Table 7.

Description of the results of the stages of the MORT method graph

Branch	Description
T	The losses generated are due to the damage of the valve in the work process. When damaged, the valves need to be replaced with new ones and this represents a loss for the company; in addition, there is a loss of the company's credibility with the customer
S/M	The aforementioned losses are the result of the company's “carelessness and omissions”
R	All the assumed risks indicated in the graph were assessed inappropriately. Later, in Table 8, it is explained better
S	The “carelessness and omissions” are due to Control Factors LTA
SA1	The incident occurs when the energy flow (employee using the wrench) comes into contact with a target (valve) without a barrier or control protecting him/her
SB1	The harmful energy flow represented by the employee using the wrench is functional, that is, it is part of the process and the control of its use is deficient, as there is no adequate distance from the energy flow
SB2	The target (valve), as well as the energy flow, is also functional, as it is part of the process. Although the target is in place, the means to allow the flow of energy not to harm it have not been provided and used. For example: when realizing that the tool is poorly positioned on the valve, the employee can adjust the position, instead of continuing the process incorrectly
SB3	It considers whether the barriers and controls were adequate to prevent targets from being exposed to harmful energy flows
SC1	It considers whether the work and process control system in question was adequate
SD1	Regarding technical information, there have been past and recent investigations aimed at solving the problem in question, but they were not adequate
	Regarding data collection, the company has not implemented a plan for monitoring the work process and does not have an adequate internal audit system to guarantee its quality. In addition, they did not adequately use information from previous similar incidents
	Regarding data analysis, there is no problem priority checklist and status display point, where managers and supervisors can monitor current problems and perform analysis of results
	The risk analysis carried out by the company aimed only to understand the consequences of the incident in question, that is, the problems in the work process were not sufficient to trigger a risk analysis before the incident. Another important point is that the training given by the company to employees was not the result of risk analysis, but an unplanned change of work
SD2	There was no specification of the operational readiness check, where resources such as facilities, equipment, control procedures and personnel were properly observed. The verification carried out was informal and did not guarantee the quality of the process
	This branch of the tree shows us that an adequate check of operational readiness would show that the incident in question did not happen only due to an employee error, but also due to the use of inadequate equipment (wrench) in the valve removal and placement process
SD3	The inspection of processes and equipment did not follow a previously established plan, in which the exact time and place for some inspection were established
	In addition, the coordination of activities is not adequate when certain equipment in the process undergoes maintenance, as there is no method in the company to minimize the effects of the absence of certain equipment and machines
SD4	Equipment maintenance did not follow an established plan. This service was outsourced when needed
	In addition, the location where the incident occurs did not receive any maintenance service
SD5	The absence of a checklist of process risks, diagrams and records contributed to the incident in question, as it prevented the risks from being detected
	The company did not realize the impact that the incident could have on costs and on the customer's perception, so it took time to look for solutions
	Although the task was properly assigned to employees, it was not informed of its possible risks during the stages. This was due to an inadequate decision by the company to consider the activity with a low gravity potential
	There was no risk prioritization procedure, where the potential severity of each one was measured. As there was no specific risk assessment for a task, no recommendation was made about the control of risks
SD6	The company's management did not develop norms and an internal regulation in the process where the incident occurred and could be controlled. Therefore, avoiding new occurrences
	The use of available resources was harmful, as the tool used was inadequate, which generated rework and higher costs for the company
	The company did not have a pre-established procedure for dealing with urgent or high-risk situations
SC2	Barriers for the energy flow were possible, but were not used. For example¸ the use of a suitable tool in the work process would prevent the employee's force from damaging the valve
	The barriers between the energy flow (employee using the wrench) and the target (valve) were not considered before and, therefore, were not used
	Barriers that would directly protect the target (valve) were also not considered and, therefore, were not used
SB4	Other events in the framework of barriers, in the future, need to be analyzed by the graph of the MORT method
SA2	The company did not have an adequate response time to stabilize and restore the situation after the incident. The creation of a new tool to remove the valve was the solution found by the company to solve the problem, but it was not put into practice immediately, which subsequently generated similar incidents
M	This branch considers how the planning or policy making processes may have contributed to the incident, that is, seeking to understand the aspects of the management system that allowed the elements of branch S to be inadequate
MA1	Despite meeting some basic corporate social responsibility requirements, such as labor rights, the company fails when thinking about policies. Specifically, because it does not have clearly defined values and this is not passed on to employees. In addition to not having policies related to tasks
MA2	Regarding the planning process, although the company took steps to minimize the effects of the incident in question, these were not related to policy planning. Another negative point is that the company did not have an efficient communication plan, where the flow of information could transmit the company's policies to all employees
	There was no policy implementation plan, so most elements of MA2 are marked in red
MA3	This branch considers the adequacy of the risk management system
MB1	There was no risk management policy, therefore, this branch is marked with the color red
MB2	This branch considers whether the problem in question is the result of how the risk management policy was implemented. As there was no risk management policy, this branch is marked in red
MB3	The company has not established risk analysis criteria that could assist in controlling the flow of harmful energy. For example, there was no automatic machinery for removing and placing the valve; in the workplace there were no warnings to alert the employee to the flow of harmful energy; there was no safe procedure for controlling the flow of energy. In addition, the error made by the employee when disproportionately forcing the tool over the valve was not foreseen and this error is one of the main contributing factors for damaging the valves
	The place where the process is carried out was also considered inappropriate, as the vise is on an uneven (uneven) floor. In addition, the equipment in use was not properly checked and tested. Supervision, although it exists, was not specified in relation to how to do this supervision, the amount needed, among other specifications
	The company does not work with established goals, so it does not have indicators that can measure its performance
	The use of harmful energy flow was not limited, being used excessively, without a barrier model or adequate control. In addition, there were no clear warnings for all situations where people or objects came into contact with harmful energy
	There was no adequate guidance regarding the minimum number of supervisions to be carried out and about the responsibilities of supervisors in the work process
	The company did not have a defined emergency method, in which instructions of procedure for the employees could be informed. Only equipment connected to a power system can be switched off using a general circuit breaker
	There is no problem minimization policy and no adequate procedure to have a quick correction of these problems
MB4	All elements of this branch are marked in red, as there is no Risk Management Guarantee Program
MB5	It is noticed that there is no defined Risk Management System. The company analyzes the risks of a process informally, without quantifying and documenting them. Therefore, a review of the risk system is not carried out

Source: Own elaboration