Build A Bowtie For Wrong-Route Risk

A late-night empty coaching stock move must use a rarely used route during a temporary timetable change. Similar train IDs are active in the same control area. Bowtie: threats and preventive barriers on the left; top event in the center; consequences and mitigating barriers on the right. The common trap is calling every action a control without saying whether it prevents the wrong route or mitigates its consequences. Threats List credible causes: similar train IDs, unusual routing, fatigue, temporary notice, and workload at the junction. Threats belong on the left side because they can push the system toward the top…

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