JournalofofEnvironmental

Journal Environmental Health

Healthand
and
Sustainable Development(JEHSD)
Sustainable Development

Helping HSE Team in Learning from Accident by Using the Management

Oversight and Risk Tree Analysis Method
1 2 3
Iraj Mohammadfam , Samaneh Mohseni , Mohammad Sadegh Sohrabi
4 1*
Mohsen Hesami Arani , Habib Allah Rezapour
1
Department of Occupational Health Engineering, School of Public Health and Research Center for Health Sciences,
Hamadan University of Medical Sciences, Hamadan, Iran.
2
University of Tehran, Tehran, Iran.
3
Department of Industrial Design, School of Architecture and Urban Design, Art University of Isfahan, Isfahan, Iran.
4
Environmental Health Engineering, Kavir Steel Complex, Aran Bidgol, Iran.

ARTICLE INFO ABSTRACT

Introduction: The effects of accidents vary from minor injuries to fatalities
ORIGINAL ARTICLE and from insignificant damage to severe damage to the environment and
property. In order to prevent accidents in the work place, the root causes of
and events should be identified using a systematic method and the results
Article History: should be published. The current study aims to investigate the given causes
Received: 15 April 2016 of an accident in order to implement preventive actions in accidents and
Accepted: 11 August 2016 similar organizations.
Materials and Methods: In this case study, after choosing the main event; to
analyze the accidents, at first a set of questions in Management Oversight
*Corresponding Author: and Risk Tree (MORT) were answered. By answering the questions, the final
Habib Allah Rezapour events, and the inappropriate management risks (color-coded red) followed
Email: by the leading causes of the accident were identified.
[Link]@[Link] Results: After analyzing the given accident, 22 inappropriate final events
(color-coded red) and 4 assumed risks were identified. Of the total 12
Tel: identified basic causes, about 75 % were classified as the management
+989113251182 policies and decision makings group, 17 % as the individual factors, and 18
% as the environmental factors group.
Conclusion: The analysis using MORT method helped the organization with
Keywords: learning lessons from the accident especially at the management level. In
Accident, order to prevent the similar and dissimilar accidents, the inappropriate
Analysis, informational network within the organization, inappropriate operational
Management, readiness, lack of proper implementation of work permit, the inappropriate
Prevention. and lack of updated technical information systems regarding equipments and
working process, and the inappropriate barriers should be considered in a
special way.

Citation: Mohammadfam I, Mohseni S, Sohrabi MS, et al. Helping HSE Team in Learning from Accident by Using
the Management Oversight and Risk Tree Analysis Method. J Environ Health Sustain Dev. 2016; 1(2): 91-9.

Introduction electricity power and machinery, contact with

Accidents are the main causes of death and chemicals and etc. have caused human beings to
disability which are placed at the third rank after encounter with countless incidents. Annually,
the cardiovascular diseases and cancer around the millions of accidents around the world occur.
world. Currently, the remarkable advances in Some of these accidents cause human death and
industrial affairs and the possibility of using others lead to the whole or partial disability.
modern transportation system to travel, the use of Generally, all accidents cause their victims suffer
 Learning from Accident by Using MORT Mohammadfam I, et al.

