Category: Summit

7 Traits of a Great Root Cause Analysis Facilitator

June 27th, 2017 by

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After decades of teaching TapRooT® and being consulted about many investigations, I’ve met lots of root cause analysis facilitators. Some were good. Some were not so good. Some were really superior. Some were horrible. Therefore, I thought it might be interesting to relate what I see that separates the best from the rest. Here are the seven traits of the BEST.

1. They don’t jump to conclusions. The worst investigators I’ve seen think they know it all. They already have their mind made up BEFORE the first interview. They START the investigation to prove their point. They already know the corrective action they are going to apply … so all they have to do is affirm that the causes they already have assumed ARE the cause they find.

What do the best investigators do? They start by seeing where the evidence leads them. The evidence includes:

  • Physical evidence, 
  • Paper evidence (documentations),
  • People evidence (interviews), and
  • Recordings (videos/pictures/tapes/computer records).

They are great at collecting evidence without prejudice. They perform “cognitive interviews” to help the interviewee remember as much as possible. (See the new book TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about cognitive interviews. The book should be released in August. Get the book with the course being held in November in Houston.) 

The best investigators may have some technical knowledge, but they know when they need help to understand what the evidence is telling them. Therefore, they get technical experts when they need them.

2. They understand What before Why. The worst investigators start by asking WHY? Why did someone make a mistake. Why did the part fail. Why didn’t the guilty party use the procedure. These “why” questions tend to put people on the defensive. People start justifying what they did rather than sharing what they know.

The best investigators start with what and how. They want to understand what happened and how those involved reacted. What did they see as the problem? What were the indications they were observing? Who did they talk to and what did they say? What was happening and in what order did it happen?

People don’t get defensive about what and how questions. They are much more likely to share information and tell the truth. And these what questions help develop an excellent SnapCharT® that helps the root cause analysis facilitator develop a “picture” of what happened.

3. They are not looking for the single root cause. The worst investigators are always looking for THE root cause. The smoking gun. The one thing that caused the problem that can be corrected by a simple corrective action. THE root cause that they are looking for.

The best investigators know that most accidents have multiple things that went wrong. They facilitate their team to understand all the causal factors and how these causal factors came together to cause that particular incident.

These root cause facilitators use their SnapCharT® and Safeguard Analysis to show how the problems came together to cause the incident. This can help show management how latent condition are hidden traps waiting to produce an accident that previously seemed impossible.

4. They dig deeper to find root causes. The worst investigator stop when they identify simple problems. For the worst investigators, HUMAN ERROR is a root cause.

The best investigators know that human error is just a starting point for a root cause analysis. They go beyond equipment failure and beyond human error by using effective investigative techniques that help them go beyond their own knowledge.

For example, if there is an equipment failure they consult the Equifactor® Troubleshooting Tables to find out more about the failure. This helps them get to the bottom of equipment problems. They often find that equipment failures are caused by human error.

For human performance related causal factors they use the Human Performance Troubleshooting Guide of the Root Cause Tree® to help them determine where they need to dig deeper into the causes of human error. 

The best investigators don’t accept false stories. They have a good BS detector because false stories seldom make a sensible SnapCharT®.

5. They find root causes that are fixable. The worst investigators find root causes that management really can’t do anything to prevent. For example, telling people to “try harder” not to make a mistake IS NOT an effective corrective action to stop human errors. 

The best investigators know that their are many ways to improve human performance. They understand that trying harder is important but that it is not a long term solution. They look for human factors related fixes that come from human performance best practices. They know that the Root Cause Tree® can help them find problems with:

  • Procedures
  • Training
  • Quality Control
  • Communications
  • Management Systems
  • Human Engineering
  • Work Direction

And that by implementing best practices related to the root causes they identify, they can reduce the probability of future human errors.

6, They recommend effective corrective actions. The worst investigators recommend the three standard corrective actions for almost every problem:

  1. MORE TRAINING
  2. COUNSELLING (tell them to be more careful and fire them if they get caught making the mistake again)
  3. If you are desperate, WRITE A PROCEDURE

That’ about it.

The best investigators start by understanding the risk represented by the incident. Higher risk incidents deserve higher order corrective actions. The highest order is to remove the Hazard. Other corrective actions may be related to strengthening the Safeguards by implementing human performance best practices. sometimes these corrective action may include training and procedures but that is seldom the only corrective actions recommended.

