Management Oversight and Tree Analysis Questions Student is required to review MORT PPT, PDF and Chapter 18. Student is required to complete attached quest

Management Oversight and Tree Analysis Questions Student is required to review MORT PPT, PDF and Chapter 18. Student is required to complete attached questions. I
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E 55 DC-u76-45/4
SSDC-4
Revision 3
f
Mort User’s Manual
For use with the Management Oversight
and Risk Tree Analytical Logic Diagram
February 1992
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MAY 0 6 1992
1
United States
Department of Energy
Deputy Assistant Secretary
for the
Office of Safety and Quality Assurance
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System Safety
DeveIo pment
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W O R K P E R F O R M E D U N D E R D O E C O N T R A , C T N O . D E – A C 0 7 – 7 6 1D O 1 5 7 0
DISTRl6UTlON OF T H S DOCUMENT IS UNLIMITED
W92 0065
DISCLAIMER
This report was prepared as an account of work sponsored by an
agency of the United States Government. Neither the United States
Government nor any agency Thereof, nor any of their employees,
makes any warranty, express or implied, or assumes any legal
liability or responsibility for the accuracy, completeness, or
usefulness of any information, apparatus, product, or process
disclosed, or represents that its use would not infringe privately
owned rights. Reference herein to any specific commercial product,
process, or service by trade name, trademark, manufacturer, or
otherwise does not necessarily constitute or imply its endorsement,
recommendation, or favoring by the United States Government or any
agency thereof. The views and opinions of authors expressed herein
do not necessarily state or reflect those of the United States
Government or any agency thereof.
DISCLAIMER
Portions of this document may be illegible in
electronic image products. Images are produced
from the best available original document.
I
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DISCLAIMER
This report was prepared as an account of work sponsored by the United
States Government. Neither the United States nor the United States
Department of Energy nor any of their employees, nor any of their
contractors, subcontractors, or their employees, makes any warranty,
expressed or implied, or assumes any legal liability or responsibility for the
accuracy, completeness, or usefulness of. any information, apparatus,
product or process disclosed, or represents that its use would not infringe
privately owned rights.
Available from:
System Safety Development Center
EG&G Idaho, Inc.
P.O. Box 1625
Idaho Falls, Idaho 83415
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DoE/SSDC–76-45/4-Rev3
DE92 013785
MORT User’s Manual
For Use With the Management Oversight
and Risk Tree Analytical Logic Diagram
Norm W. Knox
Robert W. Eicher
Published February 1992
System Safety Development Center
Idaho National Engineering Laboratory
EG&G Idaho, Inc.
Idaho Falls, Idaho 83415
Prepared for the
U.S. Department of Energy
Deputy Assistant Secretary for Safety and Quality Assurance
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ABSTRACT
This report contains the User’s Manual for MORT (Management Oversight and Risk Tree), a
logic diagram in the form of a “work sheet” that illustrates a long series of interrelated questions.
MORT is a comprehensive analytical procedure that provides a disciplined method for determining the
causes and contributing factors of major accidents. Alternatively, it serves as a tool to evaluate the
quality of an existing system. While similar in many respects to fault tree analysis, MORT is more
generalized and presents over 1,500 specific elements of an ideal “universal” management program
for optimizing environment, safety and health, and other programs.
This User’s Manual is intended to be used with the MORT diagram dated February 1992.
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ACKNOWLEDGMENTS
We gratefully acknowledge the many helpful suggestions we received from our colleagues of
the System Safety Development Center during the preparation of this manual.
The source document for this “condensation” was the MORT text, “MORT-The Management
Oversight and Risk Tree” (SAN 821-2), authored by W. G. (Bill) Johnson.
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INTRODUCTION TO REVISION 3
Revision 3 is designed primarily to add conceptual material developed by S. B. Haber and D.
P. Thurmond in “A Preliminary Identification of the Human Performance Issues Within the
Department of Energy,” Task 1 Report prepared for the U.S. Department of Energy (1989) and
applied in “Human Performance Appraisal” in June 1990. Concurrently, other minor revisions to the
User’s Manual were performed.
