Appendix G - Management Oversight and Risk Tree (MORT) Analysis

A Mini-MORT analysis chart is shown in Figure G-1. This chart is a checklist of what happened (less-

than-adequate specific barriers and controls) and why it happened (less-than-adequate management). To

perform the MORT analysis:

Identify the problem associated with the occurrence and list it as the top event.

Identify the elements on the "what" side of the tree that describe what happened in the occurrence

(what barrier or control problems existed).

For each barrier or control problem, identify the management elements on the "why" side of the

tree that permitted the barrier control problem.

Describe each of the identified inadequate elements (problems) and summarize your findings.

These findings can then be related to the ORPS cause codes using the worksheets in Appendix B. For

critical self-assessment (not an ORPS requirement), the findings can also be related to MORT elements

given in Figure G-2, MORT Based Root Cause Analysis Form. To do this, enter the findings in the left-

hand column. Next, select the MORT elements from the top of the root cause form that most closely

relate to the finding by placing a check in the column below the MORT elements and on the same line

where the finding is listed (more than one element can be related to a single finding.) Then, sum the

number of checks under each MORT element (the sum can be entered at the bottom of the page even

though there is no place designated on the form). The relative number of checks under each MORT

element (the sum of all the findings) is a measure of how widespread the element inadequacy is. The

results guide the specific and generic corrective actions.

A brief explanation of the "what" and "why" may assist in using mini-MORT for causal analyses.

When a target inadvertently comes in contact with a hazard and sustains damage, the event is an accident.

A hazard is any condition, situation, or activity representing a potential for adversely affecting economic

values or the health or quality of people's lives. A target can be any process, hardware, people, the

environment, product quality, or schedule--anything that has economic or personal value.

What prevents accidents or adverse programmatic impact events?

Barriers that surround the hazard and/or the target and prevent contact or controls and

procedures that ensure separation of the hazard from the target

Plans and procedures that avoid conflicting conditions and prevent programmatic impacts.

In a facility, what functions implement and maintain these barriers, controls, plans, and procedures?

Identifying the hazards, targets, and potential contacts or interactions and specifying the

barriers/controls that minimize the likelihood and consequences of these contacts

Identifying potential conflicts/problems in areas such as operations, scheduling, or quality

and specifying management policy, plans, and programs that minimize the likelihood and

consequences of these adverse occurrences

Providing the physical barriers: designing, installation, signs/warnings, training or

procedures

G-1