and analyze them. These differences may be the cause
MANAGEMENT OVERSIGHT AND RISK
TREE. The management oversight and risk tree
(MORT) technique uses a logic tree format as a guide
to seeking facts in mishap investigations. It involves a
long series of interrelated questions and the use of
diagrams, symbols, and charts. It is similar to a fault tree
but adds in more supervisory and human factors. Once
completed, it provides a visible trail of facts and
MORT is based on the concept that all accidental
losses arise from two sources: (1) specific job oversights
and omissions, and (2) the management system factors
that control the job. Within the MORT system, a mishap
means an unwanted transfer of energy that produces
injury, damage, and loss.
Mishaps are prevented by using energy barriers or
controls. For example, the energy of a piece of broken
grinding wheel causes the loss of an eye. The
appropriate energy barrier would have been a guard on
the grinder or eye protection on the worker.
TECHNIQUE OF OPERATIONS REVIEW.
The technique of operations review (TOR) method is
used in mishap prevention and as an investigative tool.
It is directed more at management than at hardware.
TOR is a step-by-step process whose goal is the efficient
operation of a system. Analyzing the operation using
TOR after a mishap defines weaknesses in the operation.
TOR usually uses a group discussion method of defining
all possible and probable causes and then tracing the
events. As causes are accepted or rejected, the primary
cause eventually becomes clear. TOR does not propose
solutions but does expose problems.
In this chapter you have been given some mishap
investigation fundamentals concerning investigative
techniques, collection of evidence, interviewing
witnesses, and analyzing information. These procedures
can be applied to any type of investigation, whether
ashore, afloat, or involving aviation. The results of these
investigations provide you with the information to
complete mishap reports. Chapters 6, 7, and 8 deal with
their respective areas of mishap reporting.