from pain as well as economic and financial the context of safety science and their results
losses 1. were announced to all leading countries. Experts
According to the International Labor Organization believe that using the others' information and
(ILO): experiences about past events is one of the ways
- Over 317 million on the job-accidents occur for preventing those accidents and is considered as
annually. an important factor in continuous improvement and
- More than 2.3 million workers die of work- development of safety performance 5.
related accidents and occupational diseases every A lot of accidents can be avoided by knowing
year. the factors which caused them. To realize
- About 4 percent of the world's Gross Domestic this, causes of the accident should be determined
Product (GDP) is spent on accidents and work- first. At the next step, the acquired knowledge
related diseases 2. and awareness should be employed. In this
In spite of the significant improvements case, hazards can be detected before converting to
achieved in safety science and introducing system accidents and accidents can be avoided
safety which emphasizes on hazards' identification consequently 6.
and control before converting to the accident, it is In this vein, in recent years new techniques
still impossible to reach the zero rates of accidents regarding accidents' investigation and analysis
and certainly it will not be the case in the future. have been introduced to improve the effectiveness
Investigating the occurred accidents and incidents of research and also to revise and expand
increases the authorities’ awareness to determine techniques. Management Oversight and Risk Tree
the related causes and finally design appropriate (MORT) is one of the mentioned techniques. This
programs to prevent the future similar accidents technique arose from a project undertaken and
and factors leading to human and material defined by Bill Johnson in 1970 to provide a risks
resources waste 3. management program for US nuclear industry.
A systematic approach is required to investigate This technique implementation method was
and analyze incidents to avoid them effectively. revised in 2002 and 2009 for the first and second
Therefore, accident-related studies have always time, respectively. In this study, the revised
been considered as an undeniable part of safety guideline of 2009 was used. The same as Fault
science. Moreover, the proper design and Tree Analysis (FTA), this technique is an
appropriate implementation of these studies will analytical tree in which the accident is determined
provide a platform for preventive measures by the term “loss”. This technique is able to
[Link]

regarding the possible accidents in the future. analyze the accident as well as the near miss. Due
Therefore, it can be said that, accidents and near to chart depicting and visual characteristics, this
miss provide an opportunity to avoid similar technique helps the analysts to find the relationship
incidents in the future by learning from between events and imagine the probable hazards.
experiences and taking the required lessons. The If MORT technique implementation method is
United States Department of Energy (DOE) correctly understood, it will be performed easily
92
divides accidents' investigation process into 3 due to having a ready set of questions. MORT is a
stages: collection of evidences and facts, analysis comprehensive method to detect the effective
and investigation of these facts and evidences, and factors in the accident in a regular and systematic
finally development of conclusions and judgments way. As this technique emphasizes on management
of needs, as well as writing the report and factors contributing to an accident, it can also be
publishing 4. used as a mean to evaluate the quality of safety
Accident related studies that include precise program available in the organization 7.
analysis and explanation of data followed by Alvarado-Corona et al, conducted a research on
presenting suggestions, have been used broadly in earthquake hitting the central part of chili and

JEHSD, Vol (1), Issue (2), September 2016, 91-9

Mohammadfam I, et al. Learning from Accident by Using MORT

released the effective factors causing the loss and have gone further and used MORT technique to
damage to help reducing the similar incidents’ analyze an accident which had occurred due to
consequences. Perhaps some of these factors social anomie. After analysis, the inappropriate
included the inadequate technical information information system, failing to take lessons from
related to earthquake warning, inadequate informing similar events in the past, inappropriate support and
and communication within the organization, guidance from supervisors and senior managers,
inadequate operational readiness in the times of inappropriate operational readiness, inappropriate
disaster, defects in the evacuation and rescue response in emergency situations, and inappropriate
process, and the inappropriate implementation of barriers were introduced as the root causes of the
permit to work 8. Using MORT technique, accident12. The purpose of these studies for
Appicharla conducted a research on the space investigating the accidents using this technique was
shuttle challenger disaster in 2012 to determine the to uncover the accidents' causes and to learn from
accident’s causal factors such as inappropriate them to reduce the rate of accidents' occurrence and
communications, inadequate analysis of the their unwilling outcomes in the future accidents.
previous research, inadequate risk assessment The current study was also conducted to uncover the
system and its control, inappropriate operational root causes of the accidents and to disseminate them
readiness, inappropriate policy implementation, to prevent the similar incidents.
inappropriate technical information systems, and
Materials and Methods
inappropriate barriers 9. In 2011, Appicharla
To investigate the accident which happened
analyzed a passenger train collision with a car at an
in an excavated channel, this case study was
intersection. In order to analyze the accident by
conducted in a gas power plant in Golestan
using MORT technique, the reports of the Rail
province. This accident led to a mapping
Accident Investigation Branch and the Rail Safety
technician’s death nailing in the channel. Like the
and Standards Board were applied in this study. The
Fault Tree Analysis (FTA), this technique is an
analysis results identified factors such as the
analytical tree. The accident was determined by the
inappropriate data analysis, inappropriate risk
term “loss” in this technique. This technique is
assessment and control system, inappropriate hazard
able to analyze the accident as well as the near
analysis process, inappropriate standards, and
miss. Moreover, MORT is a comprehensive
inappropriate revision of safety program 10. In
method to detect the effective factors in the
addition, one of the studies done in the natural
accident in a regular and systematic way. This
disasters' domain using this technique is a
technique emphasizes on management factors

