Management system factors

Figure 8. M branch - Management system factors LTA (Red problems that contributed to the outcome).

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). 

Figure 18-6 Management system factors. The alphanumeric notations near the lower left of each event symbol were originally used as a cross reference to the MORT User s Manual. Later versions of the MORT chart now use page numbers for cross reference purposes.

Another major management system factor is the risk assessment system. If the risks are not identified, evaluated, and reported accurately to management. 

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... 

The two next-level branches under Oversights and Omissions are labeled Specific Control Factors (S) on the left side or the branch and Management System Factors (M) on the right. On the MORT chart. Management factors are deliberately shown separate from the process that produced the specific adverse event for two reasons (DOE SSDC-4 1983) as follows ... 

SPECIFIC CONTROL FACTOR LTA MANAGEMENT SYSTEM FACTORS LTA ... 

Table 8.5 Management system factors from four sources.

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