ML19308B904

Mort:Safety Mgt Program Developed for Erda

ML19308B904
Person / Time
Site:	Crane
Issue date:	03/28/1979
From:	EG&G, INC.
To:
References
CON-EY76-C-07-1570, CON-EY76-C-7-1570, TASK-TF, TASK-TMR ERDA-77-38, UC-41, NUDOCS 8001170553
Download: ML19308B904 (14)

Text

__

\\

l l

l l

l l

i

]

\\

I i

.\\

1

(

722'$~23 Ilks 706ll105

, f > 4.j % b gg,qv,,,... g.,., / g;. :

g-g ? r y ; A, rg,., ;.,,,.e g ;,.,,

,mi-

.y

,.{%. T TK E!J Q Jfpb K y g K g Tt*]h,

-r 41 z,,.,

. ',, ~ -

ERDA 77-38

@f,g

t. / ,.. * '. -..*

o,.;, -

3 uc u

',h,'

jsf * *,

j. N' s

. _ g v.

a

... > <:, q. y'. [ :...

}

q ~.; -

a.

ws..+.

Y

~

'a T

ff.

..3.4 g}....

o.

,-. yp g>

. j.

5

',. ].s.*l s.

- q. }.-

~

G 9

Q y

u 9

.M C

D k.

' ).9

[' '

jag)

T sy J A Safety Management Program Developed t

I M

for ERDA i

>3ED b

I System Safety Development Center l

FG&G Idaho, Inc.

Energy Research & Development Administration idaho Operations Office l

Under Conteact No. EY.76 C 071570

.iYSTEM SAFETY l OD" TORMENT CENTER P

h

~

i I

i I

ENERGY Rf5fARCH AND DEVELOPMENT

()

l EGES 04 ldah0, lnC.

ERDA.

AoumisiRanoN anvissoN ew sArsiv.sv4NDARDS. ANO(OwllANCE t

, - o - o

+,

( -

{.

ve

.5 g

+ ".

4-3 A

,C R'

'.i

^

z$

44a f

... ?

_f

..__b.

2 i

4 4

f PREFACE ERDA's System Safety Development Center (SSIX')is located at the Idaho National Engineering Laboratory under the EG&G Idaho, Inc., contract administered by the Idaho Operations Office. The SSIX' performs a variety of tasks for ERDA's Division of Safety, Standards, and Compliance, for the purpose ofimprovement nd application of safety program elements. Primary l

among these tasks are development and demonstration of new methodologies, training, consultation, and technical writing. This information package (ERDA 77 38)is an example of thelatter t sk, aimed at communicatingto a j

, general audience the nature and purpose of major features of the Management j

Oversight and Risk Tree (MORT) program. The SSDC also originates a guideline series of monographs (the ERDA 7645 series) for individuals who desire more specific explanations of the MORT program.

I O

e INTRODUCTION "Ihis package provides information about the liRDA. MORT system safety program. Five information sections include:

1. General Program information

2. 'lhe MORT Seminar

3. The MORT Accident / Incident Investigation Workshop

4. Commentson Applicationsof MORT

5. An Appendix (that provides answers to the most frequently asked questions about the MORT program)

Further information relating to the program may be obtained from the following sources:

POLICY AND PROGRAMMATIC MATTERS:

M R. R. W.1 ICIIV R,5pecial lla:ards f:ngineer Industrial Safety & lire Protecthm Hranth I)ivision of Safety, Standards.& Compliance 1'nergy Rewarch & Ikvetorment Administration Washington.1)C 20545 Phone:

(301) 353-560I ITS 233-5601 TECHNICAL. INFORMATION:

System Safety llevelopnent Center Safety IMvision l'G&G Idaho,Inc.

P.O. Hos 1625 Idaho l' alls 11) 83401 Phone:

(208) 5224640.estension 1357 ITS 583-1357 I

r N

I s

e

..n a

MORT-THE MANAGEMENT OVERSIGHT AND RISK TREE

2. Express risks in quantitative form (to the maximum practicable degree) and refer these risks to proper management levels for appropriate action.

ne Management Oversight and Risk Tree (MORT)is a system safety propam

3. Make effective allocation of resources to the safety propam and to originally d(veloped for the Atomic Energy Commission (AFC). When the individual hazard control efforts.