[Link]
research conducted in 2010 by Santos-Reyes et al,
contributing to accident and can also be used as a
on the flooding disaster of Mexico's state of
means to evaluate the quality of safety programs
Tabasco. Following the accident, the root causes
applied in an organization 12.
were announced to be the inappropriate operational
readiness, inappropriate inspection process, MORT implementing method:
inappropriate barriers, inappropriate supervision An important incident was chosen among a
93
9
support, and inappropriate technical information chain of incidents occurred during the accident and
systems 11. Interestingly, Santos-Reyes et al, placed on top of the MORT diagram (Figure1).

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Learning from Accident by Using MORT Mohammadfam I, et al.

Figure 1: Top part of MORT chart

In this method the final events situation is inspection related to the problem in question. In
determined with color-coded red (inappropriate or the following each part is explained.a1. Planning
LTA; less than adequate), green (appropriate), Process LTA: This branch considers whether the
black (an event which did not occur in this scope of inspection plan considered all the areas
accident), and blue (incidents requiring more relevant to the problem in question adequately.
research to determine their situation). Then, a set Was the management aware of any aspects
of questions, more than 50 pages, were applied the relevant to the problem in question not included in
same as the technique which a small part of it is the plan?
presented below 13. For better understanding, a b1. Specification of Plan LTA: This branch
[Link]

branch of the extended MORT diagram (Figure 2) considers whether the problem in question is
is presented below. related to how the inspection plan was specified.
SD3. Inspection LTA:
This branch considers the contribution of
equipment, processes, utilities, operations, etc.
94

JEHSD, Vol (1), Issue (2), September 2016, 91-9

Mohammadfam I, et al. Learning from Accident by Using MORT

Figure 2: The parts of accident MORT chart

C1. Inspect ability LTA: is the problem in question a result of inadequate inspect ability?
[Link] of the Plan LTA: Is there an adequate inventory of what is needed or inspected
[Link] LTA: did the plan schedule inspections frequently enough to prevent or detect undesired changes? Was the
schedule readily available to the inspection personnel?
[Link]-ordination LTA: did the inspection plan address methods adequately for minimizing problems with disruption to
equipment, processes, utilities, operations, etc. when they are under inspection? Was the schedule coordinated with

[Link]
operations to minimize conflicts?
C5. Competence LTA: Was personnel competence adequately specified/ developed for the inspection tasks in question?

In order to answer these questions and judge In accidents related studies, causes are
from the events in this study, the required data investigated at three levels including: 1- direct
was gathered through investigating the existing causes (unintended release of hazardous materials
95
9
evidences (work permissions, safe work procedures, and energy), 2- indirect causes (unsafe acts or
monitoring work posts' checklists, personal conditions), 3- basic causes (policies and decisions,
protective equipment's delivery receipts, accident personal factors, and environmental factors) 14.
reports, and the accident's existing photos) as well Some researchers were conducted on accidents
as the environmental evaluations based on walking only to detect and correct the direct and indirect
talking through method (interview the staff who causes (surface causes). But, in fact these detected
witnessed the incident, research and development indirect causes are an indication of the existence of
unit experts, plan and control production experts, some root causes which are often called basic
and HSE experts). causes15. In the current study, after extracting the

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Learning from Accident by Using MORT Mohammadfam I, et al.