7. They know what they are doing. The worst investigators don’t really know what they are doing. They haven’t been trained to find root causes or the training they had was superficial at best. (Can you ask “Why?” five times?)

The best investigators are accomplished professionals. They’ve been in advanced root cause analysis training and have practiced what they have learned by performing many simple investigations before they were asked to jump into a major investigation. Even if they have several major investigations under their belt, they continue to practice their root cause analysis skills on simple investigations and on proactive audits and assessments. 

Beyond practicing their skills, they attend the only worldwide summit focused on root cause analysis and investigation facilitation – The Global TapRooT® Summit. At the Summit they benchmark their skills with other facilitators from around the world and share best practices. Think of this as steel sharpening steel. 

GOOD NEWS. The knowledge and skills that make the best investigators the best … CAN BE LEARNED.

Where? Have a look at these courses:

http://www.taproot.com/courses

And then plan to attend the 2018 Global TapRooT® Summit in Knoxville, Tennessee, on February 26 – March 2 to sharpen your skills (or have those who work for you sharpen their skills).

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Are you using the latest TapRooT® Tools and do you have the latest TapRooT® Books?

June 6th, 2017 by

Over the past three years, we’ve been working hard to take everything we have learned about using TapRooT® in almost 30 years of experience and use that knowledge (and the feedback from thousands of users) to make TapRooT® even better.

So here is the question …

Do you have the latest TapRooT® Materials?

How can you tell? Look at the copyright dates in your books.

If you don’t have materials that are from 2016 or later, they aren’t the most up to date.

Where can you get the most recent materials?

First, if you have not yet attended a 5-Day TapRooT® Root Cause Analysis Course, I’d recommend going. You will get:

Or, you can order all of these by CLICKING HERE.

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I think you will find that we’ve made the TapRooT® System even easier to use PLUS made it even more effective.

We recently published two other new books:

The TapRooT® Root Cause Analysis Leadership Lessons book helps management understand how to apply TapRooT® to achieve operational excellence, high quality, and outstanding safety performance.

The TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book explains how to use the TapRooT® Tools proactively for audits and assessments.

To order the books, just click on the links above.

And watch for the releases of the other new books we have coming out. Shortly, you will see the new books on:

  • Interviewing and information collection
  • Implementing TapRooT®
  • Troubleshooting and finding the root causes of equipment problems

That’s a lot of new information.

We have plans for even more but you will here about that at the 2018 Global TapRooT® Summit that is being held in Knoxville, Tennessee, on February 26 – March 2. The Summit agenda will be posted shortly. (Watch for that announcement too!)

Users Share Best Practices: Keep Subject Matter Experts for Each Work Area

February 23rd, 2017 by

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Here Tim Dearman informs the audience how his company keeps subject matter experts in each of their key business units to help during investigations.

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Users Share Best Practices: Recertify Investigators Every Three Years

February 9th, 2017 by

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Here Charlotte Grainger discusses how her company has instituted a program requiring investigators to be recertified every three years.

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Users Share Best Practices: Using Weekly Review Boards to Examine Incidents

February 2nd, 2017 by

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Listen as Robert Oliver talks about how his company uses weekly review boards to examine incidents.

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Users Share Best Practices: Improving Communication Between Company and the Customers

January 26th, 2017 by

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Here Emad Gomaa talks about improving communication between the company and the customers.

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User Share Best Practices: Implementing Fees to Improve Apron Safety

January 19th, 2017 by

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Watch as Megan Lowry talks about the use of fees to improve safety on the airport apron.

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Users Share Best Practices: Use Opinion Makers to Improve RCA Performance

January 10th, 2017 by

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Here is Debra Matson describing how they use opinion makers to improve their RCA performance.

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What will YOU do to make 2017 better than 2016?

January 2nd, 2017 by

2017

Did you make your New Year’s resolutions? Your ideas to improve your performance next year?

In many companies, you are expected to have plans to improve performance. Better production performance, quality, equipment reliability, safety, process safety, and financial performance are all expected parts of the normal year-to-year improvement process. If you are leading any of these improvement efforts, you better have a plan.

What if you could do something to both improve your personal performance and your company’s performance? Would that be interesting?

Plan to attend a TapRooT® Root Cause Analysis Course!