AEC was dissolved and the Energy Research and Development Administration was created, the MORT program was retained by the ERDA De methods and resources available for actu,eving the objectives.melude:

Division of Safety Standards,and Compliance (SSC).

1. External consultants, such as Johnson, who are used to develop In 1970 the AlC desire to further improve uptm an already excellent methods and to obtain an independent outsider's view on safety safety record resulted in a safety metimds development contract with W. G.

program needs.

Johnson, a former General Manager of the National Safety Council. %e first

2. Internal groups, primarily the SSDC, who provide needed services and step taward Johnson's development of an ideal, comprehensive system safety functions: MORT software and hardware, MORT consultation, safety program came in 1972 when he published a MORT text that included:

program needs surveys, development of methods, MORT propam diffusion, and intercontractor information exchange.

1. The basic analytical tree from which MORT derives its name.

3. Monographs, guideline manuals, and other types of literature that are

2. A schematic representation of a dynamic system safety nmdel.

developed ss needed for general use in the safety program and for

3. A collection of methodologies for implementation of system safety specific support of training efforts.

elements.

4. MORT training efforts that include basic MORT Seminars,

4. A collection of philosophical statements and general advice about MORT-based Accident / Incident (All) Investigation Workshops, applying system safety concepts.

MORT-based Safety Appraisal Workshops, and SSDC resident training.

Also in 1972,it was decided that Johnson would conduct pilot trials of the The training programs had reached over 600 MORT Seminar attendees and MORT model under the actual conditions of the contract activities of Aerojet over 100 MORT.A/I investigation Workshop attendees by the end of calendar Nuclear Company (ANC), then a prime contractor to the AEC Idaho year 1976. It is projected that 120 individuals will be participating in the Operations Office (ID). The experiences of these trials, as well as the safety MORT Seminars and 90 in the A/I Workshops each year fc: the next several systems developed and contributed by AEC.ID and ANC, were incorporated years.

in the second generation MORT text of 1974. On the basis of several years of development. careful modeling, and extensive trial studies the AEC adopted Feedback has indicated that these attendees generally are meeting with MORT as a system safety modelin August 1974,and established the System success in applying MORT principles to reduce oversights and omissions.

Safety Development Center (SSDC) at the Idaho National Engineering Where surveys have indicated that needed improvements are in order, the laboratory as its base for further project development.

original MORT text is either being revised or completely replaced by monographs.

With this background and development work accomplished, ERDA realized, early in 1975, that all the necessary elements of an excellent system safety Attendees who are not safety professionals have demons' rated a continuing program were present, and formalized a preliminary ten-year goal. He goal of interest in MORT. His has resulted in a desirable common base for the ERDA. MORT program is to reduce the ERDA and ERDA contractor interdiscipline communications. Individual MORT contacts have been 1975 accident rates and probabilities by an order of magnitude by 1986.

established at ERDA and ERDA contractor offices to assure direct and timely information exchanges among ERDA-SSC, the SSDC, and the individual In the process of achieving the ten-year goal, MORT is designed to accomplish

offices, the following objectives:

A continuing program of MORT seminars and workshops is being conducted I. Prevent safety-related oversights, errors, and omissions.

by the SSDC under the auspices of ERDA-SSC. He SSDC now functions within the EG&G Idaho, Inc. contract at the Idaho National Engineering laboratory.

3 2

THE MORT SEMINAR potential for accidents within ERDA may involve many energy types and forms, and different energy types are often involved in a single accident,e.g.,

MORT, a system safety concept, applies analytic procedures to all phases of fire or explosion involving radioactive materials. Training of ERDA the safety effort. MORT is a disciplined method for determining the causes investigators, therefore, is based on analytical methods which are perfectly and contributing factors of an accident through the tecimique of tracing Feneral in form:

unwanted energy flow. It is also a format for evaluating management policies and systems relating to safety (as well as the quality of safety programs) by I. Use of both fault tree and positive tree analytical methods.

evaluating the adequacy of" barriers" to unwanted energy transfer.