causes of an accident, the surface and basic (root) Personal factors: 1- Physical: Inadequate
causes, and the frequency of these three groups of strength and endurance 2- Experience: Inadequate
basic causes (policies, the management decisions knowledge and skills, a previous instance of
about safety and personal and environmental accident, implementing unsafe work methods 3-
factors) were determined. To get more familiar, Attitude: Toward others, people, firm, work,
some of these three groups of the basic causes are oneself, addiction to alcohol, using drugs,
presented in the following: emotional upset. 4- Behavioral: risk taking,
Policies and safety management decisions: undermining risk, etc.
1- safety policy: were not written or signed by the Environmental factors: 1- Unsafe designing of
senior manager of the organization. 2- Safety facilities: poor locating as well as restricted and
executive methods have not been provided for busy access ways. 2- Unsafe operational methods
performing the following items: safety sessions, in the normal and emergency state. 3- The weather
job safety analysis, housekeeping, accident 4- Geographical region and etc.16.
investigations, preventive maintenance and repair,
Results
and finally inspections and safety audit. 3- Safety
After analyzing the accident, MORT diagram
in providing supplies and services was not
was depicted (Appendix 1). Based on diagram 22
considered. 4- Employee’s safety was not
and considering table 1, the inappropriate final
considered with regard to the following cases: their
incident (color-coded red) was determined. In
selection methods, communicating with others,
addition, 4 risks incorrectly accepted by the
training, and etc.
organization are presented in table 2.
Table 1: Final incidents with red color code
No Incident code Incident description
1 SB1-b3 Controls of the energy were less than adequate (LTA).
2 SB2-c2 Evasion was impracticable.
Individuals didn’t making decisions adequately apply the knowledge from codes and
3 SC1-SD1-c1- d1
manuals.
4 SC1-SD1-c3-d7 Structure of the internal communication network wasn’t adequate.
5 SC1-SD2-b5 All actions identified through operational readiness checks weren’t adequately followed up.
6 SC1-SD2-a2 Technical support provided to assuring the readiness of the work/process wasn’t adequate.
Actual physical arrangement or configuration of the work/process wasn’t identical with that
7 SC1-SD2- a4
required by latest specifications and procedures.
8 SD3-c2 There isn’t an adequate inventory of what is to be inspected.
plan schedule inspections didn’t frequently enough to prevent or detect undesired changes.
[Link]

9 SD3-c3
10 SD3-c4 Schedule wasn’t coordinated with operations to minimize conflicts.
11 SD3-b5 Time specified in the plan's schedule wasn’t sufficient to adequately perform each task.
12 SD5-a2 Continuity of Supervision LTA.
13 SD5-a3-b1-c1 Absence of such a checklist contributed to the problem in question.
A lack of open and frank communication between upper and lower levels contributed to
14 SD6- a3
problems in the control of the work/process in question.
96 Codes, standards, and regulations (internal or external) did not cover the control of the
15 SD6- a4 work/process in question, management did not develop adequate standards and issue
appropriate directives.
16 SD6- a7 Management wasn’t adequately responsive regarding the problems proposed by lower levels.
17 SD5-b3-c14 Fit between Task Procedures and actual Situation LTA.
18 SC2- a2- b1 Barriers are not possible between energy source and target.
19 SC2-a3-b1 Barriers are not possible on persons.
20 SC2-a4-b1 Barriers are not possible to separate time and distance.
SD5-b3-e16&
21 Emergency performance criteria training LTA.
SA2-a2-c5-e16
22 MA3- MB5 Review of Risk Management System LTA.

JEHSD, Vol (1), Issue (2), September 2016, 91-9

Mohammadfam I, et al. Learning from Accident by Using MORT

Table 2: Assumed risk

Assumed risk states Risk description Risk reference in MORT analysis
When energy is released (landslide) it's impossible
Inappropriate R4 = SB2- c2
for people in situ to escape.
Creating a barrier between the energy source and
Inappropriate given person is not possible due to inadequate space R9 = sc2-a2- b1
in the given place (channel).
It is also not possible to create a barrier on the given
Inappropriate R9 = sc2- a3-b1
person to be protected from the effects of energy.
Time and place separation is also impossible for the
Inappropriate R9 = sc2-a4-b1
person who performs the given action.

