Presented by Ken Elsea
Conger-Elsea, Inc.
2000 Riveredge Parkway, Suite 740
Atlanta, GA 30328
800-875-8709 phone
770-926-8305 fax
www.conger-elsea.com
ken.elsea@conger-elsea.com
2004 Operations Conference of the Western Energy Institute
North Las Vegas, Nevada
Copyright 2014 Conger-Elsea, Inc.
1
Ken Elsea

Former college professor; former divisional VP of EG&G Inc, a Fortune 500
company; in nuclear power and electric utilities since 1980, in oil and gas
since 1994; teaches about 400 seminar participants annually;
leads/supports 4-6 large scale investigations annually.
Conger-Elsea, Inc.

Offers training, consulting and software support in risk analysis, incident
investigation, root cause analysis, and safety improvements.
Copyright 2014 Conger-Elsea, Inc.
2
Root Cause Analysis is the process by which systematic
analytical methods are used to search for the fundamental
reasons of an incident or situation.
Copyright 2014 Conger-Elsea, Inc.
3
1.
2.
3.
It is better to learn lessons sooner rather
than later.
When BIG things go wrong BIG things are
wrong.
Root CauseS rarely appear alone.
Copyright 2014 Conger-Elsea, Inc.
4
1. Management Support
 Protocol
 Training
 Learning culture
2. Use of Analytical Methods







More than 100 known
Multiple methods are encouraged for large events
Events & Causal Factors Analysis
Change Analysis
Hazard-Barrier-Target Analysis
Fault Trees Analysis
Management Oversight & Risk Tree Analysis
Copyright 2014 Conger-Elsea, Inc.
5
(Storyline)
Copyright 2014 Conger-Elsea, Inc.
6
Copyright 2014 Conger-Elsea, Inc.
7
Operator
had been
working 13
hours
Operator
was
fatigued
Operator
Operator
pulled
fuse
had
12A7B
been
working
13
0531
12/3/03
hours
Diesel generator
circuitry deenergized 0531
Diesel generator
started 05/31
Lights in
work area
burned out
Copyright 2014 Conger-Elsea, Inc.
8
(Comparison)
Copyright 2014 Conger-Elsea, Inc.
9
A
B
CHANGES (∆)
IMPACT
Copyright 2014 Conger-Elsea, Inc.
10
(Protection)
Copyright 2014 Conger-Elsea, Inc.
11
Barrier
Hazard
Target
Copyright 2014 Conger-Elsea, Inc.
12
(Logical)
Copyright 2014 Conger-Elsea, Inc.
13
Copyright 2014 Conger-Elsea, Inc.
14
(Comprehensive)
Copyright 2014 Conger-Elsea, Inc.
15
1.
2.
3.
4.
5.
6.
7.
8.
9.
H-B-T
Information Systems
Readiness
Maintenance
Inspection
Supervision
Personnel Error
Services
Emergency Response
Copyright 2014 Conger-Elsea, Inc.
16
1.
2.
3.
4.
5.
6.
7.
8.
Management Overview
Safety Evaluation
Program Review
Procedures
Design Review
Human Factors
Services
Information Systems
Copyright 2014 Conger-Elsea, Inc.
17
Copyright 2014 Conger-Elsea, Inc.
18