MORT - Management Oversight & Risk Tree

b1
SD1 MB3

2009 Revision by SD1

Technical
Information
Systems LTA
SD1 5

The Noordwijk Risk b6

MB1
f6
SD5

Initiative Foundation Damage to

people or assets Losses
Future
Undesired
Events a1
Technical
Information
LTA
5 a2
Data
Collection
LTA
8 a3
Data
Analysis
LTA
9 a4
Triggers to
Risk Analysis
LTA
10
a5
Audit &
Appraisal
LTA
10

Document Reference: NRI-2 (2009). T 1

For use with the MORT Users' Manual (NRI-1)
Communication Single Priority Use of
Unplann
Published and distributed by the Knowledge
of Knowledge Monitoring Previous Routine Health Event Problem
Planned
Change -ed Change New Info
LTA Plan A.I. info Inspections Monitoring Sensitivity
Noordwijk Risk Initiative Foundation LTA
LTA LTA LTA LTA LTA
Fixes LTA
LTA LTA LTA
Oversights Assumed b1 7 b2 7
P.O. Box 286, 2600 AG Delft, & Omissions Risks
b3 8 b5 8 b7 8 b9 9 b13 10 b14 10 b15 10 b16 10 b17 10
Learning
Upstream
The Netherlands. Independ-
ent review
from
Audits
S/M 1 R 56 Workers
LTA LTA LTA
b4 8 b6 8 b8 9
20th December 2009
Based on Internal External
Email: Info@nri.eu.com Known
Existing No Known Communication Communication Priority Status
R1 R2 R3 R4 Rn Precedent Problem Statistics Display
Website: www.nri.eu.com Precedent
Knowlege LTA LTA
List LTA LTA LTA
c1 6 c2 6 c3 7 c4 7
b10 9 b11 9 b12 9
ISBN 978-90-77284-09-4
Specific Management
Control Factors System Factors
LTA LTA
S 1 M 37 Codes & List of Local Solution Prev. Network Network Network Network
Manuals Experts Knowledge Research Inv/anal Research Structure Operation Structure Operation SA2

SA2
LTA LTA LTA LTA LTA LTA LTA LTA LTA LTA
d1 6 d2 6 d3 6 d4 6 d5 6 d6 6 d7 7 d8 7 d9 7 d10 7 Stabilisation
& Restoration
LTA
34
Accident
Stabilisation Occurrence
Oil leaks from Accident & Restoration
Policy Implementation Risk Management
PSV-504 LTA of Policy LTA System LTA
LTA
SA1 1 SA2 34
SA2 MA1 37 MA2 MA3 42
Prevention Emergency Action
Rescue and Medical Dissemination Restoration &
of Follow-on (Firefighting, etc.)
Salvage LTA Services LTA of Information Rehabilitation
Accidents LTA LTA LTA
Potentially Vulnerable Events and Energy a1 34 a2 35 a3 35 a4 36 a5 36 a6 36
Controls & a1 a1 a1 a1
Harmful Energy People c24 Barriers LTA
Flows Leading to
Flow or Condition SC4 or Objects SC3 MB3 Accident/Incident Planning Execution RM Implementation RM Assurance
Monitor- Risk Analysis Review of
SB4 Process of Plan Policy of RM Policy Programme
SB1 1 SB2 4 SB3 5 33 ing Process LTA RM System
LTA LTA LTA LTA LTA
LTA LTA
a1 37 a2 40 a3 41 MB1 42 MB2 42 MB3 42 MB4 55 MB5 56
MA2
Execution Op Rehab- Restor- Absorb
Non-functional Control of Events and Plan
Non-functional Functional Functional People Barriers & Relevant to of Plan LTA Continuity ilitation ation Loss
People or Work and Barriers LTA Energy LTA
Energy Flow Energy Flow or Objects Controls LTA Accident Transfers LTA LTA LTA R12 b6 36
Objects Process LTA b2 34
b1 34 b3 36 b4 36 b5 36
a1 2 a2 2 a2 4 SC1 5 SC2 31 SC3 33 SC4 33
a1 4
SB3 SB1
Specification Use of Leader- Capability Support Time & Delays Caused Aims Prog Docum- Assurance Prog Assurance Prog
Barriers LTA Barriers LTA of Plan Feedback Activities
ship LTA LTA Budget & Policy Scope entation Organisation Services
LTA LTA R12 b7 41 Failure LTA
LTA LTA LTA LTA LTA LTA LTA
b1 37 b2 39 b3 40 b4 40 b5 40 b6 40 b8 41 Personnel and/ Task
a1 55 a2 55 a3 55 a4 55 a5 56 a6 56 Training & Response
SD6 SD6 Notification or Equipment Logistics Performance
Experience Delay
LTA Changes LTA Errors
LTA R11 c6 35
Control Diversion Control of c5 35
Control Control Control Control People Evasive Action On the On Persons Separate in c1 34 c2 34 c3 34 c4 35 b3
Impracticable of Use of Energy Impracticable Exposure Between SD5
LTA LTA LTA Energy Source or Objects Time or Place
LTA LTA LTA Task
Task
R1
b2 2
R3 Methods, Specification of Communication
2 b2 4 Schedule Budgets Account- Performance
Performance
b1 b3 3 b4 3 b1 4 b3 4 b4 4 a1 31 a2 32 a3 33 a4 33 Criteria, Responsibilities Plan Authority Progres-
a1 a1 a1 Analyses LTA ability Errors
Errors RM Assurance Comm-
LTA LTA LTA LTA sion of
LTA LTA c8 40 Staff Perform- ittees
40 40 b3 improv’t
c1 37 c2 38 c3 38 c4 38 c5 39 c6 c7 ance LTA LTA
SD5 LTA
b1 55 b2 55 b3 55
b3
Control Divert SD5
Impracticable Means of None Barrier Did Not Use
LTA Evasion
R2 Evasion Impracticable Possible Failed
c1 3 c2 3 LTA Line Staff Task Inform-
R4 R9
b1 31 b3 Guidance
c2 4 b2 32 Respons- Respons- Assign- ation and
c1 4
ibility ibility ment Flow Directives
LTA LTA LTA LTA LTA
d1 38 d2 38 d3 38 d4 39 d5 39
Task Concepts and Design and
D/N Requirements
Performance Development
Provide LTA LTA
R10 Error
c1 32 c2 32 42
b3 a1 a2 46
SD5

