1. Presented by Dorian Conger Conger-Elsea, Inc. 2000 Riveredge Parkway, Suite 740 Atlanta, GA 3038 800-875-8709 phone 770-926-8305 fax www.conger-elsea.com dorian.conger@conger-elsea.com 2000 Center for Chemical Process Safety Orlando, FL Copyright 2014 Conger-Elsea, Inc. 1

2.  Multiple Agencies  Timing  Systematic Analysis Copyright 2014 Conger-Elsea, Inc. 2

3. 1.Thoroughness 2.Fairness 3.Efficiency Copyright 2014 Conger-Elsea, Inc. 3

4. A.Coordination B.Differing Agendas Copyright 2014 Conger-Elsea, Inc. 4

5. A.Collection to Analysis B.Analysis to Reporting Copyright 2014 Conger-Elsea, Inc. 5

6. A.Team Approach B.Multiple Methods Copyright 2014 Conger-Elsea, Inc. 6

7. 1.When multiple agencies are present, it is much more efficient to work together than to work apart. This effort at inclusion will also promote a thorough investigation. Fairness is enhanced by the increase in the volume of information required to satisfy all parties. 2.When multiple agencies with differing agendas are present, a balancing act is necessary, if the agencies are going to work together. It will work best for the root cause analysis if the two agendas can be kept as separate as possible. 3.The time gap between information gathering and analysis has a mixed effect on the measures of investigation effectiveness. Again, the team must consider carefully the value of gaining more information by delaying with the erosion of information over time. The best solution to the problem is to perform the information gathering and the analysis contemporaneously, in an iterative fashion. This process allows the objective analytical process to drive the data gathering. Copyright 2014 Conger-Elsea, Inc. 7

8. 4.The delay from the completion of the analysis to the issuing of the report is inefficient and does not enhance either the thoroughness or fairness of the report. A delay of more than 120 days minimizes the real impact the report will have on the facility involved and the industry. Other agencies and most corporations require a timelier issuance of these types of reports. 5.The use of teams with different technical disciplines and perspectives makes for a more efficient, thorough and fair root cause analysis process. This approach creates a beneficial synergy among the team members and produces a process that is more than the sum of its parts. 6.Multiple systematic analysis methods are a must for an efficient, thorough and fair root cause analysis effort. The methods assure the objectivity of the outcome and the validity of the root causes that the team identifies. Copyright 2014 Conger-Elsea, Inc. 8