Root Cause Analysis Blog

Kay Gallogly, Founder, The 42 Group, LLC

Kay is an organizational effectiveness consultant in the nuclear power industry. Focus areas are incident investigation, human performance, and safety culture. She has been investigating incidents since 1992. Prior to starting her own company Kay worked for Exelon for 13 years in a number of capacities including six years of technical fieldwork. She has a BA in Organizational Management and an MBA.

Kay will be presenting IEEE Root Cause Analysis Standard and Using TapRooT® to Evaluate Common Causes, Extent of Condition, and Extent of Cause at the Summit.

Neil Roberts will be presenting “Advanced Behavioral Management: Developing a Modern Safety Culture” on the Safety and Risk Management and Human Error Reduction & Behavior Change Best Practices Tracks at the TapRooT® Summit on Thursday, June 26 at 9:15 a.m.

Neil’s background was originally in engineering (12 years). He became interested in Health and Safety when his father was seriously injured in a workplace accident in 1978. In 1991, his first involvement in occupational health and safety training occurred while employed at Water Training International. He ran intensive Deep Excavation courses and Confined Space courses at a purpose built facility in Derby (UK). He has been involved in occupational health and safety training for 18 years and joined Woodland Grange in the UK in 1995.

His current role is Senior Tutor at Woodland Grange and he delivers safety training courses at all levels (especially IOSH and NEBOSH courses). He is the Business Development Executive for Woodland Grange’s Modern Safety Culture programme. He has an involvement working with companies to develop their safety culture. Typical inputs would include safety climate surveys and interviews together with analysis of accidents and behavioral trends. Gap analysis recommendations are performed followed by the development of action plans, training workshops and programmes. He has been involved with many training events performed both in the (UK) and internationally.

Jose Gerard will be presenting: Como Evitar Accidentes de Trafico en Monterrey (How to Avoid Traffic Accidents in Monterrey) during the 2008 TapRooT® Summit Spanish Speaking Sessions planned for Friday, June 27.

Es una descripcion de las observaciones hechas durante muchos años de servicio en ambulancias y camiones de rescate urbano de los servicios medicos oficiales de emergencia en Monterrey y su area metropolitana, mientras tratamos de resolver los problemas que ya tiene la persona involucrada en un accidente de automovil.

This presentation includes Jose’s observations during his many years of service in ambulance and urban rescue trucks of the official emergency medical services in the metropolitan Monterrey area. Jose’s work includes resolution of problems encountered by persons involved in a car accidents.

A pesar de que la presentacion esta hecha para el area de Monterrey, las observaciones hechas aplican para casi cualquier ciudad en la que pueda pensar.

Jose’s observations apply to almost any other city you may think of (not just the Monterrey area).

David Davis is the Co-founder and Vice President of The Patient Safety Solutions Consulting Company Inc., specializing in healthcare solutions for Patient Safety & Risk Managers. He will be presenting in the Medical Error Reduction Best Practices Track at the 2008 TapRooT® Summit. David is presenting “Morbidity & Mortality Reviews (Hot Case Rounds)” and “Process for Running a Healthcare Root Cause Analysis.”

He is a Certified TapRooT® Instructor and the Southeast Region Quality Management and Accreditation Support Coordinator for Clinical Operations, Southeast Region Medical Command (SERMC) in Fort Gordon, Georgia. He worked for the U.S. Army: Winn Army Community Hospital in Fort Stewart Georgia as the Patient Safety/Risk Management Coordinator and was also the Patient Safety Program Manager for the U.S. Army: Dwight David Eisenhower Army Medical Center in Fort Gordon, Georgia. His experience also includes Chief/Perioperative Nursing, Infection Control Officer/Hospital Epidemiologist, Infection Control Nurse, Staff Development Officer/Senior Clinical Nurse, Head Nurse and Operating Room Nurse.

David was awarded Department of Defense 2006 Patient Safety Award for Most Innovative Solution to Address a National Patient Safety Goal and the Army Civilian Commendation Award for Excellence. He has been awarded many distinguished medals including Legion of Merit, Meritorious Service, Army Commendation, Army Achievement, Coast Guard Good Conduct, National Defense Service and Air Force Reserve.

Bill Sirois will be presenting three sessions at the TapRooT® Summit:

Wednesday - June 25 - 1-2:20
Investigation & Root Cause Analysis Best Practices Track:
* FACTS - Computerized Analysis of Fatigue as a Cause of an Incident

Thursday - June 26 - 9:15-10:25
Medical Error Reduction Best Practices Track:
* The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment

Thursday - June 26 - 10:40-12
Human Error Reduction & Behavior Change Best Practices Track:
* The Human Design Spec: Minimizing Human Error While Working in a 24/7 World

Ken Bloch will be presenting:

*Examples of Extreme Equipment Failure Investigations
*Using TapRooT® to Solve Complex Equipment Problems

to the Equipment Reliability & Maintenance Best Practice Track at the TapRooT® Summit.  

