Presented by Ken Elsea Conger-Elsea, Inc Riveredge Parkway, Suite 740 Atlanta, GA phone fax Human Performance, Root Cause, and Trending Conference Jackson Hole, WY 1 Copyright 2014 Conger-Elsea, Inc.

Ken worked as an electrician, housepainter, salesman, debate coach, ditch digger, and college faculty member before joining the Training and Education Division of the Institute of Nuclear Power Operations. In 1982 he joined EG&G to provide commercial training and consulting in risk, safety, root cause analysis, and incident investigation. He has been co- owner and President of Conger & Elsea, Inc. since its formation in Copyright 2014 Conger-Elsea, Inc. 2

1.According to a law school writing instructor, students with which undergraduate major make the best writers: a.History b.Biology c.Engineering d.English e.None of the above 2.Psychological research has confirmed BOTH the Primacy Effect (that which appears first is more likely to be remembered) AND the Recency Effect (that which appears last is more likely to be remembered). So, where in the report should a root cause analyst place a point with weak support? a.In the middle of the report b.At the beginning of the report c.At the end of the report d.It doesn’t matter because half the reviewers will not read it. e.None of the above Copyright 2014 Conger-Elsea, Inc. 3

How many? 1.Word 2.Word(s) 3.Words The Single Cause Fallacy Copyright 2014 Conger-Elsea, Inc. 4

Which hole would you dig? “Dig Deeper” Copyright 2014 Conger-Elsea, Inc. 5

1. Extent of Condition 2. Extent of Condition/Cause Copyright 2014 Conger-Elsea, Inc. 6

3. Extent of Condition 4. Extent of Cause Copyright 2014 Conger-Elsea, Inc. 7

1.F + M = C 2.Facts + Method = Conclusion 3.Proper conclusions are fact-based and method- driven. Copyright 2014 Conger-Elsea, Inc. 8

X + 3 = 7 X = 4 Grade: ___ Grade: B- Comment: _____________ Comment: Show your work Copyright 2014 Conger-Elsea, Inc. 9

1.O (L) O, O, I, I Minimum Standard 2.I (L) I, I, I, I The Usual Beginning Team Composition (Independence, Expertise, and Interdisciplinary Membership) 3.I (L) The Usual End Team Stability L = Team Leader, O = Outsider, I = Insider Copyright 2014 Conger-Elsea, Inc. 10