MORT, Mini-MORT & PET

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MORT, Mini-MORT PET

• TECH 438
• Spring 2003
• NIU

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Reference

• Lecture slides were taken from material published
  by Stephenson in
• System Safety 2000, Van Nostrand Reinhold, 1991.

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Management Oversight and Risk Tree (MORT)
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Overview

• Developed by Bill Johnson in 1970s for DOE
• MORT chart contains approximately 1500 items
  arranged into a large/complex fault tree
• Primarily used for accident investigation

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Purpose of MORT

• To provide a systematic tool to aid in planning,
  organizing, and conducting an in-depth,
  comprehensive accident investigation to identify
  those specific that are LTA and need to be
  corrected to prevent the accident from recurring.
• Can also be used for inspection, audit, or
  appraisal purposes.

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Symbols

• Symbols used on the MORT chart are fundamentally
  the same as those used on other analytical trees
  and FTA.

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Event Symbols
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Logic Gates
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Transfers
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Abbreviations

• LTA - less than adequate
• DN - did not
• FT - failed to
• HAP - hazard analysis process
• JSA - job safety analysis
• CSR - codes standards and regulations

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Definition

• Accepted or Assumed Risk - Very specific risk
  that has been identified, analyzed, quantified to
  the maximum practical degree, and accepted by the
  appropriate level of management after proper
  thought and evaluation.
• Losses from Assumed Risks are normally those
  associated with earthquakes, tornados,
  hurricanes, and other acts of nature.
• Amelioration - Post-accident actions such as
  medical services, fire fighting, rescue efforts,
  and public relations.

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Advantage

• It aids the accident investigator by identifying
  root causes of the accident.
• Provides a systematic method of evaluating the
  specific control and management factors that
  caused or contributed to the accident.
• Serve as planning and organizational tool for the
  collection of evidence and other relevant
  information.

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Disadvantage

• Extremely time consuming and tedious when
  learning about and first using the MORT chart.
• This approach would be classified as overkill for
  most accidents.

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Input Requirements

• In a nut-shell, extensive. Detailed information
  regarding
• Hardware
• Facilities
• Environment
• Policies Procedures
• Personnel
• Implementation plans
• Risk assessment programs
• Project documents, etc...

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General Approach

• MORT analysis effort begins immediately after the
  accident occurs.
• Performed by a trained investigator.
• MORT chart is used as a working tool to aid in
  the gathering and storage of information.
• General method for working through the chart is
  from known to unknown.
• The top of the chart is typically addressed very
  early in the investigation.

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Color Coding
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Color Coding (Red)

• Any factor or event found to be LTA is colored
  red on the chart.
• Should be addressed in the accident report with
  appropriate recommendations to correct the
  deficiency.
• Use judiciously! (Must be supported by facts)

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Color Coding (Green)

• Any factor or event found to be adequate is
  colored green on the chart.
• Use judiciously! (Must be supported by facts)

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Color Coding (Black)

• MORT chart is designed to encompass any accident
  situation, therefore not all parts of the chart
  may be relevant to the particular accident that
  is being investigated.
• Any factor or event found to be not applicable is
  color coded black (or simply crossed out) on the
  chart.

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Color Coding (Blue)

• Indicates that the block has been examined, but
  insufficient evidence or information is available
  to evaluate the block. Suggests to collect more
  data.
• Typically these are colored with a blue dot or
  check mark due to the fact that they should
  change color prior to completing the
  investigation.
• All blue blocks should be replaced with another
  color by the time the accident investigation is
  complete. But this may not always be the case!

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General Approach (cont)

• Since this is a working document, neatness does
  not count (to a point!).
• Make notes on the chart as you feel necessary.
• For most investigations, analysis tends to begin
  at the specific control factors and management
  control factors blocks of the tree.

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Specific Control Factors

• Tends to answer questions about what happened.
• Addresses the accident documentation
  requirements.
• MORT tens to answer these questions in more
  detail than many traditional methods.

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Management Control Factors

• Policy LTA - Not typically a problem with major
  organizations.
• Implementation - Need be sure the policy is
  actually implemented and not just a paper
  policy.
• Risk Assessment System - Need to ensure that
  risks are properly identified, evaluated, and
  reported to management. Oversights or omissions
  can also be a problem in this area.

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Top Events
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Specific Control Factors
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Incident
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Barriers
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Targets
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Management Control Factors
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Questions Comments
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Mini-MORT
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Overview

• Mini-MORT chart is basically the full MORT chart
  with the bottom tier removed.
• This reduces the number of events to be evaluated
  from approximately 1500 --gt 150!
• The simplification also eliminates most transfers
  from the chart.
• Seldom used event symbols such as the scroll and
  stretched circle are replaced with circles and
  rectangles.

