When NRI published the first edition of MORT User¿s Manual and Chart in 2002, the only version of the manual then available in the public domain was that written for the United States Department of Energy. Understandably, the DoE edition of the manual was written in American English and referred to documents and organisations that were relatively unknown to people outside of the intended readership. The manual was also ten years old. The first edition of the NRI MORT User¿s Manual provided European users of MORT with a question set in British English. The revisers kept to the structure of the 1992 version of the MORT Chart and stayed close to the concepts of the original (1973) MORT text. The publication of the first edition also meant that the MORT method stayed available in the public domain and accessible via the internet. This second edition arose from a project to translate the MORT user¿s manual and MORT chart into Dutch. This project was undertaken by the NRI Foundation in partnership with the Royal Dutch Navy. Early on in the project, the members of translation team realised that they were investing considerable effort to clarify ¿ in English ¿ the concepts behind some of the questions posed in the manual. In effect, the team were revising the English manual as a necessary prelude to producing a Dutch text. Furthermore, some of these clarifications suggested that changes were needed to the structure of the MORT Tree. To consider these structural changes, the Foundation formed a second team. Over a period of two years, these two teams have reviewed each other¿s ideas until consensus was reached about the changes to the MORT tree and the phrasing of the questions in the manual. In this way, a translation became a revision with a scope wide enough to justify the result as a second edition rather than as a minor revision.@en

This manual describes a method that is based on ¿Events and Causal Factors Analysis¿, ECFA (Buys and Clark, 1995) and attempts to distil refinements of approach that have been collected over the last decade. These refinements were arrived at through the experiences of the authors and by applying criteria and methods published by others (see the bibliography). In order to distinguish this method from its predecessor, it is called ECFA+, Events and Conditional Factors Analysis.@en

This document is published as the result of a project to explore the preconditions for the efficient investigation of accidents and incidents. It is provided as a focus for debate and comment. The ¿Defining Operational Readiness to Investigate¿ project ran between 1995 and 1996 as a partnership between the NRI Foundation and the UK¿s Royal Society for the Prevention of Accidents (RoSPA). This document will be maintained by the Foundation and the authors are keen to hear from any reader with comments and suggestions. Operational Readiness is a philosophy that can be applied to any purposeful system. Readers of this document are encouraged to apply the operational readiness concept to other systems in which they work. Also, although this document is chiefly concerned with the investigation of accidents and incidents related to safety, the contents can be applied to other types of mishap with only little modification.@en

This paper discusses the incorporation into MORT of the Haddon energy-flow notion. It focuses on the relationships between MORT barrier analysis, Energy Trace and Barrier Analysis (ETBA), Control Change Cause Analysis (3CA) and the cybernetic conventions developed by Ashby. The implications for the next generation of MORT and the application of barrier analysis in domains outside of safety are discussed.@en

Visibility of the facts is a prerequisite for learning from incidents. ECFA+ (Events and Conditional Factors Analysis) is a method that helps investigators structure what they know and what they are uncertain about, in a format that is easy to understand. This paper provides an overview of ECFA+, its 30-year history, the investigative tasks it is designed to support, and signposts resources freely available from the NRI Foundation. These resources have been newly developed as part of the Foundation¿s mission to further understanding and sharing of knowledge in the field of risk management.@en

This manual is intended for line managers and supervisors as well as specialists. It describes a method that is based on ECFA - Events and Causal Factors Analysis (Buys and Clark, 1995) and includes many refinements of approach. In order to distinguish this method from its predecessor, it is called ECFA+, Events and Conditional Factors Analysis. The paper "Investigation tools in context" describes where ECFA+ fits in to the "investigator's toolbox". The draft ECFA+ Manual is available for download. We have developed this manual to: - help investigators produce accounts of incidents that are robust with regard to evidence and completeness; - encourage stakeholders to share information about incidents; - provide a reference point for practitioners, tool developers, researchers and students. [http://www.nri.eu.com/ECFA_Page.htm]@en