8/14/2019 2009 Revision by the Noordwijk Risk Initiative Foundation

1/1

MORT - Management Oversight & Risk Tree

People

BasedonKnown

Precedent

39 3939 39

Pointof

operation

logLTA

TimeLTA

CausedFailure

TaskPerformance

Errors

b3SD5

Pointof

operation

logLTA

TimeLTA

CausedFailure

TaskPerformance

Errors

b3SD5

Pointof

operation

logLTA

TimeLTA

CausedFailure

TaskPerformance

Errors

b3SD5

Pointof

operation

logLTA

TimeLTA

CausedFailure

TaskPerformance

Errors

b3SD5

TaskPerformance

Errors

TaskPerformance

Errors

TaskPerformance

Errors

TaskPerformance

Errors

b2b1 b3

R11

R12

SA2

b5

b6

b3 b4

a1 a2 a3 a4 a5

b1b2

c2 c3 c5c6

c1 c4 b3SD5

a1 a1 a1 a1a6

SA2

SD1

SD1

a1 a2 a3 a4a5

b1

c2

d6d5

c1

d2 d4d1 d3

c3

d8d7

c4

d10d9

b2 b3 b5 b7

b4 b6

b9

b8

b11b10 b12

b16 b17b14b13 b15

SD1b1

MB3

f6SD5

b6MB1

MA3

MB3 MB4 MB5

a1 a3 a6a5

SD6

MA2

b3SD5

a2 a4

T

S/M R

R1 R2 R3 R4 Rn

SD6

M

MA1 MA2

b7R12

b2

a1

b1

c4

d1 d3d2

b4b3

c2

a2

c1 c3 c6 c7

b6b5

d4 d5

c5

b8

a3

c8 b3SD5

a1

b4

c10 c12

c9 c11 c13

b5 b6 b7

c16

c17

c14

c15

b3

c6 c8

c7

c4

a1SD1

b2b1

c2c1

SD1

c3 c5

SD6

a2 a4 a6

a3a5

a7

b1 29 29 29 29b2 b3 b4

a1

SD6b5

MA2a5

MB4

b1 b2

SD3

a1 a2

SD3

b10MB1

c2 c3c1 c4 c5

b3 b6b4 b5 b3SD5

b1 b2

SD4

a1

b3

a2

b6b4 b5

b11MB1

b3SD5

SD4

c2 c3c1 c4 c5

d12

e14e13

d14

e23

e21

e20

f13

e22

f12

c15

e16 e18

e17 e19

d13

e15

e27

e26 e28

e24

e25

d15

e32e31e30

f17f16f15

e29

R8

c14

d9

e1e3

e2

d8

c11c10

f2 f4f1 f3

c13

R6

SD1

c12

d10 d11

f5 f6 f7

f8 f10

g1 g2

f9 f11

e4 e5e7 e11e6 e8 e9 e10

e12R7

a4

c16 c18c17

b4 b5

c19b3SD5

SD6SD6SD5

a1 a2 a3

b1

c2

d2 d4d1 d3

c3c1

d5 d6 d7

b2

R5

c4 c7c5c6

c9c8

b3

c2SC2

b6

SD3

b6

SD4

c5SA2

c8MA2

b1MB4

c18

SD5

b1 b3 b5

b2 b4

SD2SD1 SD3 SD4

a1 a4a3a2

SD1 SD3 SD4

SB4

SC4SC3a1 a2

SB2

b1 b2

c1 c2

b4b3

R4

R3

SC2

a1 a2 a3 a4

b2b1 b3

c1 c2 b3SD5

R9

R10

S

SC1

SB3

SA1SA2

SA2

SC3c24

MB3

a2

b20 b21 b22

c43

c44

b19

c39 c41

c40

c37

c38 c42

c30 c32

b14 b17 b18

c31 c33 c35

c36

d5 d7 d9 d11

c34

d13

d6 d8 d10 d12

b15 b16b10 b11 b12 b13a1SD3

a1SD4

b9

c25 c26 c27c28

d1 d4d2

c29

d3

c20

b8

c19 c21

c22 c24

c23

SB3c18