Discussion SD3.c2, SC1.SD2.b5, SC1.SD2.a4, SD3.c3,

Amongst the incidents occurred, the surface SD5.a3.b1.c1 ,SD5.a2, SD6.a3 ,SD6.a4 ,SD6.a7,
causes of the accident were presented on different SD5.b3.e16, SA2.a2.c5.e16, and.MA3.MB5
levels of the above diagram. Further, the sub- Probably, due to different types of the studied
branch, i.e., S, related to the inappropriate specific incidents, some of the causes of accidents such as
control factors (what has happened?) and 11 inadequate analysis of the previous research,
surface causes along with their associated code are inappropriate risk evaluation system and its
presented below. control, inappropriate policy implementation in
SC1. Control of work and process LTA. SC2. Appicharla’s study 9, inappropriate data analysis,
Barriers LTA. SD1. Technical Information Systems inappropriate risk assessment and control system,
LTA. SD2. Operational Readiness LTA. SD3. inappropriate risk analysis process in Appicharla’s
Inspection LTA. SD5. Supervision and Staff study 10, and failing to learn lessons from similar
Performance LTA.SD5.a3. Detection / Correction of events in the past in Santos-Reyes et al study 12 are
Hazards LTA.SD5.a4. Performance Errors. SD6. different from causes of the studied accident in the
Support of Supervision LTA. SA2.a2. Emergency current research. Some of the discovered causes in
Action LTA. SA2.a3. Rescue and Salvage LTA. this study namely inappropriate information
(Lack of quick action to save the injured person due network within the organization were repeated in
to the place's special conditions, i.e., inside channel, the researches conducted by Alvarado-Corona et al
8
and lack of the necessary equipments). , Appicharla 9, and Santos-Reyes et al 12. The
Surface causes in occurrence of an accident are inappropriate operational readiness and the lack of

[Link]
causes that appear immediately after the incident correct implementation of permit to work can be
which occur mostly due to unsafe actions and seen among the extracted causes of the accidents
conditions. However, identifying the hidden causes investigated in the 3 studies conducted by
(root causes) which are far from the accidents, in Alvarado-Corona et al, Appicharla, and Santos-
terms of time and place, and usually occur at the Reyes et al 11. The causes such as inappropriate
organization level as well as presenting corrective technical information systems and inappropriate
97
9
measures for them are very effective in preventing barriers were repeated in the research done by
accidents 17. Appicharla as well as Santos-Reyes et al 11, 12, and
In MORT technique, the root causes of the inappropriate support of supervision was
accidents appear in the sub-branch S at the final repeated in the study conducted by Santos-Reyes
levels of the diagram, while inappropriate et al 11, 12.
management factors (why it has happened), appear In the light of the above, the root causes are
in the sub-branch M , in this regard, 12 causes' divided into 3 groups, from 12 root causes
codes are presented below. obtained in this accident analysis, 9 causes were
related to defects of the management's safety

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Learning from Accident by Using MORT Mohammadfam I, et al.

