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

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

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  • 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.
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  • 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
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  • 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
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  • 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. Copyright 2014 Conger-Elsea, Inc. 4
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  • 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
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  • (Storyline) Copyright 2014 Conger-Elsea, Inc. 6
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  • (Comparison) Copyright 2014 Conger-Elsea, Inc. 9
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  • (Protection) Copyright 2014 Conger-Elsea, Inc. 11
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  • Copyright 2014 Conger-Elsea, Inc. 12
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  • (Logical) Copyright 2014 Conger-Elsea, Inc. 13
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  • Copyright 2014 Conger-Elsea, Inc. 14
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  • (Comprehensive) Copyright 2014 Conger-Elsea, Inc. 15
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  • 1.H-B-T 2.Information Systems 3.Readiness 4.Maintenance 5.Inspection 6.Supervision 7.Personnel Error 8.Services 9.Emergency Response Copyright 2014 Conger-Elsea, Inc. 16
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  • 1.Management Overview 2.Safety Evaluation 3.Program Review 4.Procedures 5.Design Review 6.Human Factors 7.Services 8.Information Systems Copyright 2014 Conger-Elsea, Inc. 17
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  • Copyright 2014 Conger-Elsea, Inc. 18