DAY ONE
Introductions: Introduction of the participants and instructor(s).
Introduction to the workshop: concepts, methods, exercises, outcomes, and expectations with emphasis on work related to root cause and corrective action applications.
Model Program for Root Cause Analysis: Presentation of the criteria and features of a state-of-the-art root cause analysis program.
Traditional Root Cause Analysis Techniques Review: Review of common root cause analysis techniques, their strengths, and common applications.
Introduction to MORT: Presentation of the Management Oversight and Risk Tree, its history, development, and applications.
Preliminary Ideas: Discussion of ideas to enhance the understanding of MORT: risk, tree structure, oversight vs. risk, conventions, time universal application, and data administration needed for source referencing the analysis.
MORT Analysis: Specific Control Factors: Discussion, application, and exercises on amelioration; H-B-T (accident); technical information; facility functional operability, maintenance; inspection; supervision; human error; and higher supervision services.
Day 1 Workshop Activities:
- Review case study and preliminary causal analysis documentation
- Begin performing MORT analysis
DAY TWO
MORT Analysis: Management System Factors: Discussion, application, and exercises on policy, implementation of policy; risk assessment system; concepts and requirements; design and development plan; human factors review; and program review.
MORT Analysis: Safety Culture: Discussion of evaluating impacts of Safety Culture using the MORT traits and attributes.
Determining Causes and Developing Corrective Actions from MORT: Discussion on discovering patterns, drawing, and supporting conclusions –writing MORT-based cause statements and preliminary defendable ‘units. Also, includes designing an effectiveness review plan.
Day 2 Workshop Activities:
- Complete MORT Analysis
- Assemble all materials including all analyses, lists of facts, conclusions, recommendations, and other work materials
- Prepare for and deliver oral briefing of analysis results
- Case study review
Teaching Approach
Training Materials
Training Course materials will be provided to each participant. These materials include the training course manual, case study and supporting documents. The training materials will also include Conger & Elsea’s Mishap Analysis & Prevention System (MAPS)® Software which includes digital tools to facilitate the performance and documentation of causal analysis including Events and Causal Factors, Change Analysis, Hazard-Barrier-Target Analysis, Fault Tree Analysis, Management Oversight and Risk Tree (MORT) Analysis, and Failure Modes and Effects Analysis. All training materials are proprietary and the property of Conger & Elsea.