Technical Supervision Support of Technical Definition of Risk Analysis Specification Information Energy Human Factors Inspection Maintenance Specification Conting- Indep- Config- Docu- Fast Design Acceptance
Operational Criteria for Life Cycle Arrange- Environ- Emrgncy Disposal
Information Inspection Maintenance & Staff Supervision Information Goals & Tolerable Criteria of Requirements Search Control (Ergonomics) Planning Planning of Operational Shutdown ency endant uration mentation Action
Readiness Procedures Analysis LTA ment ment Planning & Change Control
Systems LTA LTA LTA Performance LTA LTA System LTA Risks LTA LTA LTA LTA LTA Review LTA LTA LTA Readiness LTA Provision Planning Review Control Control Cycle
LTA LTA LTA LTA LTA LTA LTA LTA LTA Processes LTA
LTA LTA
SD1 5 SD2 11 SD3 12 SD4 12 SD5 14 SD6 29 b1 42 b2 43 b3 43 b4 44 b5 45 b6 a1 45 b7 45 b8 46 b9 47 b10 a1 49 b11 a1 49 b12 49 b13 50 b14 41 b15 52 b16 52 b17 52 b18 53 b19 53 b20 53 b21 53 b22 53
SD1 SD3 SD4 SD6 SD1 SD1 SD3 SD4