MB1 MB2

a1a1a1

SC4

SB3 SB1a1 a2

SB1

b1b2

c1 c2R2

b4b3

R1

Losses

Oversights& Omissions

Damageto

peopleorassets

FutureUndesired

Events

AssumedRisks

Specific

ControlFactors

LTA

AccidentStabilisation

& Restoration

LTA

Potentially

HarmfulEnergyFloworCondition

Non-functionalEnergy Flow

FunctionalEnergy Flow

Barriers LTA

ControlLTA

Control

ofUseLTA

Control

LTA

DiversionofEnergy

LTA

ControlImpracticable

DivertImpracticable

Non-functionalPeopleor

Objects

FunctionalPeopleorObjects

Barriers LTA

ControlLTA

Controlof

Exposure

LTA

Means ofEvasion

LTA

ControlImpracticable

EvasionImpracticable

VulnerablePeople

orObjects

EvasiveActionLTA

Controls &Barriers LTA

ControlofWork and

Process LTA

Barriers LTA

OntheEnergy Source

BetweenOnPersonsorObjects

SeparateinTimeorPlace

None

PossibleBarrier

FailedDidNotUse

D/N

Provide

TaskPerformance

Error

Events andEnergyFlows Leadingto

Accident/Incident

Barriers &

Controls LTA

Events andEnergy

Transfers

RelevanttoAccident

TechnicalInformationSystemsLTA

VerificationofReadinessLTA

DidnotSpecifyCheck

CriteriaLTA

ProcedureLTA

Compet-enceLTA

Follow-upLTA

TechnicalSupport

LTA

Interface

Ops/Maint&Testing

LTA

Config-urationLTA

OperationalReadiness

LTA

MaintenanceLTA

InspectionLTA

InspectionLTA

PlanLTA

ExecutionLTA

AnalysisofFailures

LTA

SpecificationofPlanLTA

Inventory

LTA

Inspect-ability

LTA

FrequencyLTA

Co-ord-

ination

LTA

Compet-ence

LTA

Log

Access

LTA

Time

LTACausedFailure

TaskPerformance

Errors

MaintenanceLTA

PlanLTA

ExecutionLTA

AnalysisofFailures

LTA

SpecificationofPlanLTA

Pointof

operation

logLTA

TimeLTA

CausedFailure

TaskPerformance

Errors

Planno t

Complete

Maintain-ability

LTA

Schedule

LTA

Co-ord-

ination

LTA

Compet-ence

LTA

Supervision

&StaffPerformanceLTA

Supvn

Continuity

LTA

TimeLTA

TimeLTA

House-

keeping

LTA

AuthorityLTA

BudgetLTA

TimeLTA

Supv

Judgem-

entLTA

D/NCorrectinTime

WorkforceInputLTA

DetectionPlanLTA

ChecklistLTA

DetectionorCorrectionofHazardsLTA

DetectionofHazardsLTA

CorrectionofHazardsLTA

Supv'sMonitor

PlanLTA

Change

Review

LTA

D/NRelateto

PriorEvents

InterdeptCo-ordLTA

Postponed

Logs&

Diagrams

LTA

Task

Procedures

D/NagreeW