2. Energy-b.*rrier analysis.

3. Events and causal factors analysis.

With the development of MORT, seminars have been established to provide participants the opportunity for discussion and clarification of selected The training is provided through a combination of two courses. De first of MORT concepts and methods. He seminars are structured to provide these is the one. week seminar in basic system safety. His course is based on experience and practice in the use of MORT.

the MORT text. He second is a ten day workshop specifically directed toward training in accident investigation. His workshop is based on an Ircture materials incorporate traditiona' safety concepts, such as hazard ERDA Accident / Incident investigation Manual.

review, human performance, and risk assessment, as well as innovative safety concepts, such as barrier analysis, change analysis, and tracing of unwanted Subjects included in the workshop are:

energy transfers. During detailed study of these concepts, participants focus on three major concems: (I) specific oversights and omissions,(2) assumed I. Analytical methods to be employed in investigation.

risks, and (3) general management system weaknesses.

2. Information collectron.

3. Risk projection.

MORT seminar participants have shown a marked increase in their ability to

4. Iluman behavior considerations.

quickly and skillfully conduct a thorough accident analysis and/or safety S. Reports of actual accident investigation experiences.

review. In addition, MORT precepts improve general managerial performance,

6. Roles of specialists in investigation (legal, medical, etc.).

such as in decision making, analyzing performance problems, and evaluating

7. Administrative considerations in investigation.

new experiences, findings, or technology.

8. Structuring the investigation report.

Although MORT seminars primarily are designed for safety-oriented people, Training of the investigators is based on actual case study and role-playing trials have shown that participation by management and technical personnel exercises, which simulate the accident situation to the highest practicable is extremely valuable. Such interlevel and interdisciplinary training provides a degree.

common base for communication, cooperation, and planning for improved management and more effective accident control.

ERDA's primary objectives in establishing and conducting the accident MORT seminars are sponsored by ERDA.SSC and are offered through the investigation program were:

SSIX'.

1. Understanding of the causes of an accidental occurrence in order to THE ACCIDENT / INCIDENT (A/l) INVESTIGATION prevent similar occurrenos and thereby improve the safety of ERDA WORKSHOP operations.

2. Determination of how safety respamsibilities may be clarified and ERDA has established a program for training and certification of accident subsequent errors reduced.

investigators. Government regulations (ERDAM Chapter 0502) require ihat at

3. Optimization d the efrect of practical correceive actions wlich are least one member of any board involved in investigation of serious accidents based upor$ a relatively low number of serious accidents.

occurring within ERDA have an active certification as a trained investigator.

4 5

Secondary purposes and additional benefits included:

COMMENTS ON APPLICATION OF MORT

1. Determination of the nature and extent of the event and b Dere appear to be some problems in defining and discussing MORT programmatic impact.

l application within contractor organizations. The questions relate to how

2. Improvement of policies, standards, and regulations.

MORT is applied and what results arise from application of MORT.The root

3. Demonstration to an increasingly safety. conscious public that ERDA is of this seems to lie in the tendency Io Ihink of MORT in the sense of manual making a concerted effort to improve the safety ofits operations,and chapter " requirements" or in terms of cookbook type safety programs.

is capable of making a clear and logical presentation of accident facts, analysis, and conclusions.

MORT is not this type of program.

4. Improvement of general performance, supervision, and management abilities.

1. MORT is based on the concept that all losses of the type that we call

5. Demonstration to employees of management's concern.

accidents and incidents arise from two sources:

6. Dispe!!ing any mystery associated with the occurrence.

a. Overs. hts ig

. At the present time, too few investigations have been conducted to fully (1)ln the specific jobs and tasks.

evaluate the long-term benefits of improved quality of investigation.

(2)ln the management system which controls the jobs and tasks.

hrticipants in the training program, however, have reported much improvement in their capability to conduct and report the results of

b. Properly Evaluated and " Assumed" Risks investigations.

Dese cannot properly be called " accidents" in the conventional ERDA-SSC is responsible for review of the reports and has subjected the sense, because we knew that these things were going to happen.We reports received to date to critical evaluation by panels of safety didn't know when. In terms of the MORT definitions howev-professionals.They report as follows:

g 3

g g

,gy climinated,Ihe residual risks remaining at an evaluated and accepted "ERDA's Division of Safety, Standards, and Compliance has noted a marked improvement in the quality of investigation reports generated

2. The MORT diagram itself sets down nearly all the factors which could since the initiation of the Accident / Incident (All) Investigation be included in the " oversight" category ne completeness of the Workshops. Reports received prior to the A/l program were occasionally diagram has been validated in thousands of cycles of usage by retumed to the investigation board for major revisions in factfinding, knowledgeable safety and nonsafety personnel within and outside of analysis, findings, and cimelusions. Recent reports, on the other hand, ERDA.

have been generally strong in these areas and have had only minor shortcomings in the less important areas of report organization and

{

3. The MORT diagram then provides the analyst with a valid consensus presentation / format.

basone in determining what elements must be evaluated in safety program design, appraisal, and investigation.

