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By following this guide, you will create a bowtie analysis diagram — from defining the top event through identifying threats and consequences, adding barriers, and assessing barrier effectiveness.
Who should read this: Safety managers and admins who perform risk analyses. Investigators and hazard owners also benefit from understanding how bowtie diagrams map causal pathways and controls.Prerequisites: Safety manager or admin role with risk assessment permissions. Familiarity with the Bowtie Analysis reference and the Risk Matrix is recommended.

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When to Use Bowtie Analysis

Use a bowtie analysis when:
  • A hazard has multiple causal pathways (threats) that could lead to the undesired event.
  • You need to visualize the relationship between threats, controls, and consequences for stakeholder communication.
  • The 5x5 risk matrix alone does not provide sufficient detail about which specific barriers are managing each pathway.
  • An investigation has identified barrier failures and you need to map the defense-in-depth structure.
  • A hazard is in the yellow (ALARP) or red (Unacceptable) zone and requires systematic barrier analysis.
For simple hazards with a single threat and clear controls, the 5x5 risk matrix may be sufficient on its own.

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Create a Bowtie Analysis

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Add Threats (Left Side)

Threats are the causal factors on the left side of the bowtie. Each threat represents a distinct pathway that could lead to the top event.
Use investigation findings, safety reports, and industry data to identify threats. Do not rely solely on brainstorming — review your organization’s historical data for evidence-based threat identification.

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Add Consequences (Right Side)

Consequences are the potential outcomes on the right side of the bowtie. They represent what could happen if the top event occurs and recovery barriers are insufficient.

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Add Preventive Barriers (Left Side)

Preventive barriers sit between threats and the top event. They are the controls that stop threats from causing the undesired event.

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Add Recovery Barriers (Right Side)

Recovery barriers sit between the top event and consequences. They mitigate or limit the damage after the top event has occurred.

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Assess Barrier Effectiveness

A bowtie with multiple ineffective barriers indicates systemic risk. Escalate to the safety committee and consider whether operations should continue under current conditions until barriers are strengthened (14 CFR 5.55).

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Finalize and Activate

Once threats, consequences, and barriers are documented and effectiveness is assessed, change the bowtie status from Draft to Active. Active bowties are included in ongoing safety assurance monitoring. Review active bowties periodically as part of your hazard review cycle to verify that barrier effectiveness has not degraded.

Bowtie Analysis Reference

Complete reference for bowtie structure, fields, and methodology.

Conduct a Risk Assessment

How the 5x5 risk matrix complements bowtie analysis.

Hazard Register

The hazard records that bowtie analyses link to.

Create a CPA

Implementing barriers identified through bowtie analysis.
Last modified on April 11, 2026