Kenneth Bloch is Lead Process Reliability Engineer at Flint Hills Resources’ Pine Bend Refinery in Rosemount, Minnesota. He is responsible for mitigating process-driven failure risks on refinery assets. He has published articles on equipment failure analysis, life cycle extension, and reliability improvement in Hydrocarbon Processing and Chemical Engineering magazines, and is a regular participant and speaker at the semi-annual API/NPRA Operating Practices Symposium and annual NPRA National Safety Conference. Ken holds a B.S. degree (honors) from Lamar University in Beaumont, Texas.

Heinz P. Bloch will be presenting:

*How to Become Best of Class in Equipment Reliability by Maximizing Uptime
*Best of Class in Equipment Reliability: Part II
*Examples of Extreme Equipment Failure Investigations

to the Equipment Reliability and Maintenance Best Practice track at the TapRooT® Summit.

Heinz Bloch is a consulting engineer with offices in West Des Moines, Iowa. Before retiring from Exxon, he held machinery-oriented staff and line positions with Exxon affiliates in the United States and overseas. Troubleshooting and reliability improvement missions have taken him to process plants and manufacturing facilities in 30 or more countries on all six continents. He is the author of 17 books and over 350 technical papers or similar publications on failure analysis, failure avoidance, compressors, steam turbines, oil mist lubrication and practical lubrication for industrial facilities. He is an ASME Life Fellow and graduated from the New Jersey Institute of Technology with B.S. and M.S. degrees (cum laude) in Mechanical Engineering.

Darby Allen is presenting Executive Involvement in Safety: What the Corporate Board Needs to Know About Safety at the 2008 TapRooT® Summit.

Darby served 27 years in the Royal Navy (from ‘72 to ‘99) as a Submariner, with specialism in Marine and Nuclear engineering. He got into formal Health and Safety when posted to a Naval Base as the designated officer and completed all relevant training. During his career he learned, first of all, how not to do the right thing in safety and later, how it should be done. A classic case of a reformed risk taker!

Darby left the Navy in ‘99 to set up his own very successful H&S business. The business was bought out in ‘01. Next, he, as Principal Consultant, was involved in a great deal of training at all levels but mainly accredited NEBOSH, IOSH and IEMA courses. He developed the international training for the company and delivered training in a variety of overseas venues.His current role is Business Development Manager for Woodland Grange in the UK which involves development of new clients and products as well as tutoring. Darby has delivered many training sessions to very Senior Executives in a wide cross section of Blue Chip companies and is involved in IOSH’s (Institution of Occupational Safety and Health) environmental Group.

Arturo de la Garza will be presenting Como Disminuir los Errores Humanos y Sobrevivir (How to Reduce Human Error… and Survive) during the 2008 Summit Spanish Sessions in Las Vegas.

Arturo has experience in industrial facilities in Mexico including glass (bottling) factories, oil, chemical, petrochemical, and cement. He has been the Corporate Safety Manager for two major international corporations. Arturo was the first Corporate Safety Manager in Mexico to introduce TapRooT® to analyze the root causes of accidents and incidents. His success proved the applicability of TapRooT® to analyze problems in cultures other than the US. Arturo is currently a consultant based in Monterrey, Mexico and teaches TapRooT® in Latin American and Spanish speaking countries. Arturo has a BS in Chemical Engineering and an MSc in Industrial Engineering. He also is a Certified Safety Professional from the Mexican Council of Risk Management.

Marco Flores will be presenting: Lecciones Aprendidas en 3 Decadas en el Desarrollo de la Tecnologia en Reduccion Directa y Arranque de Plantas (Lessons Learned in 3 Decades in the Development of Technology in Direct Reduction and Plant Start-up) during the 2008 Summit Spanish Sessions in Las Vegas.

From his youth, Marco Flores has dedicated himself to explore the limits. In 1965, during his school days he was a member of the International Society of Interplanetary Studies, and the University Society for Experimental Rocketry. While at M.I.T., coursing a Master’s Degree in Aeronautics and Astronautics, he was part of the Innovation Center and the Commission for Hispanic Rights, dedicated to defend the human rights of the Spanish-speaking prisoners in Massachusetts. While at the Innovation Center he produced the famous “Phantom Potential Racer” and the “Automatic Banana Peeler,” that took center place in the news in Boston, and was interviewed by Eye Witness News for the banana peeler, and by Boston Public Television on the impact of automation on rural unemployment in Latin America and migration to the United States.

For 25 years he endeavored in the development of technology, start-up and troubleshooting for direct reduction plants worldwide.

Today he is the President of TECMEN, a consulting company dedicated to develop solutions material handling and process under extreme conditions that go from automated “taco” shell handling, to high temperature components applied to chemical and nuclear processes. He has produced multiple worldwide patents for different companies. He has traveled extensively, lately spending most of his time between Australia, Germany and South America. He has been a TapRooT® instructor for seven years and is co-translator of the TapRooT® course materials into Spanish and Portuguese, and has applied the TapRooT® method for innovation, project planning, and systematic failure and accident analysis frequently.

He paints, writes poetry and wrote a play on the role of women in Mexican History.