Material Work & Task People Management Environment Management Oversight and Risk Tree Ships in Service Training Material A-M CHAUVEL Identify the Causes

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.


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.


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


MORT Identify the Causes Members of the investigating team shall lookfor answers to questions such as:

Work &Task

Work &Task


For most of these questions,an important follow-up question is

“ If not, why ? "


- 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


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



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



External Environment


http://www.taproot.com/blog/SELKIRK_SETTLER_3.JPG




Internal Environment


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:


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



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



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.


ManagementManagement

Answers to any of the preceding types of questions

logically lead to further questions such as :




- 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?



MaterialWork &

Task

People

Management

Environment



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.



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


Ship and Equipment Equipment Failure

Accident

Externalenvironment


External Environment Meteorological Conditions

- Weather

- Waves

- Light and visibility

- Hydrological

Accident

Internalenvironment


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


Personnel

Accident

Safety Organisation

- Shipboard familiarisation

- Safety familiarisation

- Emergency preparedness

- Crew co-ordination

- Training and drills

- Emergency arrangement

Personnel


Personnel

Special Training

- Survival craft

- Rescue boats,.....

- Advanced fire fighting

- First aid

- Medical care,

- Crisis management


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


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


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


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


Procedures

Accident

Procedures

Accident

Voyage

- Planning

- Notifications of deviations

- Events & Happenings

Records


Records

Accident

Records

Personnel

- Crew list

- Competency

- Medical fitness

- Experience

- Familiarisation & training


Records

Accident

Records

Ship & Equipment

- Mandatory certificates

- Classification Society inspections

- Statutory inspections

- Maintenance, modifications,

damages and repairs

- Work repair authorisations

- Navigational equipment


Records

Accident

Records

Safety & Environmental Protection

- Internal inspection reports

- Non conformities

- Accidents and damages

- Near misses

- Hazardous occurrences

- Maintenance, modifications

- Work repair authorisations


Records

Accident

Watchkeeping

- Schedules

- Master instruction

- Deck watchkeeping reports

- Engineering watchkeeping reports

Records


Records


One other way for classification

AccidentAccident

Ship andEquipment


PersonnelPersonnel


Ergonomic

AccidentAccident



PersonnelPersonnel


Psychology

AccidentAccident


ProceduresProcedures PersonnelPersonnel


Behaviour

AccidentAccident

RecordsRecords


ProceduresProcedures


Organization

AccidentAccident

RecordsRecords

ProceduresProcedures

Ship andEquipment


Standardization

AccidentAccident

Ship andEquipment

RecordsRecords EnvironmentEnvironment


Technology

AccidentAccident

Ship andEquipment

RecordsRecords EnvironmentEnvironment


ProceduresProcedures PersonnelPersonnel

BehaviourOrganisation

Technology Ergonomic

PsychologyStandardisation

People

Soft

Material

Hard


Causes & Effect : Accident


AccidentAccident

ProceduresProcedures& Records& Records

EnvironmentEnvironmentPersonnelPersonnel

Ship &Ship &EquipmentEquipment

Work &Work &TaskTask



Documents

Material Work & Task People Management Environment Management Oversight and Risk Tree Ships in Service Training Material A-M CHAUVEL Identify the Causes