What are you waiting for? TapRooT® Root Cause Analysis is proven by leading companies around the world to help them find and fix the root causes of performance problems. And the TapRooT® System can be used proactively to stop problems before major incidents happen. This can lead to improved financial performance in addition to improved safety, quality, equipment reliability, and production performance.

But beyond that, you will be adding an advanced skill to your toolbox that you can use for the rest of your career. Think of it as a magic problem-solving wand that you can use to astound others by the improvement initiatives you will lead. This can lead to promotions and personal financial gain. Sounds like a great personal improvement program.

Now is the time to make your plans for 2017. Get your courses scheduled. Get ready to make your skills better and your company a better place to work.

Users Share Best Practices: Leadership Approval Through Validation of Corrective Actions

December 20th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Listen as George Kooi describes how their
leadership validates Corrective Actions through approval of the Corrective Actions https://vimeo.com/194840836

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Users Share Best Practices: Allow Leadership To Be A Champion For Your Investigation

November 30th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. William McClung describes how they allow leadership to be a champion for their investigation.

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Users Share Best Practices: Practice on the Previous Investigations

November 23rd, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Here Rajesh Malik talks about how his company encourages students to go back and apply what they learned in the TapRooT® course to their previous investigations.

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Users Share Best Practices: Creating A Review Cell For The Incident

November 16th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Here Michael Miraglia details how his company creates what they call a “review cell” to investigate an incident.

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Users Share Best Practices: Understanding and Applying TapRooT®

October 24th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Brent Cothran describes how his company trains all new employees on the TapRooT® process.

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Users Share Best Practices: Adding Refresher to Day Two

October 21st, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Watch Randy Karasti describe how adding a refresher at the beginning of the second day of training has helped their organization.

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Users Share Best Practices: Running a Four Day Course

October 20th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Larry Perkinson shares how his company teaches a four day TapRooT® course that includes a day dedicated to exams. What a great idea!

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Users Share Best Practices: Defining Your Focus

October 18th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Here Steven Sandlin discusses his best practice of defining the focus. What is the minimum threshold that drives an investigation?

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Users Share Best Practices: Including Positives in Your Report

October 10th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Watch Matt Deluhery discuss his best practice of including positives found during an investigation. These include noting safeguards that worked as well as individuals that stepped up during the recovery process.

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Users Share Best Practices: Adding a Union Rep to an Investigation

September 28th, 2016 by

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Here is Don Marsh discussing his best practice of adding a union rep to each investigation.

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Global TapRooT® Summit User Share Best Practice Session

August 5th, 2016 by

Have you ever wondered what the Global TapRooT® Summit User Share Best Practice session is like?  Here’s some highlights of this year’s session:

TapRooT® Summit Best Practice Session from TapRooT® on Vimeo.

Start of Day 2 at the TapRooT® Summit

August 4th, 2016 by

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Wow! Just attended a great talk by Kurt Mix about the Justice Departments out-of-control prosecution after the Deepwater Horizon accident. You would be outraged if you had been here. 

Welcome to the 2016 Global TapRooT® Summit

August 3rd, 2016 by

Join us this week as we share moments from the 2016 Global TapRooT® Summit!  Here Benna and Michelle welcome you and share Pre-Summit highlights.

Summit Welcome by Benna and Michelle along with Pre-Summit Highlights from TapRooT® on Vimeo.

2016 TapRooT® Summit Best Practice Presentations for All Sessions

August 3rd, 2016 by

Here are the presentations and handouts for the 2016 TapRooT® Summit:

If you can’t find the presentation you’re looking for or you have questions, please e-mail Barb or Gabby.

Best Practice Session 1
Wednesday, August 3, 2016
10:30 a.m. – noon

TapRooT® Users Share Best Practices (Linda Unger, Benna Dortch and Michelle Wishoun)

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Who Really Own the Quality Defect? (Chris Vallee & Kevin McManus)

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The TapRooT® Software Sandbox (Dan Verlinde & Angie Comer)

*There will not be a presentation available for this track.

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Learning From the Best Maintenance Program in U.S.A. (Gary Gardner)

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7 Deadly Sins of Human Performance (Mark Paradies)

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Best Practice Session 2
Wednesday, August 3, 2016
1:30 p.m. – 2:30 p.m.

