MORT, Mini-MORT & PETMORT, Mini-MORT & PET

TECH 438TECH 438

Spring 2003Spring 2003

NIUNIU

TECH 438TECH 438

Spring 2003Spring 2003

NIUNIU

ReferenceReference

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

Management Oversight Management Oversight and Risk Tree (MORT)and Risk Tree (MORT)

OverviewOverview

• Developed by Bill Johnson in 1970’s for DOEDeveloped by Bill Johnson in 1970’s for DOE

• MORT chart contains approximately 1500 MORT chart contains approximately 1500 items arranged into a large/complex fault items arranged into a large/complex fault treetree

• Primarily used for accident investigationPrimarily used for accident investigation

Purpose of MORTPurpose of MORT

• To provide a systematic tool to aid in To provide a systematic tool to aid in planning, organizing, and conducting an in-planning, organizing, and conducting an in-depth, comprehensive depth, comprehensive accident accident investigation investigation to identify those specific that to identify those specific that are are LTA LTA and need to be corrected to prevent and need to be corrected to prevent the accident from recurring.the accident from recurring.

• Can also be used for inspection, audit, or Can also be used for inspection, audit, or appraisal purposes.appraisal purposes.

SymbolsSymbols

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

Event SymbolsEvent Symbols

Logic GatesLogic Gates

TransfersTransfers

AbbreviationsAbbreviations

• LTALTA - “less than adequate” - “less than adequate”

• DNDN - “did not” - “did not”

• FTFT - “failed to” - “failed to”

• HAPHAP - “hazard analysis process” - “hazard analysis process”

• JSAJSA - “job safety analysis” - “job safety analysis”

• CS&RCS&R - “codes standards and regulations” - “codes standards and regulations”

DefinitionDefinition• Accepted or Assumed Risk - Accepted or Assumed Risk - Very specific risk that has Very specific risk that has

been identified, analyzed, quantified to the maximum been identified, analyzed, quantified to the maximum practical degree, and accepted by the appropriate level practical degree, and accepted by the appropriate level of management after proper thought and evaluation.of management after proper thought and evaluation.

• Losses from Assumed RisksLosses from Assumed Risks are normally those are normally those associated with earthquakes, tornados, hurricanes, and associated with earthquakes, tornados, hurricanes, and other acts of nature.other acts of nature.

• AmeliorationAmelioration - Post-accident actions such as medical - Post-accident actions such as medical services, fire fighting, rescue efforts, and public services, fire fighting, rescue efforts, and public relations.relations.

AdvantageAdvantage

• It aids the accident investigator by It aids the accident investigator by identifying root causes of the accident.identifying root causes of the accident.

• Provides a systematic method of evaluating Provides a systematic method of evaluating the specific control and management factors the specific control and management factors that caused or contributed to the accident.that caused or contributed to the accident.

• Serve as planning and organizational tool for Serve as planning and organizational tool for the collection of evidence and other relevant the collection of evidence and other relevant information.information.

DisadvantageDisadvantage

• Extremely time consuming and tedious when Extremely time consuming and tedious when learning about and first using the MORT learning about and first using the MORT chart.chart.

• This approach would be classified as overkill This approach would be classified as overkill for most accidents.for most accidents.

Input RequirementsInput Requirements

• In a nut-shell, extensive. Detailed information In a nut-shell, extensive. Detailed information regarding:regarding:– HardwareHardware

– FacilitiesFacilities

– EnvironmentEnvironment

– Policies & ProceduresPolicies & Procedures

– PersonnelPersonnel

– Implementation plansImplementation plans

– Risk assessment programsRisk assessment programs

– Project documents, etc...Project documents, etc...

General ApproachGeneral Approach

• MORT analysis effort begins immediately after the MORT analysis effort begins immediately after the accident occurs.accident occurs.

• Performed by a trained investigator.Performed by a trained investigator.

• MORT chart is used as a working tool to aid in the MORT chart is used as a working tool to aid in the gathering and storage of information.gathering and storage of information.

