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Root causes at the general and SHE-management-systems levels

2 Root causes at the general and SHE-management-systems levels [Pg.76]

1 Causes derived from quality-assurance principles [Pg.76]

The theoretical basis of the different causal models becomes more obvious at the upper management level. MORT was the first comprehensive model to include organisational and individual factors at the top management level. At this level, it draws from quality assurance management principles. The SMORT and ILCI models have been influenced by this pioneering work and represent variations on the same theme. The concept of root causes originates from the MORT model. The checklist above shows the different items of a root-cause analysis. [Pg.76]

The SMORT and ILCI models represent further developments of the original MORT concept mainly for the purposes of improving user-friendliness. In the application of both models, the analysis proceeds from [Pg.76]

SMORT has in common with MORT that it brings up questions concerning deficiencies in the design of industrial systems. The intention here is to learn from accidents in order to improve the design processes and thereby to acquire safer industrial systems in the future. At the top level, we find similar elements in SMORT as those of the quality-assurance management model. [Pg.77]




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Leveling system

Managers general

Root cause

Root cause system

Root system

SHE

SHE management

SHEs

System-level

Systemic root causes

The Management System

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