
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