Application of the BowTie Method in Accident Analysis: Case of Kaziwiziwi Coal Mine

J. Matsimbe, Steven Ghambi, Abdul Samson
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Abstract

A BowTie is a diagram illustrating proactive and reactive risk management at any working environment. This case study applied the bowtie method to provide a simple visual analysis of the hazards that caused fatal accidents at Kaziwiziwi coal mine on 2nd November 2012 and 15th November 2019. Two coal miners were killed on the spot and others injured due to failure of a bucket hoisting system and hanging rock fall. The authors demonstrated that the bowtie method is an effective visualization tool that can be used to analyze the hazard, top event, threats, consequences, barriers and escalation factors of mining accidents; and therefore give an overview of everything not wanted around a certain hazard. Mining companies in Malawi will apply this new knowledge to proactively conduct situational audits of unwanted scenarios, and identify barriers to prevent accidents from happening so far as is reasonably practicable. In addition, the Department of Mines will find this bowtie visualization tool useful when carrying out accident analyses in the future which in turn will promote safety awareness and policy development in the mining industry, and suggest ways on how to keep the normal but hazardous aspects from turning into something unwanted.
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蝴蝶结法在事故分析中的应用——以卡兹维兹维煤矿为例
领结是一个图表,说明在任何工作环境中主动和被动的风险管理。本案例研究应用领结法对2012年11月2日和2019年11月15日Kaziwiziwi煤矿致命事故的危险因素进行了简单的可视化分析。由于斗式提升系统故障和悬挂岩崩,两名矿工当场死亡,另有多人受伤。论证了蝴蝶结法是一种有效的可视化工具,可用于分析矿山事故的危害、顶事件、威胁、后果、障碍和升级因素;因此,给出一个概览,在某个危险周围不需要的所有东西。马拉维的矿业公司将运用这一新知识,积极主动地对不希望发生的情况进行情景审计,并在合理可行的范围内确定防止事故发生的障碍。此外,矿业部将发现这个领结可视化工具在将来进行事故分析时很有用,这反过来将提高采矿业的安全意识和政策制定,并就如何防止正常但危险的方面变成不必要的事情提出方法。
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