MORT text cross-references to W . G. Johnson’s 1980 “MORT Safety Assurance System” are
not being done at this time since this text is under revision. The User’s Manual will be crossreferenced to the revised “MORT Safety Assurance Systems” when these revisions are complete.
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CONTENTS
INTRODUCTION TO REVISION 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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PART1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
A . Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B . Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D . System Safety Analysis Versus the Safety System Program . . . . . . . . . . . . . . . . . . .
E . The Roles of Change Analysis and the Energy Barrier Concept . . . . . . . . . . . . . . . . .
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PART11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
A . General Features of the MORT Event Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B . Working With the MORT Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C . Plan of the User’s Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Questions for the MORT Analyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Appendix .MORT Diagram Construction Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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FIGURES
1.
2.
A-1
A-2
A-3
A-4
Schematic of the MORT Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MORT Top Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Schematic of a Fault Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Examples of Good and Poor Logic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MORT Logic Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MORT Event Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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10
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PART I
A.
PURPOSE
This document was prepared for a two-fold purpose:
1.
Primarily, it is intended to be a practical working tool. It is designed to help the novice
Management Oversight and Risk Tree (MORT) practitioner achieve quicker, deeper
insight and understanding of the MORT safety program concepts by: (a) providing a
brief explanation of the related rationale supporting the word statement given in a
specific event “box” of the MORT logic diagram and (b) listing page references to
detailed explanations of the original MORT text, “MORT – The Management Oversight
and Risk Tree,” published in 1973 as ERDA publication SAN 821-2.*
2.
Additionally, it is intended to serve as an information document directed to system safety
professionals, program managers, and higher level management with responsibility for
accident investigation or program evaluation. It seeks to explain simply the MORT
“programmatic” concepts and “analytical” methodology, and to inform those people that
MORT is available for immediate use: (a) in investigating the elements of management
oversight and risk relative to an accident that has happened; or (b) in the evaluation of
an existing program to determine the likelihood that a significant accident is about to
happen.
While this document is generally applicable to any issue of the MORT logic diagram, it is
keyed or indexed specifically to the MORT logic diagram revision dated April 1986.
B.
BACKGROUND
Prior to 1970, the Energy Research and Development Administration (ERDA) had no svstem
safety program as such. During that time, ERDA (the predecessor to the Department of
Energy [DOE]) Division of Safety, Standards, and Compliance (SSC), funded a study prepared
by W. G. (Bill) Johnson, who had recently retired as General Manager of the National Safety
Council.
The argument for the study and the planned objectives, paraphrasing the words of the original
proposal, was as follows:
.Emerging concepts of systems analysis, accident causation, human factors, error
reduction, and measurement of safety performance strongly suggest the practicality of
developing a higher order of control over hazards (than now exists).”
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“The formulation of an ideal system appears to be a valuable precondition for knowing
what information to seek after an accident and what aspects of performance (of the
accident-related safety system) to seek to measure.
”
*The original text has since been revised and published as “MORT Safety Assurance Systems,”
W. G. Johnson, Marcel Dekker (1980).
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Johnson advanced the idea that application of controls and resources made by managements of
occupational safety programs could be categorized into five levels:
1.
Less than minimal compliance with regulations and codes.
2.
Minimal compliance with regulations and codes.
3.
Application of manuals and standards.
4.
Advanced safety programs exemplified by those currently found in leading
industrial companies and in DOE.
5.
An as-yet-nonexistent, superlative safety program synthesized by combining the
“system safety” concepts pioneered by the military and aerospace industry with
the best occupational safety practices and factoring in the newer concepts of the
behavioral, organizational, and analytical sciences.
In Johnson’s view, there were sufficient data to suggest that progression from one one level of
safety program to the next better level might result in an order of magnitude reduction in the
annual rate of disastrous accidents experienced by a specific enterprise. Accordingly, the goal
set for the conceptualized fifth level system, to be developed by the ERDA study, was an order
of magnitude improvement in the already exemplary ERDA safety record.
