1. Identify the Causes 2009 MORT Management Oversight and Risk Tree
Material
Work &
Task
People
Management
Environment
MORT
Management Oversight and Risk Tree
Approach for accident investigation
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2. MORT Identify the Causes
Accident Causation Models
Many models of accident causation
have been proposed, ranging from :
- Heinrich's domino theory to
- The Management Oversight
and Risk Tree (MORT).
The MORT model attempts to
illustrate that the causes
of any accident can be
grouped into five categories.
Many models of accident causation have been proposed, ranging from Heinrich's domino theory to the sophisticated Management Oversight and Risk Tree (MORT).
The MORT model attempts to illustrate that the causes of any accident can be grouped into five categories
- task, material, environment, personnel, and management.
When this model is used, possible causes in each category should be investigated.
Each category is examined more closely.
Remember that these are sample questions only:
no attempt has been made to develop a comprehensive checklist
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3. MORT Identify the Causes
Management
When the
model is used
What are the
possible causes
in each category
to be investigated.
Work &
Task
Material
People
Environment
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4. MORT Identify the Causes
Members of the investigating team shall look
for answers to questions such as:
Work &
Task
- Was actual safe work procedure used ? - Was the actual method used make
the current procedure unsafe ?
- Where appropriate PPE, tools and
materials available ?
- Were they are used ?
- Was actual safety devices working
properly ?
- Was actual lockout used
when necessary ?
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5. MORT Identify the Causes
Work &
Task
For most of these questions,
an important follow-up question is “ If not, why ? "
Here the actual work procedure being used at the time of the accident is explored.
Members of the accident investigation team will look for answers to questions such as :
- Was a safe work procedure used ?
- Had conditions changed to make the normal
procedure unsafe ?
- Were the appropriate tools and materials available ?
- Were they used ?
- Were safety devices working properly ?
- Was lockout used when necessary ?
For most of these questions, an important follow-up
question is “ If not, why not? "
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6. MORT Identify the Causes
To seek out possible causes resulting from the equipment and materials, investigators might ask:
- Was there a possible equipment failure ?
- What could caused it to fail ?
- Was the machinery poorly designed ?
- Where hazardous substances involved ?
- Where they clearly identified ?
- Was a less hazardous alternative
substance possible and available ?
- Was a raw material substandard could
have an effect ?
- Should personal protective equipment
(PPE) be used ?
Material
To seek out possible causes resulting from the equipment and materials used, investigators might ask :
- Was there an equipment failure ?
- What caused it to fail ?
- Was the machinery poorly designed ?
- Were hazardous substances involved ?
- Were they clearly identified ?
- Was a less hazardous alternative substance possible
and available ?
- Was the raw material substandard in some way ?
- Should personal protective equipment (PPE) have
been used ?
- Was the PPE used ?
Each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist.
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7. MORT Identify the Causes
Material
Each time the answer reveals an potential unsafe condition,
the investigation team must ask
why this situation
was allowed to exist ?
To seek out possible causes resulting from the equipment and materials used, investigators might ask :
- Was there an equipment failure ?
- What caused it to fail ?
- Was the machinery poorly designed ?
- Were hazardous substances involved ?
- Were they clearly identified ?
- Was a less hazardous alternative substance possible
and available ?
- Was the raw material substandard in some way ?
- Should personal protective equipment (PPE) have
been used ?
- Was the PPE used ?
Each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist.
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8. MORT Identify the Causes
The physical environment,
and
especially sudden changes
to that environment,
External and Internal,
are factors that need to be identified.
The situation at the time of the accident is what is important,
Not what the "usual" conditions were.
Environment
The physical environment, and especially sudden changes to that environment, are factors that need
to be identified.
The situation at the time of the accident is what is important, not what the "usual" conditions were.
For example, accident investigators may want to know :
- What were the weather conditions ?
- Was poor housekeeping a problem ?
- Was it too hot or too cold ?
- Was noise a problem ?
- Was there adequate light ?
- Were toxic or hazardous gases, dusts, or fumes
present ?
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9. External Environment
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10. Internal Environment
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11. MORT Identify the Causes
The investigation team may want to know:
Environment
- What are the weather conditions?