Situation

SupvJudgem-

entLTA

TaskAssignment

LTA

AuthorityLTA

BudgetLTA

TimeLTA

TaskPerformance

Errors

Task-SpecificRiskAssessment

NotPerformed

HighPotentialNotIdentified

LowPotential

TaskAnalysisNotReqd

TaskAnalysis

LTA

TaskAnalysis

NotMade

Pre-Task

Briefing

LTA

Task-SpecificRisk Assessment

LTA

Task-SpecificRisk Analysis

LTA

RecommendedRiskControls

LTA

K no wl ed ge LT A E xe cu ti on LT A

Useof

WorkersInputLTA

Technical

Information

SystemsLTA

TimeLTA

BudgetLTA

ScopeLTA

AnalyticalSkillLTA

Hazard

Selection

LTA

HazardIdentifica-

tionLTA

HazardPrioritisa-

tionLTA

Compat-

ibilityLTA

Testing

ofcontrolLTA

DirectivetoUse

LTA

Avail-ability

LTA

Adapt-abilityLTA

Clarity

LTA

UsenotMandatory

Consideration

o fBehaviou ra l

VariationLTA

NormalVariability

Changes

SupvObserva-

tionLTA

Re-instru

ctionLTA

Enforce-mentLTA

SupervisorCorrectionLTA

Personnel

Performance

Discrepancy

Personnel

SelectionLTA

Criteria

LTA

Testing

LTA

Training

LTA

NoTraining

Methods

LTA

Verific-ation

LTA

Trainer

SkillsLTA

Definition

ofNeedsLTA

PersonnelMotivation

LTA

Leadership& Example

LTA

Time

Pressure

PerformisPunishing

Non-PerformisRewarded

Job

InterestBuilding

LTA

Group

NormsConflict

Obstaclestoperform

PersonalConflict

Deviant

Traits

With

Super-visor

With

Others

GeneralMotivationProgLTA

Performance

Errors

Errors in

Performanceof

UnrelatedTasks

AllowedActivities

ProhibitedActivities

Emergency

Shut-off

Errors

Incident

has occurred

EmergencyPerformance

Errors

Errorsin

Unrelatedtasks

SupportofSupervision

LTA

Supportof

SupervisorsLTA

ResearchSupport

LTA

InfoExchange

LTA

Standards

&Directives

LTA

ResourcesLTA

Training

LTA

Access to

ExpertiseLTA

AccesstoEquipment

LTA

He lp&Training

LTA

Co-ordofResources

LTA

Useo f

ResourcesLTA

ResponsetoRisk

ReferralsLTA

PreventionofFollow-on

Accidents

RescueandSalvageLTA

MedicalServices LTA

DisseminationofInformation

LTA

Execution

ofPlanLTA

Personneland/orEquipment

Changes

Plan

LTA

Op

ContinuityLTA

Rehab-ilitation

LTA

Restor-ationLTA

AbsorbLoss

Training&

ExperienceLTA

Notification

LTA

Logistics

LTA

Task

Performance

Errors

EmergencyAction

(Firefighting,etc.)

