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Root Cause Analysis
Presented by Ken ElseaConger-Elsea, Inc.
2000 Riveredge Parkway, Suite 740Atlanta, GA 30328
800-875-8709 phone770-926-8305 fax
2004 Operations Conference of the Western Energy InstituteNorth Las Vegas, Nevada
1Copyright 2014 Conger-Elsea, Inc.
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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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
3
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
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
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Essential Elements
5
Events & CausalFactors Analysis
(Storyline)
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Events & Causal FactorsChart Symbols
7
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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
Change Analysis(Comparison)
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Change Analysis:Condensed Worksheet
A B CHANGES (∆) IMPACT
10
Hazard-Barrier-TargetAnalysis(Protection)
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Barrier
TargetHazard
Fault Tree Analysis(Logical)
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Analytical Trees
14
Management Oversight and Risk Tree (MORT) Analysis
(Comprehensive)
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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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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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Other Questions
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