- Was poor housekeeping a problem ?
- Was it too hot or too cold?
- Was noise a problem ?
- Was there adequate lighting ?
- Were toxic or hazardous gases,
dusts or fumes present?
The physical environment, and especially sudden changes to that environment, are factors that need
to be identified.
The situation at the time of the accident is what is important, not what the "usual" conditions were.
For example, accident investigators may want to know :
- What were the weather conditions ?
- Was poor housekeeping a problem ?
- Was it too hot or too cold ?
- Was noise a problem ?
- Was there adequate light ?
- Were toxic or hazardous gases, dusts, or fumes
present ?
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12. MORT Identify the Causes
The physical and mental condition
of individuals directly involved
in the event must be explored.
The purpose for investigation
is not to establish blame
against someone,
but
the inquiry will not be complete unless personal characteristics
are considered.
People
The physical and mental condition of those individuals directly involved in the event must be explored.
The purpose for investigating the accident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics are considered.
Some factors will remain essentially constant while others may vary from day to day :
- Were workers experienced in the work being done ?
- Had they been adequately trained ?
- Can they physically do the work ?
- What was the status of their health ?
- Were they tired ?
- Were they under stress (work or personal) ?
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13. MORT Identify the Causes
Some factors will remain essentially
constant while others may vary
from day to day :
- Where workers experienced in
the work being done?
- Had they been adequately trained?
- Can they physically do the work?
- What was the status of their health?
- Were they tired or under stress?
People
The physical and mental condition of those individuals directly involved in the event must be explored.
The purpose for investigating the accident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics are considered.
Some factors will remain essentially constant while others may vary from day to day :
- Were workers experienced in the work being done ?
- Had they been adequately trained ?
- Can they physically do the work ?
- What was the status of their health ?
- Were they tired ?
- Were they under stress (work or personal) ?
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14. MORT Identify the Causes
Management holds
the legal responsibility for
the safety of the workplace,
therefore the role of supervisors
and higher management must
always be considered in
an accident investigation.
Management
Answers to any of the preceding types of questions
logically lead to further questions such as :
Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management must always be considered in an accident investigation.
Answers to any of the preceding types of questions logically lead to further questions such as :
- Was safety rules communicated to and understood
by all employees ?
- Were written procedures available ?
- Were they being enforced ?
- Was there adequate supervision ?
- Were workers trained to do the work ?
- Had hazards been previously identified ?
- Had procedures been developed to overcome them ?
- Were unsafe conditions corrected ?
- Was regular maintenance of equipment carried out ?
- Were regular safety inspections carried out ?
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15. MORT Identify the Causes
- Were safety rules communicated to
and understood by all employees?
- Were written procedures and
orientation available?
- Were they being enforced?
- Was there adequate supervision?
- Were workers trained to do the work?
- Had hazards been previously identified?
- Had procedures been developed to
overcome them?
- Were unsafe conditions corrected?
- Was regular maintenance of equipment
carried out?
- Were regular safety inspections carried
out?
Management
Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management must always be considered in an accident investigation.
Answers to any of the preceding types of questions logically lead to further questions such as :
- Was safety rules communicated to and understood
by all employees ?
- Were written procedures available ?
- Were they being enforced ?
- Was there adequate supervision ?
- Were workers trained to do the work ?
- Had hazards been previously identified ?
- Had procedures been developed to overcome them ?
- Were unsafe conditions corrected ?
- Was regular maintenance of equipment carried out ?
- Were regular safety inspections carried out ?
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16. MORT Identify the Causes
Management
Work &
Task
Material
People
Environment
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17. MORT Identify the Causes
Some investigators may prefer to place some
of the sample questions in different categories.
However, the categories are not important,
as long as each pertinent question is asked.
Obviously there is considerable overlap between
categories, this reflects the situation in real life.
It should be emphasized that the above
sample questions do not make up
a complete checklist, but are examples only.
Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management must always be considered in an accident investigation.
Answers to any of the preceding types of questions logically lead to further questions such as :
- Was safety rules communicated to and understood
by all employees ?
- Were written procedures available ?
- Were they being enforced ?
- Was there adequate supervision ?
- Were workers trained to do the work ?