LTA

Restoration&Rehabilitation

LTA

ResponseDelay

Stabilisation& Restoration

LTA

Accident

Occurrence

Codes &Manuals

LTA

ListofExperts

LTA

LocalKnowledge

LTA

NoKnownPrecedent

InternalCommunication

LTA

ExternalCommunication

LTA

DataCollection

LTA

TechnicalInformation

Systems LTA

SolutionResearch

LTA

Prev.Inv/anal

LTA

ResearchLTA

NetworkStructure

LTA

NetworkOperation

LTA

NetworkOperation

LTA

NetworkStructure

LTA

Monitoring

Plan

LTA

HealthMonitoring

LTA

Routine

Inspections

LTA

Upstream

Audits

LTA

PreviousA.I.info

LTA

Independ-entreview

LTA

LearningfromWorkersLTA

CommunicationofKnowledge

LTA

KnowledgeLTA

DataAnalysis

LTA

Triggers toRisk Analysis

LTA

PriorityProblemListLTA

Priority

Problem

FixesLTA

StatusDisplay

LTA

UseofNewInfo

LTA

Audit&Appraisal

LTA

StatisticsLTA

PlannedChange

LTA

Unplann

-edChange

LTA

TechnicalInformation

LTA

BasedonExisting

Knowlege

SingleEvent

SensitivityLTA

SupportLTA

PolicyLTA

ImplementationofPolicy LTA

Delays

Management

SystemFactors

LTA

Risk AnalysisProcess LTA

RiskManagement

SystemLTA

Methods,Criteria,Analyses

LTA

LineRespons-

ibilityLTA

TaskAssign-mentLTA

StaffRespons-

ibilityLTA

BudgetsLTA

SpecificationofPlan

LTA

Useof Feedback

LTA

SpecificationofResponsibilities

LTA

PlanningProcess

LTA

ExecutionofPlanLTA

CapabilityLTA

ScheduleLTA

AuthorityLTA

Account-abilityLTA

CommunicationPlanLTA

Inform-ationFlowLTA

Guidanceand

DirectivesLTA

Leader-ship

LTA

CausedFailure

Monitor-ing

LTA

TaskPerformance

Errors

Time&

Budget

LTA

Reviewof

RMSystemLTA

Aims

& PolicyLTA

Docum-entation

LTA

ActivitiesLTA

ProgScope

LTA

AssuranceProgOrganisation

LTA

RMAssuranceProgramme

LTA

AssuranceProgServices

LTA

Comm-itteesLTA

RMPolicy

LTA

ImplementationofRMPolicy

LTA

Progres-siono fimprovt

LTA

RMAssuranceStaffPerform-

anceLTA

Concepts andRequirements

LTA

InformationSearch

LTA

RiskAnalysis

Criteria

LTA

ChangeAnalysis

LTARequired

Alternatives

LTA

Analytical

MethodsLTA

Measure-

mentScale

LTA

Solution

PrecedenceSequence

LTA

CriteriaforProcedures

LTA

Specification

ofRequirements

LTA

Customer

&Stake-

holders

National

Laws

National&Internat'nl

Codes&Stds

LocalCodes&Byelaws

InternalStandards

LifeCycle

AnalysisLTA

ScopeLTA

Env'lImpact

AnalysisLTA

RqmtforLifeCycleAnalysis

LTA Extend-edUseAnalysis

LTA

TechnicalInformationSystemLTA

Definitionof

Goals& Tolerable

RisksLTA

PerformGoals&

RisksnotDefined

Plan

LTA

ES&HGoals&

RisksnotDefined

DesignandDevelopment

LTA

EnergyControl

LTA

D/N

LimitEnergy

Warnings

LTA

Manual

ControlsLTA

AutomaticControl

LTA

Safe

EnergyRelease

LTA

HumanFactors(Ergonomics)ReviewLTA

Controls &

Barriers LTA

Ergo-nomics

knowledgeLTA

TaskAnalysis

LTA

TaskAllocation

LTA

InterfaceDesignLTA

DefinitionofUsers

LTA

Error

Predict-ionLTA

DisplayDesign

LTA

Media-

tionLTA

ControlDesign

LTA

MaintenancePlanning

LTA

InspectionPlanning

LTA

Arrange-ment

LTA

Environ-ment

LTA

SpecificationofOperationalReadiness LTA

Test&Qualifica-

tionLTA

Super-vision

LTA

TaskProceduresD/N

MeetCriteria

MatchtoHardwareChange

LTA

Match

toUsersLTA

MatchtoTask&Equipmnt

LTA

EmergcyProvisions

LTA

Emrgncy

ShutdownProvision

LTA

Warnings

LTA

Lockouts

LTA

Task

Sequence

LTA

Comms

Interfaces

LTA

Spec.ofWork

ConditionsLTA

Personnel

SelectionLTA

MonitorPoints

LTA

PersonnelMotivation

LTA

Training&Qualif-icationLTA

Conting-ency

PlanningLTA

Disposal

PlanningLTA

Config-urationControl

LTA

Indep-endantReview

LTA

Docu-mentationControl

LTA

Fast

ActionCycle

LTA

DesignAcceptance

&ChangeControl

ProcessesLTA

Standard-isationof

PartsLTA

Design

Description

LTA

CodeCompliance

Verification

LTA

Engine-ering

StudiesLTA

Accept-

ance

Criteria

LTA

TestingLTA

Control

ofChange

Process

LTA

Reliab-

ility&QA

LTA

D/NSubstitute

SaferEnergy

2009 Revision by

The Noordwijk Risk

Initiative FoundationDocumentReference:NRI-2(2009).

