key challenge of this mission was to turn around the reluctance to risk management from overworked staff members. As they mostly saw risk management as an unwelcomed additional constraint in their already overloaded schedule. The operational teams were already so busy fixing their mistakes, that they thought they did not have the bandwidth to modify their processes.
Thankfully, senior management was very supportive of the mission, demonstrating their commitment through excellent attendance to the training sessions, and participation to the exercises by the executive directors themselves.
The leading example from the top encouraged everyone to get involved and give risk management a fair try.
We deployed a highly interactive training programme of one or two days depending on the function and needs of the groups in each audience. The programme included workshops of risk identification, risk assessment, bow tie analysis and key risks indicators.
The bow tie workshops proved to be the ones with the highest impacts. When the teams took the time to deep-dive into the ramification of causes and consequences of past incidents, they quickly identified repeated patterns that acted as common triggering factors.
The multiple bow tie analyses also revealed an imbalance between preventative and corrective controls: even though the teams were good at detecting and correcting errors, they could improve at preventing them in the first place. This finding led to a thorough redesign of the operating processes, especially in the commercial part of the business.
Equally interestingly, bow tie analyses performed with the senior management team revealed that some key losses in the past were due to either a lack of checks and balances in the governance process, or to some complacency and deviations from the strict values of the company. These findings came as a positive shock to senior executives who, from then on, made bow tie analysis mandatory for all signification incidents.
The large-scale application of the bow tie analysis in this company brought multiple benefits:
higher risk awareness;
identification of patterns of failures and common causes of operational incidents;
evidence of imbalances between preventative controls and detective controls in the operations team.
To the senior management, it gave insights into the importance of sticking to the strict ethical value of the company, as well as operating strong governance, with proper checks and balances at executive level, to improve strategic decision-making.
The systematic bow tie analysis on all major incidents allowed the firm to make the best of the lessons learned, to prevent future avoidable mistakes and improve their performance.