De fact that the improved reports are consistent in their use of sound logic and investigative techniques has resulted in the satisfactory

4. The remainder of the MORT material provides two sorts of guidance:

achievement of one of the primary objectives of accident investigations-prevention of similar occurrences. Rather than wasting

a. Criteria and guidelines for determining the adequacy of the various time in criticizing the report itself, efrorts are now concentrated on 5*fe'Y P'os'*m *"d m*"*8emea' elemea'$-

corrective actions and reduction of deficiencies identified by the board of investigation. ERDA anticipates that there will be measurable reduction in

b. Consensus methods of choice and guidelines for upgrade of program elements which are determined to be deficient.

its loss experience over the next five years as a result of this program."

6 7

What this sneans is that the use of MORT can be considered in several senses:

An independeat consultant has estimated, howeser, that over several years, ERDA realistically might expect an order of magnitude improvement in

1. If individuals participate in MORT training activities, they will always safety performance through MORT application. The subject of cost-benefit "use" MORT.The training and exercises provide a permanent upgraded relations is left by MORT to the individual MORT user. MORT does require, capability for detection and correction of oversights in a!! areas of the Imwever, that if, say, a contractor safety program is shown to be resource participant's activity (on the job and off). In this sense, over 600 limited by budget restrictions, the consequences of failure to upgrade be

. Individuals within ERDA are "using" MORT at the present time.

evaluated and be transferred from the " accident" to the " assumed risk"

" #E"

2. MORT is "used"in all A/l investigations of type A and type B levels occurring within ERDA. While use of the MORT diagram is not h all of %

6 h h a mes pim n W"

. specifically requised, it is required that a MORT A/I trained MORT in the full sense if it is:

investigator participate in all type A and type B investigations. It.is further recommended by ERDA that MORT be used in investigation of I. Diagnosing problems in the MORT format.

selected lesser events, and such investigations may be, and have already been, requested by a number of ERDA field offices.

2. Implementing fixes in an orderly, systematic way.

3. The future ERDA Safety Appraisal Program may be MORT based.1his

3. Assuring assumption of residual risks at proper management levels in will result in further MORT diagnostic "use" in a day.toslay sense.

the contractor and ERDA organiistions.

Some contractors are already beginning to respond to the future Proper use of MORT does not,in any way, imply that the contractor should appraisal program by doing self-appraisal now.

have improvement projects active in all elements of the MORT diagram, or

4. MORT technology is being increasingly used in specific applications to that they should be implementing all of the guideline methods included in the specific problems by specific organizations. His is arising from program material.

self-diagnosis of problems by individual organizations. These organizations are diagnosing their own problems and are using the The proper application as the MORT acronym implies, involves:

MORT techniques eo develop their own solutions.

I. Evaluat. ion of the safety orogram in such a manner as to prevent oversights.

item 4 indicates a very important aspect of MORT application. There are hundreds of safety program elements on the MORT diagram. It is not the

.. Orderly upgrade based on fixing priority problems as seen by the intent that every organization initiate improvement plans in all of these areas.

contract r and its ERDA overview and monitoring personnel.

If an element does not need fixing, we should not change it.

3. Proper definition and assumption of residual risks within the E"

ne whole idea of the MORT diagram is to avoid oversight and to look at everything which might give us safety problems. Similarly, every organization is not expected to utilize every MORT improvement method and guideline.

Again, methods of solving problems are intended to be used only if an organization has the problems.

All of this brings us to the matter of results to be expected in the use of MORT. Because MORT is intended to be used in individual diagnosis and I

solution of individual organization problems, the results will vary in nature from organization to organization.

8 9

e

APPENDIX The completeness of the MORT diagram has been estabhshed through literally thousands of application cycles within ERDA and outside of ERDA, in both classroom exercise and in actual real-life appraisal and investigation MORT QUESTION-ANSWER PACKAGE activities. Both safety professionals and personnel outside of the safety field have used the tree and provided comments relating to format and content.