The study was titled “Development of Systems Criteria for Accident Reporting and Analysis
and for the Measurement of Safety Performance.
In 1971 the first generation MORT text was published and the study moved to the next logical
phase of pilot use at an actual ERDA contract activity. The Idaho National Engineering
Laboratory (INEL), then known as the National Reactor Testing Station, was chosen primarily
because the prime operating contractor, Aerojet Nuclear Company (ANC), then known as the
Idaho Nuclear Corporation, had a well-established safety program and additionally was
developing and using “system safety” techniques patterned after methodologies pioneered by
National Space and Aeronautics Administeation (NASA) and Department of Defense (DOD).
The first generation MORT text introduced four key innovative features basic to the MORT
program:
1.
An analytical “logic tree” or diagram from which MORT derives its name,
“Management Oversight and Risk Tree.” This diagram arranges safety program
elements in an orderly, coherent, and logical manner.
2.
Schematic representation of a dynamic idealized or “universal” safety system
model by using Fault Tree Analysis methodology.
3.
Methodology for analyzing a specific safety program through a process of
evaluating the adequacy of implementation of the individual safety system
elements.
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4.
A collection of philosophical statements and general advice relative to the
application of the MORT system safety concepts and listed criteria by which to
make an assessment of the affectivity of their application.
A major MORT premise is that the MORT safety system is congruous (i.e., harmonious) with
a goal-oriented, high performance, complex management system.
Working under the direction of a Steering Committee composed of senior ANC line and staff
managers, a MORT development team was formed consisting of Johnson and three ANC
employees, Dr. Robert Nertney, Jack Clark, and Jack Ford. During the next two years,
MORT concepts were subjected to trial use under actual operational conditions. Additional
systems concepts were developed and tested.
In 1973, the second generation MORT text was published. It included additional safety
systems developed and refined by ANC and the Idaho Field Office of the ERDA, and
incorporated the result of an intensive effort of collecting and organizing the best safety
elements from different programs throughout the world.
It should be emphasized that MORT does not represent new and untried methodology. MORT
does represent the synthesis of those best safety program elements and concepts with the
state-of-the-art techniques of safety program analysis and evaluation.
Careful review of the results of numerous studies conducted over nearly four years, coupled
with the ANC trial application results, led ERDA-SSC to embark upon a full-scale orientation
and training program of ERDA and ERDA contractor personnel throughout all of the ERDA.
In August 1974, the System Safety Development Center (SSDC) was established at Aerojet
under the joint sponsorship of ERDA-SSC and ANC. In October 1976, EG&G Idaho was
awarded the prime operating contract at the INEL, including the management role of the
SSDC.
Staffing and responsibility for the MORT orientation and training program was assigned to the
SSDC. The formal implementation plan adopted consisted of four points:
1.
2.
3.
4.
MORT Five-Day Training Seminars
MORT Management Briefings
Mini-MORT Seminars
Safety Program Improvement Projects (SPIPs).
To date, many seminars have been conducted, both at the INEL and at other DOE facility
locations. The continued activities of the SSDC are presently projected to a 10 year program
of further MORT development. This includes presentation of MORT orientation and training
seminars for DOE, DOE contractors, and NRC with seminar locations spotted throughout the
U.S. In addition, several MORT-based workshops have been developed. These workshops are
also being held throughout the country to certify “trained investigators” as prescribed by DOE
Orders as well as other training.
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C.
INTRODUCTION
The MORT principle has two meanings:
1.
A total safety program concept (viewed as a specialized management subsystem)
focused upon programmatic control of industrial safety hazards, and
2.
The actual logic diagram which displays the structured set of interrelated safety
program elements and concepts comprising the ideal management program model
called MORT. This universal logic diagram becomes a master “work sheet” for
use in analyzing a specific accident or alternatively for use in the evaluation and
appraisal of an existing safety program for accidenthncident potential.
As an ideal management program, MORT was designed to include the following:
1.