Supvn Detection or Performance

Time Correction of
Continuity Errors
LTA Hazards LTA b6 b6 c18
LTA SD3 SD4 SD5 ES&H Perform Change Solution Rqmt for D/N Controls & Super-
Goals & Measure- Automatic Manual Personnel Personnel
a1 14 a2 14 a3 14 a4 18 Goals &
Analysis Precedence Scope Life Cycle Substitute vision
Risks not Risks not ment Scale
Safer Control Controls Barriers LTA Selection Motivation
Sequence LTA Analysis
Defined Defined LTA LTA Energy LTA LTA LTA LTA LTA
LTA Env'l LTA Extend-
c2 c5 c8 b1 c1 43 c2 43 Plan c4 43 Analytical c6 44 Required c8 44 c14 45 c16 46 c18 c24 47 c31 50 c33 51 Training c35 52
Impact ed Use 46 c20 46 c22 47 Test & Task Monitor
Detection of Correction of SC2 SA2 MA2 MB4
LTA Methods Alternatives
Analysis Analysis
SB3
Qualifica- & Qualif-
LTA Procedures D/N ication
Points
Hazards LTA Hazards LTA LTA LTA LTA tion LTA Meet Criteria LTA
Safe LTA
c3 43 c5 43 c7 44 c15 46 c17 46 D/N
b1 14 b2 16 Task Errors in Emergency Energy c30 50 c32 50 c34 52 c36 52
Limit Warnings
Performance Performance of Shut-off Release
Errors Unrelated Tasks Energy LTA
Errors LTA
Verification of Interface Config-
Technical c19 46 c21 46 c23 47
Ops/Maint b3 18 b4 28 b5 28
Readiness LTA Support uration Incident Local
& Testing
LTA LTA LTA has occurred National Codes &
a1 11 a2 11 a3 11 a4 11 Supv Laws Byelaws
Detection Time Workforce Interdept D/N Correct House-
Checklist Postponed keeping Judgem- Customer National Ergo- Task Task Interface Error Match to Match Spec. Code Standard- Accept- Control
LTA Plan LTA LTA Input LTA Co-ord in Time c10 45
& Internat'nl
c12 45 Internal nomics Predict- Hardware to Task & Warnings Lockouts of Work Compliance isation of ance of Change
LTA ent LTA & Stake- Analysis Allocation Design LTA
LTA R5
c6 16
Emergency Codes & Standards knowledge Change Equipmnt LTA LTA Conditions Verification Parts Criteria Process
Allowed Errors in holders LTA LTA ion LTA
c1 14 c2 15 c3 16 c4 16 c5 16 c7 17 c8 17 c9 17 Prohibited Performance Stds LTA LTA LTA LTA LTA LTA LTA LTA
Activities Unrelated c28 48
Did not Activities Errors c9 45 c11 45 c13 45 c25 47 c26 47 c27 47 c29 49 d5 50 d7 51 d9 51 d11 51 d13 51 c37 53 c39 53 c41 54 c43 54
tasks
Specify Procedure Follow-up
c16 28 c17 28 c18 b3 28 c19 28
Check LTA LTA SD5
D/N Engine- Design
b1 11 b3 11 b5 11 Logs & Supv's Change Match Emergcy Task Comms Testing Reliab-
Relate to Authority Budget Time ering Description
Compet Monitor to Users Provisions Sequence Interfaces ility & QA
Criteria Diagrams Review Prior Studies LTA
LTA -ence Plan LTA LTA LTA LTA LTA LTA LTA LTA LTA
LTA LTA
LTA LTA Events
LTA d6 50 d8 51 d10 51 d12 51 c38 53 c40 54 c42 54 c44 54
b2 11 b4 11 d1 15 d2 15 d3 15 d4 15 d5 17 d6 17 d7 17 39 Display
39 Media-
39 Control
39
Definition
of Users Design tion Design
LTA LTA LTA LTA
d1 48 d2 48 d3 48 d4 48

Task-Specific Task-Specific Personnel

Task Pre-Task Task
Risk Assessment Risk Assessment Procedures Performance
Assignment Briefing Discrepancy
Not Performed LTA D/N agree W
LTA LTA
c11 18 c12 20 Situation c15 23
c10 18 c13 22
c14 22

High Potential
Not Identified
R6
Low
Potential
d9 19
Task-Specific
Risk Analysis
LTA
Recommended
Risk Controls
LTA
Personnel
Selection
LTA
Training
LTA
Consideration
of Behavioural
Variation LTA
Personnel
Motivation
LTA
(Provisional) Assumed Risks
d8 18 d10 20 d11 21 d12 23 d13 23 d14 24 d15 25

