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FOGHORN
It’s a rainy summer morning and passengers are beginning 
to board. At a glance, the gangway looks fine, but there is 
needed maintenance that hasn’t been addressed. The non-
skid surface has been degrading, and the handrail wobble is 
something the crew works around rather than report.
An elderly passenger reaches for the loose handrail, loses 
her footing, and falls, breaking her wrist. As the incident 
unfolds, the response is delayed due to crew being unaware 
of the location of the first aid kit. Unfamiliarity with the 
incident response procedures result in late U.S. Coast 
Guard notification resulting in a complaint filed against 
the operator. The hazards presented by the gangway were 
known and the gaps in the response were preventable. A 
bowtie risk assessment could have identified the hazards 
and the gaps in response before anyone got hurt.
THE BOWTIE MODEL
The bowtie risk assessment is a visual tool that maps risk 
in two directions at once. Originally developed in the oil 
and gas industry, the bowtie model has since been adopted 
across many maritime sectors.
On one side are the threats that could lead to an incident, 
on the other are the potential outcomes if the incident oc-
curs. In the middle is the incident itself, what risk profes-
sionals call the top event. The diagram gets its name from 
its shape. 
Threats and controls fan out to the left, mitigations and 
potential outcomes fan out to the right, and the top event 
sits in the center like the knot of a bowtie. Controls act as 
preventive barriers, stopping the incident from occurring. 
Mitigations act as reactive barriers, limiting the damage 
once the incident has occurred. The result is a single dia-
gram that gives you a complete picture of a risk from cause 
to consequence. (See figure 1.)
Returning to the gangway scenario, the top event is the 
passenger fall. On the left, three threats contributed to it. 
A degraded non-slip surface, a loose handrail, and lack of a 
formal inspection process.
Controls are what come between those threats and the fall 
itself. A routine gangway inspection, scheduled mainte-
nance plan, and crew hazard reporting could have prevent-
ed this entirely.
On the right side, the potential outcomes are shaped by 
what mitigations you have in place. Carrying a fully stocked 
first aid kit and training crew in the location and use of the 
first aid kit can treat an injury promptly. A documented 
incident reporting protocol ensures the Coast Guard no-
tification is handled correctly. When clear passenger com-
munication standards are in place, the situation is handled 
professionally, and the operation’s reputation is less likely 
to take a hit. (See figure 2.)
FOGHORN FOCUS
Figure 1
DIAGRAMS: SAFETY MANAGEMENT SYSTEMS, LLC 

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