MORT, Mini-MORT PET

1. MORT, Mini-MORT & PET TECH 438 Spring 2003 NIU

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

3. Management Oversight and Risk Tree (MORT)

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

5. 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.

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

7. Event Symbols

8. Logic Gates

9. Transfers

10. Abbreviations LTA - “less than adequate” DN - “did not” FT - “failed to” HAP - “hazard analysis process” JSA - “job safety analysis” CS&R - “codes standards and regulations”

11. 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.

12. 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.

13. 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.

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

15. 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.

16. Color Coding

17. 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)

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

19. 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.

20. 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!

21. General Approach (con’t) 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.

22. 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.

23. 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.

24. Top Events

25. Specific Control Factors

26. Incident

27. Barriers

28. Targets

29. Management Control Factors

30. Questions & Comments

31. Mini-MORT

32. 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 --> 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.

33. 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 --> right” and “top --> bottom.”

34. Mini-MORT, Page 1

35. Amelioration LTA

36. 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?

37. 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?

38. 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?

39. 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?

40. 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?

41. 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?

42. Mini-MORT, Page 2

43. Mini-MORT, Page 3

44. Mini-MORT, Page 4

45. Separate Time or Space LTA

46. 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.

47. 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?

48. 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?

49. Execution LTA Did everyone do what they were supposed to do? Did control systems work properly? Was the barrier effective?

50. None Practical Did management identify, evaluate, and accept the risks associated with the operation?

51. Mini-MORT, Page 5

52. 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.

53. Mini-MORT, Page 6

54. Hazard Analysis Process Considers whether the tools, techniques, plans, and requirements for performing hazard analysis are adequate.

55. Summary Questions at various points were phrased in the past tense. When using this tool for inspections, audits, etc…phrase 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.

56. Questions & Comments

57. Project Evaluation Tree (PET)

58. 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.

59. 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...

60. 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 User’s Guide, to evaluate each part of the system or project. Use the same color coding scheme from MORT.

61. PET Chart

62. Procedures Branch

63. Personnel Branch

64. Personnel Branch (HF)

65. Facilities & Hardware Branch

66. PET Worksheet

67. Questions & Comments