policies and decisions, 2 causes were associated formulated for discovering unwanted changes in this
with personal factors, and 1 was related to the program, the other operations’ starting and unsafe
environmental factors domain. implementing followed by possible accidents could
have been prevented. By studying similar basic
Conclusion
causes in the accidents' analysis mentioned
As the initial investigation of HSE unit showed,
previously 7-11. It can be said that lack of appropriate
the cause of accident was determined to be
updated technical information systems regarding
unsafe excavation against the existing codes and
equipments, working processes and inappropriate
standards such as lack of using protective box
barriers should be considered in a special way.
and performing action without permit to work.
Thus, taking corrective and preventive actions for
However, the analysis using MORT technique
this category of the root causes are effective in
helped the organization with learning lessons from
preventing similar and dissimilar accidents. It is
the accident by uncovering the root causes
also recommended to analyze a variety of
especially at the management level. These causes
accidents in different organizations using diverse
had not been uncovered through the previous
and new techniques and report the results. This
methods used by the workshop HSE team.
helps the organization managers and HSE experts
In most industries, usually, surface causes
to increase their knowledge by studying these
(direct and indirect) are determined after the
extracted causes, especially the root and basic ones
accident's occurrence and investigation. But
which play a significant role in occurring
analyzing the accident using MORT method has
accidents, and accordingly create programs, codes,
revealed more root causes. This technique is very
standards, and executive methods or revise them.
useful in root analysis of incidents especially for
In order to obtain better results and uncover this
finding causes at management organization level.
technique’s weaknesses and strengths, it is
From the 12 basic identified causes, 75% of them
required to measure the efficiency of this technique
(with codes, SD5-a2, SC1.SD5.a3.b1.c1, SD3.c3,
in the analysis of more accidents, either
SD3.c2, SC1.SD2.b5 MA3. MB5, SA2.a2.c5.e16,
occupational or non-occupational ones. In addition,
SD5.b3.e16, SD6.a3) were placed in the management's
it is needed to compare the results obtained from
policies and decisions group, 17 % of causes
this technique with the results obtained from other
(namely; SD6.a7,SC1.SD2. a4) were put in personal
techniques of accident analyses.
factors' group, and 8 % of them (SD6.a4) were
placed in the environmental factors' group. This Appendix
indicates the importance of management policies More information available at: http:
[Link]

and decisions in the occurrence of accident. [Link].

Organizations with the working operations such Acknowledgements
as the one in which this accident occurred can Authors gratefully acknowledge Hamadan
prevent the same incidents by studying the surface University of Medical Sciences and MAPNA
and root causes and learning from them. For groups for support of this research.
98 instance, if the inspection and monitoring program
had been implemented regarding the surface causes Funding
coded as SC, 1during the excavation operation; This study was funded by the authors.
the same accidents could have been avoided. Conflict of interest
If preventive measures had been implemented We have no competing interests.
for SD3.c2 and SD3.c3 root causes, in other
words if the comprehensive, complete and This is an Open Access article distributed in
scheduled inspection, and monitoring program accordance with the terms of the Creative Commons
with determined times of repetition had been Attribution (CC BY 4.0) license, which permits others

JEHSD, Vol (1), Issue (2), September 2016, 91-9

Mohammadfam I, et al. Learning from Accident by Using MORT

to distribute, remix, adapt and build upon this work, for Conference on System Safety. 2012 Oct 15-18;
commercial use. Edinburgh,UK.
9. Appicharla S. Modelling and analysis of
References Herefordshire level crossing accident using
1. Ghamari F, Mohammad beige A. management oversight and risk tree ( MORT ).
Epidemiological survey of occupational Paper presented at: 6th IET International
accidents and related factors in azarab factory Conference on system safety.2011 Sep 20-22;
from 2004 to 2006. A research project in Arak Birmingham, UK.
University of Medical Science; 2007. 10. Santos-Reyes J, Alvarado-Corona R, Olmos-
2. International Labour Organization. Safety and Peña S. Learning from tabasco’s floods by
health at work: a vision for sustainable applying MORT. Safety Science. 2010; 48(10):
prevention. Paper presented at: XX world 1351–60.
congress on safety and health at work. 2014 Aug 11. Santos-Reyes J, Olmos-Peña S, Alvarado-
24-27; Frankfurt, Germany. Corona R, et al. Applying MORT to the analysis
3. Amoozad khalili H, Maleki A, Tavakoli of the “Tláhuac” incident. Reliab Eng Syst Saf.
moghadam R. Explanation and analysis of risk 2009; 94(10): 1547–56.
factors in safety management of mining industry. 12. Frei R, Kingston J, Koornneef F et al. NRI-1
Paper presented at Second international HSE NRI MORT user’s manual. 2nd ed. Noordwijk
conference. 2009; Tehran, Iran. Risk Initiative Foundation, The Netherlands.
4. Sklet S. Methods for accident investigation. 2009. Available from: [Link] [Link]/
Norweigian University of Science and NRI1. pdf [Cited: Sep 18, 2016 ]
Technology. Trondheim; 2002. Available from: 13. Frei R, Kingston J, Koornneef F et al. NRI-2
[Link] NRI MORT CHART. 2nd ed. 2009. Available
[Cited Sep 18, 2016 ] from: [Link] [Cited
5. Kletz TA. Learning from accidents. 3rd ed. Sep 19, 2016].
Oxford: Gulf Professional; 2001. 14. Cheremisinoff NP. Practical guide to
6. Reese CD. Accident/ incident prevention industrial safety: Methods for process safety
techniques, 2nd ed. Boca Raton: Taylor & professionals. Boca Raton: CRC Press; 2000.
Francis; 2011. 15. Reese CD. Occupational health and safety
7. Alvarado-Corona R, Mota-Hernández C, management: A practical approach, 2nd ed. Boca
Félix-Hernández JL. What can be learnt from Raton: CRC Press; 2008.