Foruse withthe MORTUsers'Manual(NRI-1)

Publishedand distributedby theNoordwijk Risk InitiativeFoundation

P.O.Box 286,2600 AGDelft,TheNetherlands.

1stOctober2009Email:Info@nri.eu.comWebsite:www.nri.eu.com

ISBN

Anevent,usually afault oroversight,expressedingenericterms.

Aneventdescribed by abasiccomponentorpart failure.Itmarksthelowestlevel ofdevelopmentin the tree .

Aneventwhere sequenceis endedforlack ofinformationorsolutions.Theevent may betransferredto"AssumedRisks".

Aneventthat is satisfactory.

ANDGate- Requires thecoexistenceof allgateinputs toproduceoutput.

ORGate- Requires any onegate inputtop roduceou tpu t.Ifmore thanone inpu t,theoutputwillstill occur.

Aneventthat is normallyexpectedtooccur.

Conditionalgate(either ANDorOR) -Inputsproducethe outputprovidedthe conditionis true.

Constraintsymbol-Applies conditions toga teo rou tpu t.

Triangle-Used totransfersequence toanotherlocationon page.

TransfertoAssumedRisk branch- denotesproblems forwhichthereis nopracticablecountermeasure

D /N D id n ot

D/NP Didnotprovide

ES&HEnvironment,Safety& Health

F /T F ai le d to

RM Risk Management

W With

LTA Less thanadequa te

NRI-2,SecondEdition,August 2009.Revisedby JohnKingston,FloorKoornneef, Jaapv.d.Ruit, RudolfFrei,and PhilippeSchallier.MajorrevisionofMORT1992,US Departmentof Energy,drawnby JohnKingston.

MORT Reference Description of (Provisional) Assumed Risks Judgement

(Provisional) Assumed Risks

Rn

ConditionInput

46

46 46

46 46

46 49 49 49 4150

50

50

50

50 51

51 51 51

51 51 51

50

54

54

54

54 54

51 52

52

52 52 52

52

48

48 48 48 48

47 4747

47

47

47

47

49

53 53 53

5353

53

53 53

36 36

36 36 36

36

3535 36

34

34

3434

34 34 34 35 3535

5 8 9 1010

10 10 10 10 107 7

6

6 6 6 6 6 6 7 7 7 7

6 7 7

8 8 8 9

9 9 9

8 98

5

55 55 55

55

55 56 56

56

5555

55

42

41

41

29

29

2929

29

29

30

30

22

24 24

24

24

24 24

23 23 23 23

23 23

23

242323

23

25

26 26

26 26 27

27 2727

27

25

25

1818

18

18

19

19 19 19 19

1919

2220

20 21

20

20 20 20

20 21

2121

2121

2021 21 21 21 22 22

22

14

18

18 28 28

28 28 28 28

29

14

14

14

14 14

15

15 15 15 15

16 16 1616

16

17

17 17 17

17 17

5 11 12 12

11 11 11 11

1111

11 11

11

33

33 33

1

1 56

1

1

22

3 3

2 2

3 3

4

4 4

4 4 4 4

44

5

5

32

32

32 32

33 33

31

31

31

34

1 37

37

37

42

42 42 42

12

12

12 12 12 12 12

13

13

12

13131313

12

12

12 12 12 12 12

13

13

12

13131313

37

37 38

38 38 38

38 38

40 4039

39

39 39

40 40

40 4040

40 41

46 46

43 43

43 43

43 44 44

44 45

45

4545

45 45

45

45 46

45

44

43 43

42