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Instructions

• Following the General Approach described in the
  MORT lecture, use the questions and comments to
  color code the chart. Ensure that adequate notes
  and comments are made to substantiate the
  evaluations, especially the red ones.
• The notes and comments become particularly useful
  when writing the final report.
• You typically would look at the chart from left
  --gt right and top --gt bottom.

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Mini-MORT, Page 1
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Amelioration LTA
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Rehabilitation LTA

• How soon and how effectively were operations back
  to normal?
• Includes injured personnel, hardware/software,
  and facility damage.
• Were plans in place to aid in rehabilitation
  efforts?
• Were they adequate? Were they implemented?
• How could they be improved?

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Relations LTA

• How were relations handled with families of
  injured personnel? Were they notified in a
  prompt, courteous professional manner?
• How were relations handled with the press,
  unions, corporate, clients, and others affected
  by the accident?
• Was there a plan? Was it adequate? Was it
  implemented?

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Rescue LTA

• Did appropriate emergency response organizations
  do their job properly?
• Were evacuation and rescue plans in place?
• Were they adequate? Were they implemented? How
  could they be improved?

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Medical Services LTA

• Was appropriate first aid administered on the
  scene? Was the medical response rapid and
  adequate?
• Were the injured handled and treated properly at
  the scene?
• Were emergency medical services adequately
  planned? Was the plan implemented?
• How could the plan be improved?

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Prevent Second Accident LTA

• Were the losses limited to those from the initial
  unwanted energy flow?
• Were rescue or other response personnel injured?
• Was unnecessary property damage done during the
  rescue effort?

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Emergency Action LTA

• Did the system respond properly? Did alarms and
  reporting systems work?
• Did individual employees take the appropriate
  actions?
• Did emergency response personnel take the
  appropriate actions?
• Did management take the appropriate actions? Were
  adequate plans in place? Were they implemented?

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Mini-MORT, Page 2
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Mini-MORT, Page 3
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Mini-MORT, Page 4
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Separate Time or Space LTA
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Separate Time or Space LTA

• Another type of barrier is separate time or
  space. The most practical barrier may be to
  simply vacate the area. Works well with
• nuclear weapons testing
• gunnery ranges
• demolition work
• other places where a large quantity of energy
  will be released in a short time period.

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Plan LTA

• Was an adequate plan in place for ensuring that
  the area has been vacated?
• Did the plan provide for orderly, controlled
  evacuation? Did the plan include methods for
  accounting of evacuated personnel property?
• Did the plan have adequate provisions for
  ensuring that unauthorized persons could not
  enter a danger area or enter at a hazardous time?

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Controls LTA

• Were the controls provided as specified in the
  plan?
• Did they provide timely protection, and did they
  provide verification that the appropriate areas
  were evacuated at the appropriate times?

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Execution LTA

• Did everyone do what they were supposed to do?
• Did control systems work properly?
• Was the barrier effective?

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None Practical

• Did management identify, evaluate, and accept the
  risks associated with the operation?

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Mini-MORT, Page 5
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Management System Factors

• The root causes of most accidents are found
  during an analysis of the Management System
  Factors. This major branch of the chart
  addresses the why issues.

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Mini-MORT, Page 6
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Hazard Analysis Process

• Considers whether the tools, techniques, plans,
  and requirements for performing hazard analysis
  are adequate.

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Summary

• Questions at various points were phrased in the
  past tense. When using this tool for inspections,
  audits, etcphrase questions in the present
  tense.
• After chart completion, check results against the
  Events Causal Factors chart and Change
  Analysis.
• Reconcile any differences.
• Use all (3) tools to aid in writing the final
  report.
• Provide findings, conclusions, and
  recommendations, for each factor deemed LTA.

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Questions Comments
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Project Evaluation Tree (PET)
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Purpose of PET

• To provide a relatively simple, straightforward,
  and efficient method of performing an in-depth
  evaluation or analysis of a project or operation.
• Best suited for performing Operating Hazard
  Analysis or Accident Analysis.
• Valuable review and inspection tool.
• Can also be helpful in performing the PHA.

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Input Requirements

• Same as described for MORT and Mini-MORT.
• Additionally
• Job descriptions
• Organization charts
• Training records
• Interviews
• Drawings and specifications
• Test plans and records, etc...

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General Approach

• Basically, just a graphic checklist.
• Systematically identify each procedure,
  individual/organization, facility or piece of
  equipment to be analyzed, and use the appropriate
  branch of the PET tree.
• Follow the PET Users Guide, to evaluate each
  part of the system or project.
• Use the same color coding scheme from MORT.

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PET Chart
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Procedures Branch
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Personnel Branch
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Personnel Branch (HF)
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Facilities Hardware Branch
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PET Worksheet
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Questions Comments