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Mort, Mini-Mort & Pet: TECH 438 Spring 2003 NIU
Mort, Mini-Mort & Pet: TECH 438 Spring 2003 NIU
Reference
Lecture slides were taken from material published by Stephenson in:
System Safety 2000, Van Nostrand Reinhold, 1991.
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
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.
Symbols
Symbols used on the MORT chart are fundamentally the same as those used on other analytical trees and FTA.
Event Symbols
Logic Gates
Transfers
Abbreviations
LTA - less than adequate
DN - did not FT - failed to
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.
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.
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.
Input Requirements
In a nut-shell, extensive. Detailed information regarding:
Hardware
Facilities
Environment Policies & Procedures Personnel Implementation plans Risk assessment programs Project documents, etc...
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.
Color Coding
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!
Top Events
Incident
Barriers
Targets
Mini-MORT
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.
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.
Mini-MORT, Page 1
Amelioration LTA
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?
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?
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?
Did management take the appropriate actions? Were adequate plans in place? Were they implemented?
Mini-MORT, Page 2
Mini-MORT, Page 3
Mini-MORT, Page 4
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?
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?
Execution LTA
Did everyone do what they were supposed to do? Did control systems work properly? Was the barrier effective?
None Practical
Did management identify, evaluate, and accept the risks associated with the operation?
Mini-MORT, Page 5
Mini-MORT, Page 6
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.
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.
Input Requirements
Same as described for MORT and Mini-MORT. Additionally:
Job descriptions Organization charts Training records Interviews
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.
PET Chart
Procedures Branch
Personnel Branch
PET Worksheet