• General method for working through the chart is General method for working through the chart is from from known to unknownknown to unknown..

• The top of the chart is typically addressed very early The top of the chart is typically addressed very early in the investigation.in the investigation.

Color CodingColor Coding

Color Coding Color Coding (Red)(Red)

• Any factor or event found to be Any factor or event found to be LTALTA is is colored colored redred on the chart. on the chart.

• Should be addressed in the accident report Should be addressed in the accident report with appropriate recommendations to correct with appropriate recommendations to correct the deficiency.the deficiency.

• Use judiciously! (Must be supported by facts)Use judiciously! (Must be supported by facts)

Color Coding Color Coding (Green)(Green)

• Any factor or event found to be Any factor or event found to be adequateadequate is is colored colored greengreen on the chart. on the chart.

• Use judiciously! (Must be supported by facts)Use judiciously! (Must be supported by facts)

Color Coding Color Coding (Black)(Black)

• MORT chart is designed to encompass any MORT chart is designed to encompass any accident situation, therefore not all parts of accident situation, therefore not all parts of the chart may be relevant to the particular the chart may be relevant to the particular accident that is being investigated.accident that is being investigated.

• Any factor or event found to be Any factor or event found to be not not applicableapplicable is color coded is color coded blackblack (or (or simply crossed out) on the chart.simply crossed out) on the chart.

Color Coding Color Coding (Blue)(Blue)

• Indicates that the block has been examined, but Indicates that the block has been examined, but insufficient evidence or information is available to insufficient evidence or information is available to evaluate the block. Suggests to collect more data.evaluate the block. Suggests to collect more data.

• Typically these are colored with a Typically these are colored with a blue dot or blue dot or check markcheck mark due to the fact that they should due to the fact that they should change color prior to completing the investigation.change color prior to completing the investigation.

• All All blueblue blocks should be replaced with another blocks should be replaced with another color by the time the accident investigation is color by the time the accident investigation is complete. But this may not always be the case! complete. But this may not always be the case!

General Approach (con’t)General Approach (con’t)

• Since this is a working document, neatness Since this is a working document, neatness does not count (to a point!).does not count (to a point!).

• Make notes on the chart as you feel Make notes on the chart as you feel necessary.necessary.

• For most investigations, analysis tends to For most investigations, analysis tends to begin at the begin at the specific control factorsspecific control factors and and management control factorsmanagement control factors blocks of the blocks of the tree.tree.

Specific Control FactorsSpecific Control Factors

• Tends to answer questions about what Tends to answer questions about what happened.happened.

• Addresses the accident documentation Addresses the accident documentation requirements. requirements.

• MORT tens to answer these questions in MORT tens to answer these questions in more detail than many traditional methods.more detail than many traditional methods.

Management Control Management Control FactorsFactors

• Policy Policy LTA - LTA - Not typically a problem with major Not typically a problem with major organizations. organizations.

• Implementation - Need be sure the policy is Implementation - Need be sure the policy is actually implemented and not just a “paper actually implemented and not just a “paper policy.”policy.”

• Risk Assessment System - Need to ensure that Risk Assessment System - Need to ensure that risks are properly identified, evaluated, and risks are properly identified, evaluated, and reported to management. Oversights or reported to management. Oversights or omissions can also be a problem in this area.omissions can also be a problem in this area.

Top EventsTop Events

Specific Control FactorsSpecific Control Factors

IncidentIncident

BarriersBarriers

TargetsTargets

Management Control Management Control FactorsFactors

Questions & CommentsQuestions & Comments

Mini-MORTMini-MORT

OverviewOverview

• Mini-MORT chart is basically the full MORT chart Mini-MORT chart is basically the full MORT chart with the bottom tier removed.with the bottom tier removed.

• This reduces the number of events to be This reduces the number of events to be evaluated from approximately 1500 --> 150!evaluated from approximately 1500 --> 150!

• The simplification also eliminates most transfers The simplification also eliminates most transfers from the chart.from the chart.

