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 Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

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 ? Ships in Service Training Material A-M CHAUVEL

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? " Ships in Service Training Material A-M CHAUVEL

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. Ships in Service Training Material A-M CHAUVEL

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. Ships in Service Training Material A-M CHAUVEL

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 ? Ships in Service Training Material A-M CHAUVEL

External Environment Ships in Service Training Material A-M CHAUVEL

Internal Environment Ships in Service Training Material A-M CHAUVEL

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 ? Ships in Service Training Material A-M CHAUVEL

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) ? Ships in Service Training Material A-M CHAUVEL

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) ? Ships in Service Training Material A-M CHAUVEL

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 ? Ships in Service Training Material A-M CHAUVEL

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 ? Ships in Service Training Material A-M CHAUVEL

MORT Identify the Causes Management Work & Task Material People Environment Ships in Service Training Material A-M CHAUVEL

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 ? Ships in Service Training Material A-M CHAUVEL

The Potential Causes Causes Effect Diagram Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

Meteorological Conditions External Environment Meteorological Conditions External environment - Weather - Waves - Light and visibility - Hydrological Accident Ships in Service Training Material A-M CHAUVEL

Internal Environment Arrangements Accident - General arrangement - Hull and deck arrangement - Specific deck arrangement - Emergency arrangement Accident Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

Personnel Safety Organisation Accident - Shipboard familiarisation - Safety familiarisation - Emergency preparedness - Crew co-ordination - Training and drills - Emergency arrangement Accident Ships in Service Training Material A-M CHAUVEL

Personnel Special Training Accident - Survival craft - Rescue boats,..... - Advanced fire fighting - First aid - Medical care, - Crisis management Accident Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

Records Voyage Accident - Planning - Notifications of deviations - Events & Happenings Accident Ships in Service Training Material A-M CHAUVEL

Records Personnel Accident - Crew list - Competency - Medical fitness - Experience - Familiarisation & training Accident Ships in Service Training Material A-M CHAUVEL

Records Ship & Equipment Accident - Mandatory certificates - Classification Society inspections - Statutory inspections - Maintenance, modifications, damages and repairs - Work repair authorisations - Navigational equipment Records Accident Ships in Service Training Material A-M CHAUVEL

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 Ships in Service Training Material A-M CHAUVEL

Records Watchkeeping Accident - Schedules - Master instruction - Deck watchkeeping reports - Engineering watchkeeping reports Accident Ships in Service Training Material A-M CHAUVEL

One other way for classification Ships in Service Training Material A-M CHAUVEL

Ergonomic Accident Ship and Equipment Environment Personnel Ships in Service Training Material A-M CHAUVEL

Psychology Accident Environment Personnel Management Ships in Service Training Material A-M CHAUVEL

Behaviour Accident Procedures Personnel Management Ships in Service Training Material A-M CHAUVEL

Organization Accident Records Procedures Management Ships in Service Training Material A-M CHAUVEL

Standardization Accident Ship and Equipment Records Procedures Ships in Service Training Material A-M CHAUVEL

Technology Accident Ship and Equipment Records Environment Ships in Service Training Material A-M CHAUVEL

Causes & Effect : Accident Technology Ship and Equipment Ergonomic Records Environment Material Hard People Soft Accident Standardisation Psychology Procedures Personnel Management Organisation Behaviour Ships in Service Training Material A-M CHAUVEL

Accident Ship & Equipment Management Procedures & Records Work & Task Personnel Environment Ships in Service Training Material A-M CHAUVEL

Ships in Service Training Material A-M CHAUVEL