Critical Control Management for an Aluminium Smelting Refinery
Executive Summary:
Challenge: Client required assurance that existing BowTie models and CCM framework were effectively preventing major accidents.
Approach
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Benchmarking against ICMM, CCPS, and internal standards.
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Validation of BowTie controls for independence, auditability, and effectiveness.
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Assessed degradation factors, incident history, root cause analyses, and resource adequacy.
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Conducted in-depth interviews with CCM stakeholders.
Outcome
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Identified assurance and control gaps.
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Provided prioritised recommendations to refine BowTies, improve control classification, and strengthen performance standards.
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Insights informed leadership decisions on resourcing, training, and redesign of controls.
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Strengthened governance and alignment with international best practices.
Case Study
AFRISHE was engaged by the leadership team of a major aluminium smelting refinery to assess the effectiveness of their existing Top 15 Major Accident Hazards (MAH) BowTie models and the Critical Control Management (CCM) system. The client sought an independent, expert review to determine whether their critical control framework was achieving its intended function of preventing or mitigating catastrophic events. The project aimed not only to evaluate the quality and completeness of their control framework but also to identify opportunities for alignment with international best practices and internal governance expectations.
AFRISHE conducted a detailed benchmarking exercise comparing the client’s MAH BowTies and CCM implementation against globally recognised frameworks, including the International Council on Mining and Metals (ICMM), the Center for Chemical Process Safety (CCPS), and the client’s own internal standards. Each MAH BowTie was scrutinized to verify whether designated controls met the threshold to be considered valid and effective critical controls, based on their functionality, independence, auditability and other pertinent criteria. AFRISHE also introduced a structured assessment of degradation factors and degradation controls, which are designed to detect, prevent, or mitigate such erosion. This allowed for a more comprehensive evaluation of BowTie integrity by ensuring that not only primary controls, but also their supporting safeguards, were clearly defined, validated, and resourced.
AFRISHE also conducted a systemic review of incidents across all severity levels, assessing the quality of root cause analysis and identifying recurring gaps in control assurance.
The adequacy of resourcing was assessed against CCM expectations, and the integrity of performance standards was critically reviewed to determine if they enabled reliable, auditable, and survivable critical controls.
This was complemented by in-depth interviews with key CCM stakeholders such as verifiers, planners, and operational leaders to understand practical implementation challenges.
The outcome of the engagement resulted in several transformative shifts. AFRISHE delivered a prioritised set of recommendations to refine the client’s BowTie logic, improve control classification, and strengthen the structure and content of performance standards to enhance operational assurance. These insights were used to inform leadership decisions on resourcing, verifier training, and control redesign anchored in a clearer understanding of control effectiveness, implementation quality, and assurance gaps.