Prevent management oversights, errors, and omissions.
2.
Result in identification, assessment, and referral of residual risks to proper
management levels for appropriate action.
3.
Optimize allocation of resources available to the program and to individual hazard
control effort.
The many state-of-the-art safety system concepts and safety program elements synthesized to
produce “programmatic MORT” are presented in considerable detail in the second generation
MORT text. Integrated into the MORT program model are the best features of exemplary
safety programs found in the U.S., Le., management implementation, hazard analysis, human
factors analysis, work processes, monitoring, information systems, and organization systems
and services.
Innovative concepts, such as the sequential role of unwanted energy flow, barriers to energy
transfer, error, change, and risk, are systematically related along with the most current
concepts of the behavioral, organizational, and analytical sciences.
Translated to “analytical MORT” (the MORT logic diagram), these features of “programmatic
MORT” accumulate to over 1,500 “basic events” (Le., causative problems or preventive
measures related to an ideal safety system). These, in turn, underlie nearly 100 different
generic problems identified in successively broader areas of management and accident
prevention. Incorporated into the above listed concepts are some 50-70 “new ideas.” (The
actual number is highly subjective, depending upon a person’s background and experience.)
The way in which the MORT concept (programmatic MORT) is schematically represented by a
logic diagram (analytical MORT) is shown in Figure I.
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MORT is simply a diagram which arranges safety program elements in an orderly
and logical manner. It presents a schematic representation of a dynamic,
idealized (universal) safety system model using Fault Tree Analysis methodology.
MORT structures the largely unstructured safety literature and current best
safety practices into three levels of relationships:
a. Generic Events (Problems)
I98 Generic Problems I
b. Basic Events (Causes)
c. Criteria (Judgment rationale from
the MORT text)
/Thousands of criteria
Judge Adequacy
MORT makes explicit:
a. The functions necessary to
complete a process.
b. The steps to fulfill a function.
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Functions
c. Judgment criterh (from the MORT text)
by which to judge when a step is well
done or is “less than adequate” (LTA).
It provides relatively simple decision points in an accident analysis or safety
system evaluation and enables an analyst or evaluator to detect omissions,
oversights, or defects.
Figure 1. Schematic of the MORT Process
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MUMS
Fundamental to a successful accident investigation or safety program evaluation is the
assignment by higher management of technically qualified, competent, safety-motivated
personnel to participate in the investigation. Even so, experience, to date, indicate that a well
qualified person (but novice MORT practitioner), armed with only the MORT text and the
MORT “work sheet” with its collection of symbols and terse statements, will likely find the
initial encounter with the MORT proposition somewhat overwhelming.
This User’s Manual was prepared to help the MORT practitioner develop a quick familiarity
with the MORT process.
In the remaining sections of Part I, the reader is introduced to the basic concepts of system
analysis and the role of change. Fault Tree Analysis (FTA), from which the more generalized
MORT analytical procedure is derived, is briefly discussed in the Appendix.
In Part I1 the actual User’s Manual plan is presented. The structured relationship of each
generic causative problem or preventive measure to the idealized safety system is explained and
fitted into the event indexing scheme adopted for the MORT diagram. As each major branch
and its principal subbranches are listed, occasionally commentary relative to the safety program
concept or best practice safety program element involved is made. With this additional insight,
more probing questions can now be asked by the MORT analyst.
The analyst, with enhanced understanding, is able to make a better judgment whether the
specific safety program element being examined is “adequate” or “less than adequate” (LTA).
The analyst, as previously mentioned, is encouraged to use the MORT diagram as a master
“work sheet,” marking the individual program elements. Suggestions for working with the
MORT analysis are made.
The cross-reference tabulation to the index code used on the MORT diagram is presented in
“indexed” fashion for easy location. Page number references back to the MORT text are
provided in the parentheses that follow the indexed event tabulation.
Once completed, the MORT analytical “work sheet” provides an all-important visibility to the
accident investigation process or to the safety program evaluation. Th…
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