Session Brief: MORT Analysis

Goal

Artifact: MORT Worksheets

Working Question

Which specific controls and which management oversight functions were involved in the incident, were effective, insufficient, or missing, and which systemic levers follow from this?

Context

Incident description with damage profile; timeline; list of relevant processes, procedures, trainings, audits; known prior incidents; management structure and accountability lines.

Setup

• Format: Method session
• Duration: Several days to weeks
• Mode: Workshop or async
• Participants: A MORT-experienced investigator (lead); two to four investigators with domain expertise; a sponsor with mandate (often safety or compliance lead); interview partners from operations and management.
• Owner: A MORT-experienced investigator (lead)
• Participation mode: Team round, shared work and alignment
• Outcome logic: Finish artifact

Participation Logic

Use the session for shared understanding. Contributions are collected visibly, assumptions are aligned, and open differences remain traceable in the artifact.

Outcome Logic

The session works directly toward MORT Worksheets. After the session, the artifact should be shareable, reviewable, or reusable.

Input

MORT diagram (standard tree with approx. 1,500 nodes); worksheet template with columns for node, status (Less Than Adequate, Adequate, Not Applicable), evidence, owner; access to documentation, logs, interviews; version control for worksheets.

Preparation

Make the MORT diagram visible on a wall or in a tool. Set up the worksheet template. Kickoff with sponsor to align mandate, confidentiality, and reporting deadline; pre-plan interview slots.

Agenda

1. Phase 1: Mandate and scope (1 day) Owner: Facilitator Action: Sponsor briefing: define investigation scope, confidentiality, reporting deadline, and output format. Name team and interview partners. Set definition of done for the report (for example findings, recommendations, systemic causes). Hint: Without clear mandate, Phase 4 (management branches) stalls early. Sponsor must confirm in writing that management findings can be published. Output: MORT Worksheets

2. Phase 2: Consolidate evidence base (2-4 days) Owner: Facilitator Action: Finalize timeline. Collect documents (procedures, audits, trainings, test protocols). Conduct initial interviews. Prepare data basis for each MORT node. Hint: Interviews without psychological safety yield sanitized answers. Communicate the blameless norm and sponsor confirmation before interviewing. Output: Findings je Zweig

3. Phase 3: Review specific controls (3-7 days) Owner: Facilitator Action: Review the left MORT main branch (Specific Control Factors) node by node against the incident. For each node set status (Less Than Adequate / Adequate / Not Applicable) and evidence. Hint: There is a temptation to only test controls that obviously failed. Full traversal of nodes is the method core. Half a MORT is no MORT. Output: Korrekturmaßnahmen

4. Phase 4: Review management oversight (2-5 days) Owner: Facilitator Action: Review the right main branch (Management System Factors) node by node: policy, implementation, risk assessment, lessons learned, trainings, audit accountability. Back findings with evidence. Hint: This phase is most politically sensitive. Findings must be evidence-based, not speculative. Secure sponsor mandate and escalate if needed. Output: Systemische Empfehlungen

5. Phase 5: Findings, systemic causes, recommendations (2-3 days) Owner: Facilitator Action: Categorize less-than-adequate nodes as findings. Extract systemic causes across multiple nodes. Formulate recommendations: immediate, medium term, structural. Add owner and deadline per recommendation. Hint: Findings without recommendations become shelfware. Recommendations without owner and deadline are also shelfware. Both are required. Output: MORT Worksheets

6. Phase 6: Review and handover (1-2 days) Owner: Owner Action: Review report with sponsor. Incorporate factual corrections without watering down findings. Deliver final report including worksheets and schedule follow-up implementation check in 3-6 months. Hint: Removing findings at sponsor request prevents learning. Wording debates are acceptable, substance debates are not. If needed, document dissent. Output: Findings je Zweig

7. Publish artifact (10 min) Owner: Owner Action: Check the artifact for completeness, define location, set version or status, and name review recipients. Output: MORT Worksheets

Closeout

• Update result artifact: MORT Worksheets
• Define location, version, and review recipients.
• Define owner, next step, and review date.

MORT Worksheets: MORT Analysis

Working Question

Which specific controls and which management oversight functions were involved in the incident, were effective, insufficient, or missing, and which systemic levers follow from this?

Context

Incident description with damage profile; timeline; list of relevant processes, procedures, trainings, audits; known prior incidents; management structure and accountability lines.

Participants

• Owner: A MORT-experienced investigator (lead)
• Participants: A MORT-experienced investigator (lead); two to four investigators with domain expertise; a sponsor with mandate (often safety or compliance lead); interview partners from operations and management.

Input

MORT diagram (standard tree with approx. 1,500 nodes); worksheet template with columns for node, status (Less Than Adequate, Adequate, Not Applicable), evidence, owner; access to documentation, logs, interviews; version control for worksheets.

Template

MORT Analysis Working Matrix

Output artifacts

• MORT worksheets:
• Findings by branch:
• Corrective actions:
• Systemic recommendations:

Decision or recommendation

What consequence follows from the matrix?

Completion Check

• MORT Worksheets is complete enough for review:
• Location:
• Version / status:
• Review by:
• Next step:

Next Step

• Review result
• Mark open questions
• Schedule review or decision