Erik Hollnagel

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The first source is Hollnagel's Barriers and Accident Prevention book.

He combines barrier thinking with a systemic view of accidents.

Here, accidents can arise from complex combinations of conditions rather than one distinct cause or failed component.

You build it from a fault tree on the left and an event tree on the right, joined by a top event in the center.

But what it produces is a model, a selective representation of a hazard scenario.

Hollnagel himself calls it the bow tie model.

So when we criticize the bow tie, we're more criticizing the model it produces, the abstraction.