• Seldom used event symbols such as the scroll Seldom used event symbols such as the scroll and stretched circle are replaced with circles and and stretched circle are replaced with circles and rectangles.rectangles.

InstructionsInstructions

• Following the General Approach described in the Following the General Approach described in the MORT lecture, use the questions and comments MORT lecture, use the questions and comments to color code the chart. Ensure that adequate to color code the chart. Ensure that adequate notes and comments are made to substantiate notes and comments are made to substantiate the evaluations, especially thethe evaluations, especially the red red ones.ones.

• The notes and comments become particularly The notes and comments become particularly useful when writing the final report.useful when writing the final report.

• You typically would look at the chart from “left --You typically would look at the chart from “left --> right” and “top --> bottom.”> right” and “top --> bottom.”

Mini-MORT, Page 1Mini-MORT, Page 1

Amelioration Amelioration LTALTA

Rehabilitation Rehabilitation LTALTA

• How soon and how effectively were operations How soon and how effectively were operations back to normal?back to normal?

• Includes injured personnel, hardware/software, Includes injured personnel, hardware/software, and facility damage.and facility damage.

• Were plans in place to aid in rehabilitation Were plans in place to aid in rehabilitation efforts?efforts?

• Were they adequate? Were they implemented?Were they adequate? Were they implemented?

• How could they be improved?How could they be improved?

Relations Relations LTALTA

• How were relations handled with families of How were relations handled with families of injured personnel? Were they notified in a injured personnel? Were they notified in a prompt, courteous & professional manner?prompt, courteous & professional manner?

• How were relations handled with the press, How were relations handled with the press, unions, corporate, clients, and others unions, corporate, clients, and others affected by the accident?affected by the accident?

• Was there a plan? Was it adequate? Was it Was there a plan? Was it adequate? Was it implemented?implemented?

Rescue Rescue LTALTA

• Did appropriate emergency response Did appropriate emergency response organizations do their job properly?organizations do their job properly?

• Were evacuation and rescue plans in place?Were evacuation and rescue plans in place?

• Were they adequate? Were they Were they adequate? Were they implemented? How could they be improved?implemented? How could they be improved?

Medical Services Medical Services LTALTA

• Was appropriate first aid administered on the Was appropriate first aid administered on the scene? Was the medical response rapid and scene? Was the medical response rapid and adequate?adequate?

• Were the injured handled and treated Were the injured handled and treated properly at the scene?properly at the scene?

• Were emergency medical services adequately Were emergency medical services adequately planned? Was the plan implemented?planned? Was the plan implemented?

• How could the plan be improved?How could the plan be improved?

Prevent Second Accident Prevent Second Accident LTALTA

• Were the losses limited to those from the Were the losses limited to those from the initial unwanted energy flow?initial unwanted energy flow?

• Were rescue or other response personnel Were rescue or other response personnel injured?injured?

• Was unnecessary property damage done Was unnecessary property damage done during the rescue effort?during the rescue effort?

Emergency Action Emergency Action LTALTA

• Did the system respond properly? Did alarms and Did the system respond properly? Did alarms and reporting systems work?reporting systems work?

• Did individual employees take the appropriate Did individual employees take the appropriate actions?actions?

• Did emergency response personnel take the Did emergency response personnel take the appropriate actions?appropriate actions?

• Did management take the appropriate actions? Did management take the appropriate actions? Were adequate plans in place? Were they Were adequate plans in place? Were they implemented?implemented?

Mini-MORT, Page 2Mini-MORT, Page 2

Mini-MORT, Page 3Mini-MORT, Page 3

Mini-MORT, Page 4Mini-MORT, Page 4

Separate Time or Space Separate Time or Space LTALTA

Separate Time or Space Separate Time or Space LTALTA

• Another type of barrier is Another type of barrier is separate time or separate time or spacespace. The most practical barrier may be to . The most practical barrier may be to simply vacate the area. Works well with:simply vacate the area. Works well with:– nuclear weapons testingnuclear weapons testing

– gunnery rangesgunnery ranges

– demolition workdemolition work

– other places where a large quantity of energy will other places where a large quantity of energy will be released in a short time period.be released in a short time period.

