The formulation of an ideal system appears to be a valuable precondition for knowing what information to seek after an accident and what aspects of performance (of the accident-related safety system) to seek to measure.
BACKGROUND Prior to 1970, the Energy Research and Development Administration (ERDA) had no svstem safety program as such. During that time, ERDA (the predecessor to the Department of Energy [DOE]) Division of Safety, Standards, and Compliance (SSC), funded a study prepared by W. G. (Bill) Johnson, who had recently retired as General Manager of the National Safety Council. The argument for the study and the planned objectives, paraphrasing the words of the original proposal, was as follows: .Emerging concepts of systems analysis, accident causation, human factors, error reduction, and measurement of safety performance strongly suggest the practicality of developing a higher order of control over hazards (than now exists).” ‘I.. “The formulation of an ideal system appears to be a valuable precondition for knowing what information to seek after an accident and what aspects of performance (of the accident-related safety system) to seek to measure. ” *The original text has since been revised and published as “MORT Safety Assurance Systems,” W. G. Johnson, Marcel Dekker (1980). 1 Johnson advanced the idea that application of controls and resources made by managements of occupational safety programs could be categorized into five levels: 1. Less than minimal compliance with regulations and codes. 2. Minimal compliance with regulations and codes. 3. Application of manuals and standards. 4. Advanced safety programs exemplified by those currently found in leading industrial companies and in DOE. 5. An as-yet-nonexistent, superlative safety program synthesized by combining the “system safety” concepts pioneered by the military and aerospace industry with the best occupational safety practices and factoring in the newer concepts of the behavioral, organizational, and analytical sciences. In Johnson’s view, there were sufficient data to suggest that progression from one one level of safety program to the next better level might result in an order of magnitude reduction in the annual rate of disastrous accidents experienced by a specific enterprise. Accordingly, the goal set for the conceptualized fifth level system, to be developed by the ERDA study, was an order of magnitude improvement in the already exemplary ERDA safety record. The study was titled “Development of Systems Criteria for Accident Reporting and Analysis and for the Measurement of Safety Performance. In 1971 the first generation MORT text was published and the study moved to the next logical phase of pilot use at an actual ERDA contract activity. The Idaho National Engineering Laboratory (INEL), then known as the National Reactor Testing Station, was chosen primarily because the prime operating contractor, Aerojet Nuclear Company (ANC), then known as the Idaho Nuclear Corporation, had a well-established safety program and additionally was developing and using “system safety” techniques patterned after methodologies pioneered by National Space and Aeronautics Administeation (NASA) and Department of Defense (DOD). The first generation MORT text introduced four key innovative features basic to the MORT program: 1. An analytical “logic tree” or diagram from which MORT derives its name, “Management Oversight and Risk Tree.” This diagram arranges safety program elements in an orderly, coherent, and logical manner. 2. Schematic representation of a dynamic idealized or “universal” safety system model by using Fault Tree Analysis methodology. 3. Methodology for analyzing a specific safety program through a process of evaluating the adequacy of implementation of the individual safety system elements. 2 4. A collection of philosophical statements and general advice relative to the application of the MORT system safety concepts and listed criteria by which to make an assessment of the affectivity of their application. A major MORT premise is that the MORT safety system is congruous (i.e., harmonious) with a goal-oriented, high performance, complex management system. Working under the direction of a Steering Committee composed of senior ANC line and staff managers, a MORT development team was formed consisting of Johnson and three ANC employees, Dr. Robert Nertney, Jack Clark, and Jack Ford. During the next two years, MORT concepts were subjected to trial use under actual operational conditions. Additional systems concepts were developed and tested.
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