helping hse team in learning from accident by using the management oversight and risk tree (mort) analysis method

introduction: the effects of accidents vary from minor injuries to fatalities and from insignificant damage to very severe damage to the environment and property. in order to prevent accidents in the work place, the root causes of and events should be identified using a systematic method and the results should be published. the current study aims to investigate the given causes of an accident in order to implement preventive actions in accidents and similar organizations. methods: in this case study, after choosing the main event; to analyze the accidents, at first a set of questions in mort were answered. by answering the questions, the final events, and the inappropriate management risks (color-coded red) followed by the leading causes of the accident were identified. results: after analyzing the given accident, 22 inappropriate final events (color-coded red) and 4 assumed risks were identified. of the total 12 identified basic causes, about 75% were classified as the management policies and decision makings group, 17% as the individual factors, and 18 % as the environmental factors group. conclusion: the analysis using mort method helped the organization with learning lessons from the accident especially at the management level. in order to prevent the similar and dissimilar accidents, the inappropriate informational network within the organization, inappropriate operational readiness, lack of proper implementation of work permit, the inappropriate and lack of updated technical information systems regarding equipments and working process, and the inappropriate barriers should be considered in a special way.