material work & task people management environment management oversight and risk tree ships in...
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MaterialWork &
Task
People
Management
Environment
Management Oversight and Risk Tree
Ships in Service Training Material A-M CHAUVEL
Identify the Causes
Approach for accident investigation
2009
- 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.
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MORT Identify the Causes Accident Causation Models
Many models of accident causation have been proposed, ranging from :
When the model is used
What are thepossible causesin each category
to be investigated.
Ships in Service Training Material A-M CHAUVEL
MaterialWork &
Task
People
Management
Environment
MORT Identify the Causes
- 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 ?
Work &Task
Work &Task
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MORT Identify the Causes Members of the investigating team shall lookfor answers to questions such as:
Work &Task
Work &Task
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For most of these questions,an important follow-up question is
“ If not, why ? "
MORT Identify the Causes
- 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 ?
MaterialMaterial
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:
Each time the answer reveals an potential unsafe condition,
the investigation team must askwhy this situation
was allowed to exist ?
MaterialMaterial
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MORT Identify the Causes
The physical environment,and
especially sudden changesto 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.
EnvironmentEnvironment
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MORT Identify the Causes
External Environment
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Internal Environment
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EnvironmentEnvironment - 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?
MORT Identify the Causes The investigation team may want to know:
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The physical and mental condition of individuals directly involved in the event must be explored.
The purpose for investigationis not to establish blame
against someone,
but the inquiry will not be complete unless personal characteristics
are considered.
PeoplePeople
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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?
PeoplePeople
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 mustalways be considered in an accident investigation.
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ManagementManagement
Answers to any of the preceding types of questions
logically lead to further questions such as :
MORT Identify the Causes
ManagementManagement
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- 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?
MORT Identify the Causes
Ships in Service Training Material A-M CHAUVEL
MaterialWork &
Task
People
Management
Environment
MORT Identify the Causes
Ships in Service Training Material A-M CHAUVEL
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.
MORT Identify the Causes
Ships in Service Training Material A-M CHAUVEL
The PotentialCauses
Causes EffectDiagram
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
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Ship and Equipment Equipment Failure
Accident
Externalenvironment
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External Environment Meteorological Conditions
- Weather
- Waves
- Light and visibility
- Hydrological
Accident
Internalenvironment
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Internal Environment Arrangements
- General arrangement
- Hull and deck arrangement
- Specific deck arrangement
- Emergency arrangement
Accident
Qualification & Work Organisation
- Deck officers and deck crew
- Engineers and engine crew
- Catering crew
- Knowledge of Flag State’s
marine legislation
- Ability to communicate
Personnel
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Personnel
Accident
Safety Organisation
- Shipboard familiarisation
- Safety familiarisation
- Emergency preparedness
- Crew co-ordination
- Training and drills
- Emergency arrangement
Personnel
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Personnel
Special Training
- Survival craft
- Rescue boats,.....
- Advanced fire fighting
- First aid
- Medical care,
- Crisis management
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Personnel
Accident
Personnel
Accident
Management
Ship
- 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
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Management
Safety Commitment
- 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
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Management
Accident
Management
Accident
Safety
- 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
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Procedures
On Board Operation
- 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
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Procedures
Accident
Procedures
Accident
Voyage
- Planning
- Notifications of deviations
- Events & Happenings
Records
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Records
Accident
Records
Personnel
- Crew list
- Competency
- Medical fitness
- Experience
- Familiarisation & training
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Records
Accident
Records
Ship & Equipment
- Mandatory certificates
- Classification Society inspections
- Statutory inspections
- Maintenance, modifications,
damages and repairs
- Work repair authorisations
- Navigational equipment
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Records
Accident
Records
Safety & Environmental Protection
- Internal inspection reports
- Non conformities
- Accidents and damages
- Near misses
- Hazardous occurrences
- Maintenance, modifications
- Work repair authorisations
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Records
Accident
Watchkeeping
- Schedules
- Master instruction
- Deck watchkeeping reports
- Engineering watchkeeping reports
Records
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Records
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One other way for classification
AccidentAccident
Ship andEquipment
EnvironmentEnvironment
PersonnelPersonnel
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Ergonomic
AccidentAccident
EnvironmentEnvironment
ManagementManagement
PersonnelPersonnel
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Psychology
AccidentAccident
ManagementManagement
ProceduresProcedures PersonnelPersonnel
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Behaviour
AccidentAccident
RecordsRecords
ManagementManagement
ProceduresProcedures
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Organization
AccidentAccident
RecordsRecords
ProceduresProcedures
Ship andEquipment
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Standardization
AccidentAccident
Ship andEquipment
RecordsRecords EnvironmentEnvironment
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Technology
AccidentAccident
Ship andEquipment
RecordsRecords EnvironmentEnvironment
ManagementManagement
ProceduresProcedures PersonnelPersonnel
BehaviourOrganisation
Technology Ergonomic
PsychologyStandardisation
People
Soft
Material
Hard
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Causes & Effect : Accident
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AccidentAccident
ProceduresProcedures& Records& Records
EnvironmentEnvironmentPersonnelPersonnel
Ship &Ship &EquipmentEquipment
Work &Work &TaskTask
ManagementManagement
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