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Figure  4-4.—Sample  fault  tree  diagram
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Naval Safety Supervisor - Military manual on safety practices
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Chapter 5 - Navy Occupational Safety and Health Program Fundamentals
and analyze them. These differences may be the cause factors. 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 investigative  steps. 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. SUMMARY 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. 4-17

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