MORT Reference Description of (Provisional) Assumed Risks Judgement

R6 The staff might though low risk. Although pump-A & B were both faulty. Bad
Supv
Job General
Task Task No Verific- Supervisor Leadership Perform Personal
Task Compat- Testing Directive Avail- Adapt- Use not Criteria Testing Methods Normal is Interest Obstacles Motivation Pressure blind was not installed might it be assumed that the line will not be pressurized as pump is under maintenance. Bad
Analysis Analysis Knowledge LTA Execution LTA Clarity ation Observa- Correction LTA & Example Conflict R10
Analysis ibility of control ability ability Mandatory LTA LTA Training LTA Variability LTA Punishing Building to perform Prog LTA
Not Reqd Not Made LTA to Use tion LTA
LTA LTA LTA R7 LTA e24 25 LTA
LTA LTA LTA e12 22 Production from Tartran, MCP01 and Claymore was continue by assuming the situation in control at
e3 19 e4 20 e5 20 e13 23 e14 23 e15 23 e17 23 e19 23 e20 24 e22 24 e23 24 e26 25 Non- e28 26 e30 26 e31 27 e32 27
e1 18 e2 19 e6 21 e7 21 e8 21 e9 21 e10 22 e11 22 Trainer Group R11
Definition Time Perform is Piper. Bad
Skills Norms
of Needs Changes Pressure Rewarded
LTA Conflict
LTA
e16 23 e18 23 e25 e27 26 e29 26 R12 Maintenance of pump-A was delayed due to unavailability of spares. PSV-504 job was not completed on Bad
e21 24
urgent basis. The delay was caused, by assuming pump-B will remain in operation till pump-A
Supv Technical Hazard Re-instru Enforce- With With Deviant
Use of maintenance completion.
Budget Time Time Scope ction LTA ment Super- Traits
Authority Judgem- Workers’ Information Selection
LTA Others
LTA LTA Input LTA Systems LTA LTA LTA LTA visor R8 f17 27
LTA ent LTA
f12 24 f13 24 f15 27 f16 27
f11 21
f1 19 f2 19 f3 19 f4 19 f5 20 f6 20 f7 20 f9 21
SD1
Budget Analytical
LTA Skill LTA
f8 20 f10 21
b5 a5
SD3 SD4 SD6 MA2 MB4

SD3 SD4 SD6

Hazard Hazard Maintenance Support of
Inspection
Identifica- Prioritisa- Supervisors
LTA LTA
tion LTA tion LTA LTA
g1 21 g2 21 12 12 29

b10 b11
MB1 MB1

Research Standards Use of

Plan Execution Plan Execution Support & Directives Resources
LTA LTA LTA LTA LTA LTA LTA
An event, usually a fault or AND Gate - Requires the coexistence of all D/N Did not a2 29 a4 29 a6 30
oversight, expressed in generic gate inputs to produce output. a1 12 a2 13 a1 12 a2 13 Response
Help & Info
terms. Exchange Resources to Risk
D/NP Did not provide Training Referrals
An event described by a basic OR Gate - Requires any one gate input to LTA LTA LTA
LTA
component or part failure. It marks produce output. If more than one input, the Environment, Safety a1 29 a3 29 a7 30
output will still occur. ES&H a5 29
the lowest level of development & Health
in the tree.
Conditional gate (either AND or OR) - Inputs Specification Log Task Specification Analysis Point of Task
Condition F/T Failed to Analysis Caused Time Performance Caused Time Performance
An event where sequence is ended Input produce the output provided the condition of Plan LTA of Failures Access of Plan LTA of Failures operation
for lack of information or solutions. is true. Failure LTA Errors Failure LTA Errors
LTA Less than adequate LTA LTA LTA log LTA
The event may be transferred to b1 b2 b3 b4 b5 b6
Constraint symbol - Applies conditions to b1 12 b2 13 b3 13 b4 13 b5 13 b6 b3 13 12 13 13 13 13 b3 13
"Assumed Risks". SD5 SD5
gate or output. W With
An event that is satisfactory. Training Access to Access to Co-ord of
Triangle - Used to transfer sequence to RM Risk Management Expertise Equipment Resources
another location on page. LTA
LTA LTA LTA
An event that is normally Transfer to Assumed Risk branch - denotes Co-ord- Compet- Co-ord- Compet- b1 29 b2 29 b3 29 b4 29
Inspect- Inventory Maintain Plan not Schedule
expected to occur. Rn problems for which there is no practicable Frequency ination ence ination ence
ability -ability Complete LTA
countermeasure LTA LTA
LTA LTA LTA LTA LTA LTA
c1 12 c2 12 c3 12 c4 12 c5 12 c1 12 c2 12 c3 12 c4 12 c5 12
NRI-2, Second Edition, August 2009. Revised by John Kingston, Floor Koornneef, Jaap v.d. Ruit, Rudolf Frei, and Philippe Schallier. Major revision of MORT 1992,
US Department of Energy, drawn by John Kingston.