Discussion 7.2.docx - The Management Oversight and Risk...

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The Management Oversight and Risk Tree (MORT) analysis is fundamentally an investigative concept that is utilized to focus on a variety of factors that can result in an accident or incident (Vincoli, 2014). It outlines back undesirable energy sources and will deliberate the capacity of the provided barriers to ascertain the contributing factors that led to the accident. Additionally, when applying the MORT analysis, investigative teams will typically examine particular factors such as management’s safety work procedures, the working condition of the safety devices, and so forth. With that said, the MORT analysis can be used for the American Airlines Flight 191 accident to find out the safety-related oversights, errors, and/or omissions (Vincoli, 2014). From this accident, it can be seen that crashing in less than a minute after taking off from the runway, which caused 273 fatalities, the casualties and substantial damage done to the DC-10-10 is the top event of the MORT analysis (Federal Aviation Administration [FAA], n.d.). Thus, identifying the causal factors of this accident and top event, one contributing factor was the lack of system isolation considered by McDonnell-Douglas manufacturers and engineers in the event of an inflight engine separation. This is because, of the aircraft design, despite there being a built-in hydraulic redundancy for the extension and retraction of the leading edge slats, engineers did not consider the inability of the leading edge system to accommodate a single failure, or in this case a loss of hydraulic pressure to the leading edge slats on an aircraft wing (FAA, n.d.). Hence, during the take-off roll of American Airlines Flight 191, as soon as the left engine and pylon had detached from the aircraft’s left wing, the separation had damaged the electrical supply and severed the hydraulic lines to specific cockpit instruments, including the stick shaker and slat asymmetry indication system (AlmostWins, 2018). Also, with the damaged hydraulic line, this led to the loss of hydraulic pressure and the retraction of the left wing’s leading-edge slats, which eventually led to an uncontrollable lift asymmetry at the left wing to develop (AlmostWins, 2018). But the pilots were unaware of the asymmetry as losing the No. 1 engine and its associated electrical generator, disrupted a multitude of warning and safety systems. Consequently, the mentioned accident chain had caused the catastrophic accident of American Airlines Flight 191. Therefore, using the MORT analysis color code, the causal factor of insufficient system isolation is assigned as red since this mishap has shown Less Than Adequate controls/barriers to prevent a transfer of hazardous energy (Vincoli, 2014). However, as the previous factor was rooted and identified due to an uncontrollable event of an engine separation, specific causal factors that had stemmed from the component separation culminate to the findings of the National Transport Safety Board (NTSB), stating that the accident was a result of maintenance-induced damage leading to the separation of the No. 1 engine and pylon assembly at a

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