Q. What is MORT?

The result of this is that we can have a high degree of confidence that the elements induded in the tree are necessary and sufficient to an ideal safety A. Originally, MORT meant the basic diagram or " tree" that lists all of the program;i.e., everything that's needed is there and nothing that isn't needed elements-both management and task performance-that must exist to has been included, establish an ideal safety program. The initials MOR.T stand for

" Management Oversight and Risk Tree". That's because two purposes of the The second area of concem in workability of MORT has to do with tree are to prevent oversight in establishing and evaluating safety programs methods and guidelines. That is, the "how-to-do-it" detail that stands behind and to assure acceptance of risks at proper management levels within the lhe basie blocks on the trees.

contractor and ERDA organizations.

Since the beginning of the MORT program under the able guidance of Mr.

In the course of program growth," MORT" has come into use in two other W. G. Johnson, a strict policy of "no experimentation" has been exercised in program design. This means that all basic elements of MORT represent proven senses:

methods-the best methodology used by the safety leaders in industry and

• As a name for a complete system safety program.

government. In addition, the basic materials (guideline documents, texthooks.

• As an adjective for elements of the MORT program. For example, a etc.) are first submitted to selected reviewers in contractor and i RDA mganizations fw crith ue nd conunent prim toissue. Du ni tenalis further l

" MORT Tree" relating to fire protection or a MORT training seminar.

modified through experience Fained in initial classroom use and ERDA field The program is based primarily upon:

application. The basis for advertising workability, then,is consensus opinion and general I RDA and national experience. This is a general criterion for I. MORT Seminars acceptance of almost all safety methods and media.1he unfortunate fact of

2. MORT Accident / Incident investigadon Workshops and Refreshers

• "Y I"

' ' *I

• 8' "". work has been done in the area of formal validation of most of the media and methods used by the safety profession.

3. Special MORT guideline literature and textbooks It must be realized, howser, that cost. benefit /value/ effectiveness of

4. %e services center called the System Safety Development Center individual MORT program elements applied in individual organizations having (SSI)C) their own unique problems must be determined on a case basis.

5. A minimal amount of command literature (e.g., ERDAM 0502)

Q. Why do we have to change? Isn't what we're doing good enough?

The next element to be added is MORT-based training in Safety Program A. " God enough" relates to policy which we, at the SSDC, don't set. All Appraisal.

safety policy is established by ERDA. We have some " understandings",

Q. Ilow do we know that MORT will work?

l. public demands are raising the " good enough" safety standards A. We'll answer that in two parts-everywhere. It would seem natural that ERDA and ERDA contractor

\\

In the first place, the basic MORT diagram (tree) will workin preventing standards would float with this general trend.

oversights only to the degree that it is complete and is used by smart people.

2. There has been great need for standardization of safety language, bases We can dispense with the " smart people" problem immediately because of for safety program design, appraisal and investigative methodohr the high standards that ERDA.AEC and their contractors have traditionally etc., within ERDA.1his relates to " comparability" rather than used in staffing their safety organizations.We have the smart people.

10 1I e

e h

2. ERDA4pimsored MORT Accident / Incident investigation Workshops cookbook " similarity". It is inevitable that areas of emphasis wdl shift are conducted at four geopaphic h>catiore 'our times a year. Dese are somewhat in investigation and appraisal. The safety program elements also tuition free and food and lodging are also provided. The only studied will also broaden in the future. This means effectively that expense incurred by the attendee's organization is actual travel to and deficiencies, widch were overlooked in the past, will be evaluated and from the workshop site.

criticized in the future.

3. MORT manuals and other literature are distributed by ERDA.SSC to

3. ERDA,in establishing the MORT program,has set a long-range goal of all field safety of0ces for subsequent distribution to contractor "an order of magnitude" improvement in safety performance. He organizations. Requests for such material should be made to the local areas in which this could be accomplished would, of course, be ERDA field safety office. De SSDC also has a limited supply of such determined to some degree by cost.benent consider + ions.

literature for emergency "special case" distribution.

Q. Does MORT permit the setting up of safety programs geared to the

4. De SSDC provides MORT consulting services on a continuing basis.

individual contractor's specific needs?

