1. 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 1 Copyright 2014 Conger-Elsea, Inc.

2. 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

3. 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

4. 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

5. 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

6. (Storyline) Copyright 2014 Conger-Elsea, Inc. 6

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9. (Comparison) Copyright 2014 Conger-Elsea, Inc. 9

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11. (Protection) Copyright 2014 Conger-Elsea, Inc. 11

12. Copyright 2014 Conger-Elsea, Inc. 12

13. (Logical) Copyright 2014 Conger-Elsea, Inc. 13

14. Copyright 2014 Conger-Elsea, Inc. 14

15. (Comprehensive) Copyright 2014 Conger-Elsea, Inc. 15

16. 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

17. 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

18. Copyright 2014 Conger-Elsea, Inc. 18