Plan Plan LTALTA

• Was an adequate plan in place for ensuring that Was an adequate plan in place for ensuring that the area has been vacated? the area has been vacated?

• Did the plan provide for orderly, controlled Did the plan provide for orderly, controlled evacuation? Did the plan include methods for evacuation? Did the plan include methods for accounting of evacuated personnel & property?accounting of evacuated personnel & property?

• Did the plan have adequate provisions for Did the plan have adequate provisions for ensuring that unauthorized persons could not ensuring that unauthorized persons could not enter a danger area or enter at a hazardous enter a danger area or enter at a hazardous time?time?

Controls Controls LTALTA

• Were the controls provided as specified in Were the controls provided as specified in the plan?the plan?

• Did they provide timely protection, and did Did they provide timely protection, and did they provide verification that the appropriate they provide verification that the appropriate areas were evacuated at the appropriate areas were evacuated at the appropriate times?times?

Execution Execution LTALTA

• Did everyone do what they were supposed to Did everyone do what they were supposed to do?do?

• Did control systems work properly?Did control systems work properly?

• Was the barrier effective?Was the barrier effective?

None PracticalNone Practical

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

Mini-MORT, Page 5Mini-MORT, Page 5

Management System Management System FactorsFactors

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

Mini-MORT, Page 6Mini-MORT, Page 6

Hazard Analysis ProcessHazard Analysis Process

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

SummarySummary

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

• After chart completion, check results against the After chart completion, check results against the Events & Causal FactorsEvents & Causal Factors chart and chart and Change Analysis. Change Analysis.

• Reconcile any differences.Reconcile any differences.

• Use all (3) tools to aid in writing the final report.Use all (3) tools to aid in writing the final report.

• Provide findings, conclusions, and recommendations, Provide findings, conclusions, and recommendations, for each factor deemed for each factor deemed LTA.LTA.

Questions & CommentsQuestions & Comments

Project Evaluation Tree Project Evaluation Tree (PET)(PET)

Purpose of PETPurpose of PET

• To provide a relatively simple, To provide a relatively simple, straightforward, and efficient method of straightforward, and efficient method of performing an in-depth evaluation or analysis performing an in-depth evaluation or analysis of a project or operation.of a project or operation.

• Best suited for performing Best suited for performing Operating Hazard Operating Hazard AnalysisAnalysis or or Accident AnalysisAccident Analysis..

• Valuable review and inspection tool.Valuable review and inspection tool.

• Can also be helpful in performing the Can also be helpful in performing the PHAPHA..

Input RequirementsInput Requirements

• Same as described for MORT and Mini-MORT.Same as described for MORT and Mini-MORT.

• Additionally:Additionally:– Job descriptionsJob descriptions

– Organization chartsOrganization charts

– Training recordsTraining records

– InterviewsInterviews

– Drawings and specificationsDrawings and specifications

– Test plans and records, etc...Test plans and records, etc...

General ApproachGeneral Approach

• Basically, just a graphic checklist.Basically, just a graphic checklist.

• Systematically identify each procedure, Systematically identify each procedure, individual/organization, facility or piece of individual/organization, facility or piece of equipment to be analyzed, and use the equipment to be analyzed, and use the appropriate branch of the PET tree.appropriate branch of the PET tree.

• Follow the PET User’s Guide, to evaluate each Follow the PET User’s Guide, to evaluate each part of the system or project.part of the system or project.

• Use the same color coding scheme from MORT.Use the same color coding scheme from MORT.

PET ChartPET Chart

Procedures BranchProcedures Branch

Personnel BranchPersonnel Branch

Personnel Branch (HF)Personnel Branch (HF)

Facilities & Hardware Facilities & Hardware BranchBranch

PET WorksheetPET Worksheet

Questions & CommentsQuestions & Comments