- Had hazards been previously identified ?
- Had procedures been developed to overcome them ?
- Were unsafe conditions corrected ?
- Was regular maintenance of equipment carried out ?
- Were regular safety inspections carried out ?
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18. The Potential Causes Causes Effect Diagram
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19. Ship and Equipment Equipment Failure Accident
- Propulsion system & control
- Navigational equipment & system
- Communication equipment
- Electrical system
- Ballast system
- Substances hazardous to health
- Control system
- Cargo handling system
- Cargo lashing equipment
- Emergency & life saving equipment
- Spare parts inventory
Ship &
Equipment
Accident
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20. Meteorological Conditions
External Environment
Meteorological Conditions
External
environment
- Weather
- Waves
- Light and visibility
- Hydrological
Accident
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21. Internal Environment Arrangements Accident - General arrangement
- Hull and deck arrangement
- Specific deck arrangement
- Emergency arrangement
Accident
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22. Qualification & Work Organisation
Personnel
Qualification & Work Organisation
Personnel
- Deck officers and deck crew
- Engineers and engine crew
- Catering crew
- Knowledge of Flag State’s
marine legislation
- Ability to communicate
Accident
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23. Personnel Safety Organisation Accident - Shipboard familiarisation
- Safety familiarisation
- Emergency preparedness
- Crew co-ordination
- Training and drills
- Emergency arrangement
Accident
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24. Personnel Special Training Accident - Survival craft
- Rescue boats,.....
- Advanced fire fighting
- First aid
- Medical care,
- Crisis management
Accident
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25. Management Ship Accident - Background of the ship
- Compliance with international
conventions
- Certificates valid
- Statutory inspections
- Classification society inspections
- Adequate manning of the ship
- Knowledge of Flag State’s
regulation
Management
Accident
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26. Management Safety Commitment Accident - Safety and Environment
Protection Policy
- Company responsibilities &
authority
- Designated person responsibility
& authority
- Master responsibility & authority
- Contingency plan
- Safety management internal audit
- Safety management system review
- Annual safety improvement plan
Management
Accident
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27. Procedures Safety Accident - Passenger information
- Safety organisation
- Safety & Environmental manual
- Crew training manual
- Internal safety audits
- Watchkeeping
- Emergency plan
- Report & analysis of
non conformities, accidents
and hazardous occurrences
Procedures
Accident
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28. Procedures On Board Operation Accident - Plan for shipboard operation
- Cargo handling and
planning loading
- Permits to work and repair
- Maintenance plan for ship &
critical equipment
- Maintenance plan for
safety equipment
Procedures
Accident
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29. Records Voyage Accident - Planning - Notifications of deviations
- Events & Happenings
Accident
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30. Records Personnel Accident - Crew list - Competency - Medical fitness
- Experience
- Familiarisation & training
Accident
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31. Records Ship & Equipment Accident - Mandatory certificates
- Classification Society inspections
- Statutory inspections
- Maintenance, modifications,
damages and repairs
- Work repair authorisations
- Navigational equipment
Records
Accident
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32. Safety & Environmental Protection
Records
Safety & Environmental Protection
- Internal inspection reports
- Non conformities
- Accidents and damages
- Near misses
- Hazardous occurrences
- Maintenance, modifications
- Work repair authorisations
Records
Accident
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33. Records Watchkeeping Accident - Schedules - Master instruction
- Deck watchkeeping reports
- Engineering watchkeeping reports
Accident
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34. One other way for classification
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35. Ergonomic Accident Ship and Equipment Environment Personnel
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36. Psychology Accident Environment Personnel Management
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37. Behaviour Accident Procedures Personnel Management
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38. Organization Accident Records Procedures Management
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39. Standardization Accident Ship and Equipment Records Procedures
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40. Technology Accident Ship and Equipment Records Environment
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41. Causes & Effect : Accident
Technology
Ship and
Equipment
Ergonomic
Records
Environment
Material
Hard
People
Soft
Accident
Standardisation
Psychology
Procedures
Personnel
Management
Organisation
Behaviour
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42. Accident Ship & Equipment Management Procedures & Records Work & Task
Personnel
Environment
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43. Ships in Service Training Material
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