Accidents management system factors

The purpose of MORT analysis is to provide a systematic tool to aid in planning, organizing, and conducting an in-depth, comprehensive accident investigation (or inspection, audit, or appraisal) to identify those specific control factors and management system factors that are less than adequate and need to be corrected to prevent recurrence of the accident (or to prevent other undesired events). 

The root causes of most accidents are found during an analysis of the management system factors (Fig. 18-19). This major branch of the chart addresses the why issues. Specific factors and branches to be analyzed include... 

From a safety management perspective a specific goal within this broader purpose is then to identify likely factors or system elements in the sequence of events leading to near misses which in turn may be considered as precursors to actual future accidents. From such a qualitative analysis two ways emerge to reduce the likelihood of such actual accidents error-inducing factors can be eliminated (or their potential impact weakened), and recovery-promoting factors can be strengthened (or even introduced) in the system. 

The third set of causal factors is only indirectly related to the events and conditions, but these indirect factors are critical in fully understanding why the accident occurred and thus how to prevent future accidents. In this case, the systemic factors include the owner of the ferry (Townsend Thoresen) needing ships that were designed to permit fast loading and unloading and quick acceleration in order to remain competitive in the ferry business, and pressure by company management on the captain and first officer to strictly adhere to schedules, also related to competitive factors. 

In some industries, the safety control structure is called the safety management system (SMS). In civil aviation, ICAO (International Civil Aviation Authority) has created standards and recommended practices for safety management systems and individual countries have strongly recommended or required certified air carriers to establish such systems in order to control organizational factors that contribute to accidents. 

Most accident analyses stop at this point, particularly in that era. To their credit, however, the investigation continued and looked at why the technical deficiencies existed, that is, the management and systemic factors involved in the loss. They found deficient specifications, deficient shipbuilding practices, deficient maintenance practices, inadequate documentation of construction and maintenance actions, and deficient operational procedures. With respect to documentation, there appeared to be incomplete or no records of the work that had been done on the submarine and the critical materials and processes used. 

Cacciabue, Pietro C. 2004a. Guide to Applying Human Factors Methods - Human Error and Accident Management in Safety Critical Systems. London, Springer-Verlag. 

Radionuclides are released to the containment as gases and as aerosol particles by a variety of processes during severe accidents. Modem, mechanistic analyses of these radionuclide releases and the subsequent behaviour of aerosols and vapours under reactor accident conditions strive to be realistic. This realistic approach contrasts with the deliberate attempt to be conservative (which may not have been successful) in the definition of radionuclide behaviour for the design of nuclear power plant safety systems. A discussion of the various radionuclide release processes during severe reactor accidents is presented in Chapter II. Of primary interest in these discussions of release is the potential magnitude of radionuclide release and the radionuclides of most concern. Factors that most affect radionuclide release but can also be affected by accident management measures are discussed. 

The mission of this independent federal agency is to investigate accidents at plant sites and determine root causes. The Board has found that the root-cause deficiencies are often within safety management systems, but can be ary factor that would have prevented the accident. Some other causes involve equipment failures, human errors, unforeseen chemical reactions or other hazards. 

Unfortunately, such an analytical method—focusing on the first proximate and most easily prevented cause and assigning but one causal factor for an accident— would produce questionable results. Many safety professionals have promoted safety management systems that focus extensively on what the worker does, meaning on the prevention of worker unsafe acts. (I did that early in my career.) And some management personnel have been taught by safety professionals that the focus of their safety management systems should be principally on worker behavior. 

Safety professionals should consider making a needs assessment, from the top down, to determine how much creative destruction and reconstruction through re-education are needed to achieve a mind-set that gives a proper place to reducing the potential for serious injury. Safety management systems that concentrate largely on the personal aspects of safety do not include activities to anticipate and identity the causal factors for low-probability/severe-consequence accidents. Nor do they include specially crafted efforts for their prevention. 

Several references were made in Chapter 3, Serious Injury Prevention, to human errors as the causal factors for accidents. And it was said that many serious injuries result from recurring but potentially avoidable human errors, and that organizational, cultural, technical, and management systems deficiencies often lead to those errors. Emphasizing human error reduction above the worker level, although proposed many years ago as a preventive measure, is not prominent in the work of safety professionals. 

R. B. Whittingham s The Blame Machine Why Human Error Causes Accidents, a 2004 publication, is also referenced and recommended in Chapter 3, Serious Injury Prevention. Its emphasis is on human errors and defective management systems as causal factors for major accidents. From the Preface ... 

These statements appear in the Abstract 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 [safety management] system. This MORT User s Manual is a 57-page paper issued in 1992. The concepts on which MORT is built have staying power, as is evidenced by the following reference puhhshed a decade later. 

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