[Link]
past disasters? Analysis of the mw 8.8 mega 16. Reese CD. Industrial safety and health for
earthquake of central chile with MORT. Jordan J goods and materials services. Boca Raton: CRC
Earth and Environ Sci. 2014; 6(1): 1–7. Press; 2008.
8. Appicharla SK. Analysis and modelling of 17. Asia industrial gases association.
space shuttle challanger accident using Incident/Accident investigation and analysis.
management oversight and risk tree (MORT). 2005; Available from: [Link]
99
9
Paper presented at: 7th IET International [Cited: Sep 18, 2016 ].

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Learning from Accident by Using MORT Mohammadfam I, et al.

Appendix (1) the Management Oversight and Risk Tree (MORT)

The Death of an Employee, The
negative impact on staff morale
and the company reputation
T

Oversights Assumed
& Omissions risks
S/M R

R R

Specific Control Management

Factors LTA System
Factors LTA
S M

Risk
Policy Implementation
management
LTA Of Policy LTA
system LTA
MA1 MA3
MA2

Risk Risk Management review risk

Implementation of
manageme Risk Analysis Assurance management
risk management
nt policy Process LTA Program LTA system LTA
LTA
LTA MB2 MB4 MB5
MB1 MB3

Mapping technician
Stabilization and
Death in excavated
reconstruction LTA
channel due to caving

SA1 SA2
SA2

Potentially
Harmful Energy Mapping Controls and
SC3 C24
Flow or Condition technician barriers LTA MB3

SB1 SB2 SB3

[Link]

Control of
Work and Barriers LTA
Process LTA
Non- SC1 SC2
Functional
functnonional SC1
people
people
a1 a2 Between
On the energy On
Barriers energy source person Separate in
source a2 & person Time or Place
LTA a4
a3
I a1
Non- This branch This branch
functnonional Functnonional Escape operation analysis is the analysis is the
Encounter LTA same as a2 branch same as a2 branch
Energy Flow Energy Flow
control LTA
a1 a2 b4
Barriers Barriers Did Not
b3 None
LTA failed Use
Possible
R9 b1 b2 b3

Non- Means of Evasion Did Not

None Barrier
Control of functional evasion s failed
Use
Impracticable Possible b3
Used LTA Energy Flow LTA R9 b1 b2
R4
b4 c1 c2
b3

Task Performance
Barrier was not Error
provided
R10 c2
c1 b3
SD5

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Mohammadfam I, et al. Learning from Accident by Using MORT
Appendix (1) the Management Oversight and Risk Tree (MORT)

SC1

Technical
Information Operational Maintenance Supervision & Staff
Inspection LTA Support of
Systems LTA readiness LTA LTA Performance LTA Supervision LTA
SD1 SD4
SD2 SD3 SD5 SD6
SD1
SD3 SD6

