Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328...

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Root Cause Analysis 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 [email protected] 2004 Operations Conference of the Western Energy Institute North Las Vegas, Nevada 1 Copyright 2014 Conger-Elsea, Inc.

Transcript of Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328...

Page 1: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Root Cause Analysis

Presented by Ken ElseaConger-Elsea, Inc.

2000 Riveredge Parkway, Suite 740Atlanta, GA 30328

800-875-8709 phone770-926-8305 fax

[email protected]

2004 Operations Conference of the Western Energy InstituteNorth Las Vegas, Nevada

1Copyright 2014 Conger-Elsea, Inc.

Page 2: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Root Cause Analysisby

Ken ElseaConger-Elsea, Inc.

Introduction

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.

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Page 3: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Root Cause Analysis is the process by which systematic analytical methods are used to search for the fundamental

reasons of an incident or situation.

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Definition

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Page 4: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

1. It is better to learn lessons sooner rather than later.

2. When BIG things go wrong BIG things are wrong.

3. Root CauseS rarely appear alone.

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Principles

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Page 5: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

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

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Essential Elements

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Page 6: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Events & CausalFactors Analysis

(Storyline)

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Copyright 2014 Conger-Elsea, Inc.

Events & Causal FactorsChart Symbols

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Page 8: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

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Operator had been working 13 hours

Operator was fatigued

Lights in work area burned out

Operator had been working 13 hours

Operator pulled fuse 12A7B 0531 12/3/03

Diesel generator started 05/31

Diesel generator circuitry de-energized 0531

Page 9: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Change Analysis(Comparison)

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Page 10: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Copyright 2014 Conger-Elsea, Inc.

Change Analysis:Condensed Worksheet

A B CHANGES (∆) IMPACT

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Page 11: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Hazard-Barrier-TargetAnalysis(Protection)

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Page 12: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

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Barrier

TargetHazard

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Fault Tree Analysis(Logical)

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Page 14: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

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Analytical Trees

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Page 15: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Management Oversight and Risk Tree (MORT) Analysis

(Comprehensive)

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Page 16: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

1. H-B-T2. Information Systems3. Readiness4. Maintenance5. Inspection6. Supervision7. Personnel Error8. Services9. Emergency Response

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MORT AnalysisSpecific Control Factors

(Working Level)

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Page 17: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

1. Management Overview2. Safety Evaluation3. Program Review4. Procedures5. Design Review6. Human Factors7. Services8. Information Systems

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MORT AnalysisManagement System Factors

(Planning Level)

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Page 18: Presented by Ken Elsea Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 30328 800-875-8709 phone 770-926-8305 fax .

Other Questions

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