Uns relates to general consultation. At the present time, the Center is not permitted to perform major analytical tasks for individual A. nat's exactly how MORT is intended to work. It is not intended that all contractors or field offices.

contractors engage in massive redesign of their safety programs to a standard model program. In fact a little study will quickly reveal that MORT does not

5. Any requests for special MORT seminars, brie fings, t raining-even provide a cookbook approach to a standard program. MORT provides an in-residence at the Center, etc., utiliiing Center staff, must receive prior analytical method for considering all elements of an individual safety ERDA-SSC approval. Such activities are severely limited at the present program. It then provides guidelines for judging these elements for adequacy.

time. Simrt liaison visits to the Center are welcomed, however.

Finallv,it provides additional guidelines relating to fixing those portions of the program which are judged to be "less than adequate" Q. Does it require a supergenius and/or specialstaff people toimplement the In proper application, MORT results only in changes which are judged necessary to prevent accidents and incidents. If existing program elements are A. Generally speaking, this isn't the case. Bree qualifications on that:

judged to be adequate, no change occurs. Furthermore, the guideline remedial

1. It is generaEy m re effectw, e to have someone more or less ramrod methods and m:dia provided by MORT represent "a" proven way of solving thedetected problem. Any other alternative method or modification of the Program implementation. Uns relates more to providing a focal point MORT method which solves the problem is equally acceptable. De than to a requirement for a lot of time and talent. From the SSDC important thing is to eliminate the deficiency in the most (cost) effective point of view, we generally look at the " MORT Contact" in this role.

• 2Y-

2. MORT is generally intended to be a cooperative safety program. This means that an organization oriented toward MORT implementation Q. Ilow do we learn about and get involved in implementing MORT?

should think in terms of a number of MORT trained personnelin the A. As indicated earlier, MORT training, literature, consultation, and safety orpnization and outside. We have been successfulin structuring development af methods are provided by ERDA-SSC as a central service to all the MORT training in such a manner that nonsafety professionals get g

enough fm Memselves out of the MORT training, that they are contractors and 0cid offices.

referring iheir colleagues to the sessions for general systems engineering Training quotas and central distribution of MORT documents are handled and systems management training. De point of all this is that if an by ERDA.SSC via the local field offices (contact R. W. Eicher, ERDA.SSC).

organisation attempts MORT implementation with only one or two Morticians who have to "do it all themselves", overload can occur for I. ERDA-sponsored MORT Seminars are com*ucted at four geographic these individuals.

locations four times each year. Rese are tuition free but travel and

3. Certain MORT speciality areas, for example, sophisticated risk living expenses must be borne by the attendee's h> cal organization.

projection, require special skills within or outside of the safety organization. These skills, however, can generally be developed as one yy moves along in program implementation, 13 9

4 0

W

1i Q. Ulut pressure can we expect from ERDA on MORT implementation?

A. From the beginning, MORT has been conceived as a service by ERDA.SSC. Training seminars, guideline literature, etc., have been available to contractors and field offices for some time. The only" pressure"has been an indirect one, relating to inverigation and appraisal. At the present time,if a contractor experiences an accident or incident, investigations will be performed in accordance with the MORT format and guidelines, in the future, it is planned that safety program appraisal will be performed in the same manner.

The only relationship between command literature (e.g., ERDAM) and the MORT program is in areas where MORT methods and media can be substituted, or used to augment existing requirements. For example, the new manual chapter 0502 added a requirement for use of a MORT-A/I trained investigator to the preexisting investigation requirement. According to our understanding of present thinking, the MORT program implementation will continue to be based primarily uptm guideline material with minimal backup command literature.

Q. Is MORT just for safety professionals?

A. No!

I. MORT program implementation requires active participation by nearly all organizational elements. For maximum effectiveness, the program needs a cadre of key nonsafety professionals who have received complete MORT training, as well as individuals who have received mini-MORT training. The latter includes selected MORT elements designed to fill the specific needs of nonsafety individuals and groups.

2. For nonsafety professionals, MORT is by far the most palatable form of safety training with which we have had experience.

3. The usefulness of MORT training in the nonprofessional's own work is indicated by the following examples:

s

a. The basic M7RT analytical trees have been converted to analyticel trees for cost control and cost overrun analysis by a cost control analyst.

b. Growth of a proposed single MORT seminar to eleven in one contractor organization. This was largely the result s.f nonsafety participants in the initial seminar referring co-workers.

c. A contractor's use of the MORT seminars as the basic systems engineering training for their maintenance planning group.

d. Two ERDA contractors have conducted full MORT seminars for their top management persamnel.

I4

.......--m,,.,im......mn.

I

.