Detection or
Supervision Performance
Correction of
Time LTA Continuity Errors
Hazards LTA
LTA
a1 a2 a3 a4
Verification of Technical Interface Configuration
Readiness LTA Support LTA Ops/Maint & LTA
Testing LTA
a1 a2 a3
a4 Detection of Correction of
Hazards LTA Hazards LTA

b1 b2

Check Detection Workforce

Plan LTA Time LTA
lists LTA Input LTA

Lack of clear c1 c2 c3 c4
Readiness Investigation
and specific process of Competenc Follow-up
criteria LTA
inspection readiness LTA e LTA LTA

b1 b2 b3 b4 b5

b6 c18
SD3 SD5

c2 c5
SC2 SA2

Task Errors in Emergency

performance Performance of Shut-off Errors
errors Unrelated Tasks
b3 b4 b5

Task Task-Specific Risk Task

Task-Specific Risk Personnel Performance

[Link]
Assignment Assessment Pre-Task Procedures did
Assessment LTA Briefing LTA Discrepancy
LTA Not Performed not agree whit
Situation
c10
c11 c1 2 c1 3 c1 5
c14

II
I
Consideration of Personnel
Personnel behavioral variation of
Training LTA Motivation
Selection LTA personnel performance LTA
in doing tasks LTA
d12 d13
d14 d15

Lack of Definition Trainer

Methods Verification &
education Of Needs Skills
LTA identification, of
LTA LTA
e16 e17 e18 individuals LTA
e15
e19

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Learning from Accident by Using MORT Mohammadfam I, et al.

Appendix (1) the Management Oversight and Risk Tree (MORT)

SA2

SA2 Stabilization and

Restoration LTA

Accident
Occurrence

Prevention of Emergency Dissemination Reconstruction

Rescue and Medical of Information
Follow-on Action and rehabilitation
Salvage LTA Services LTA LTA
Accidents LTA LTA
a1 a2 a3 a4 a5 a6

Execution of Plan
Plan LTA
LTA
b1
b2

Training & Task Performance

Notification Experience Equipments and Errors(Response)
Logistics Delay
LTA LTA persons change
LTA in response
c1 c2 c3 c5
c4
R11
c6

Plan LTA Execution of Plan

LTA

b1 b2
[Link]

Training &
Notification Equipments and Task Performance
Experience Logistics Delay in response
LTA persons change Errors
LTA LTA
R11 c6
c1 c2 c3 c5
c4 b3
SD5

III

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Mohammadfam I, et al. Learning from Accident by Using MORT

Appendix (1) the Management Oversight and Risk Tree (MORT)

SD1

SD1 Technical information

systems LTA

Audit &
Technical Data collection Data analysis Triggers to Risk
Appraisal
information LTA LTA LTA Analysis LTA
LTA
a1 a2 a3 a4 a5

Inadequate
Inadequate
communication
knowledge
Information transfer
Information

b1 b2

The available
knowledge and No Known Precedent
information for unanticipated
c1 c2 energy and prevent it

SD3 SD3

Inspection LTA

Inappropriat Inappropriate
e use of Inappropriat knowledge and Inadequate
Codes & e experts list internal and local researches
d1 Manuals d2 information d4
d3

Inadequate Inadequate
Execution
internal external Plan LTA LTA
communication communication
a1 a2
c3 c4

Inadequate [Link]
Inappropriate internal
Network Network
Structure Operation Report Close to Caused Task
d8 Time LTA Performance
d7 the Operations Failure
LTA Errors
b5
b6
b3 b4

IV
I

Specification of Analysis
Plan LTA Of Failures
LTA
b1
b2

Inspectability Inventory Frequency Coordination Competence

LTA LTA LTA LTA LTA

c4 c5
c1 c2 c3

JEHSD, Vol (1), Issue (2), September 2016, 91-9

 Learning from Accident by Using MORT Mohammadfam I, et al.

Appendix (1) the Management Oversight and Risk Tree (MORT)

SD6 SD6

Support and supervision

LTA

Insufficient Inadequacy of Response to the

Inadequacy of Inadequate Use of
guidance and guidelines and Resources LTA referred risk
exploration and exchange of resources LTA
training of standards LTA
discovery information
supervisors
a2 a5
a6
a1 a3 a4 a7
[Link]

JEHSD, Vol (1), Issue (2), September 2016, 91-9