Weatherford’s Global Journey to HSE & Quality Improvement with TapRooT® (David Smith & Shawn Holden)

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Grade Your Investigations (Mark Paradies & Jack Frost)

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Bhopal Disaster (A Definitive TapRooT® Analysis) (Ken Bloch)

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Using the Optional Techniques in the TapRooT® Software (Dan Verlinde)

*There will not be a presentation available for this track.

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What is Equifactor®? (Ken Reed)

*There will not be a presentation available for this track.

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TapRooT® Changes in the Medical Community (Ed Skompski)

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Best Practice Session 3
Wednesday, August 3, 2016
2:45 p.m. – 3:45 p.m.

Proactive Use of TapRooT® (Dave Janney)

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What’s New in the TapRooT® Software? (Dan Verlinde)

*There will not be a presentation available for this track.

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Human Error Causes of Quality Problems (Chris Vallee & Tommy Garnett)

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How to Do a New Implementation of TapRooT® (Ed Skompski)

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What is RAM Modeling? (Mark Olson)

*This presentation will not be available due to confidentiality reasons.

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A Life of Illusion: Getting to What is Real (Carl Dixon)

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Best Practice Session 4
Thursday, August 4, 2016
10:15 a.m. – 11:45 a.m.

Certified TapRooT® Instructor Recertification Workshop (Linda Unger, Michelle Wishoun, Ken Reed)

*There will not be a presentation available for this track.

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TapRooT® Software Advisory Board- Future APIs (Dan Verlinde, Angie Comer, Leah Cartwright)

*There will not be a presentation available for this track.

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The Business End of Equipment Reliability, Part I (Heinz Bloch)

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Interviewing Behaviors & Body Language (Barb Phillips)

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Character Driven Success (Dr. Beverly Chiodo)

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Improve Accountability, Execution & Performance (David Doyle)

*This presentation will not be available due to confidentiality reasons.

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Best Practice Session 5
Thursday, August 4, 2016
12:45 p.m. – 1:35 p.m.

Deep-Dive Into Procedures & Management System (Ralph Brickey)

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The Right & Wrong Way to Analyze an Audit Compliance Finding (Alethea Arnold & Nancy Hitchens)

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Praising the 49 Character Traits (Dr. Beverly Chiodo)

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Risking Assessing the Perfect Murder (Alan Smith)

*This presentation will not be available due to confidentiality reasons.

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Contract Instructor Software Training (Ken Reed & Dan Verlinde)

*There will not be a presentation available for this track.

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Best Practice Session 6
Thursday, August 4, 2016
1:50 p.m. – 2:40 p.m.

CHAP (Joel Haight)

*There will not be a presentation available for this track.

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The Business End of Equipment Reliability, Part II (Heinz Bloch)

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Writing TapRooT® Driven Preventative & Corrective Actions Workshop (David Davis & Troy Bonar)

*This presentation will not be available due to confidentiality reasons.

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Building Reports & Templates Using the TapRooT® Software (Dan Verlinde)

*There will not be a presentation available for this track.

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Arc Flash Loss Prevention (Scott King & Terry Butler)

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Best Practice Session 7
Thursday, August 4, 2016
2:55 p.m. – 3:45 p.m.

TapRooT® Advisory Board (Mark Paradies, Linda Unger, Dan Verlinde & Ken Reed)

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12 Steps for Conducting a Professional Interview  | Excellent video on Cognitive Interviewing  (Barb Phillips)

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Anatomy of a Medical Investigation (Ed Skompski & Michele Lindsay)

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What’s Holding You Back- Common Barriers to Process Excellence (Kevin McManus)

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TapRooT® in “What If Analysis” (Joel Solomon)

*There will not be a presentation available for this track.

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Fast Investigations for Simple Incidents (Mark Paradies)

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Best Practice Session 8
Friday, August 5, 2016
9:00 a.m. – 10:40 a.m.

Planning Your Improvements (System Improvements Team)

 

If you can’t find the presentation you’re looking for or you have questions, please e-mail Barb or Gabby.

Pictures from the Summit – The Courses #taprootsummit

August 1st, 2016 by

Here are pictures from the 11 pre-Summit Courses ….

TapRooT® Incident Investigation & Root Cause Analysis Course

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Equifactor® Equipment Troubleshooting and Root Cause Analysis

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Advanced Causal Factor Development Course

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Advanced Trending Techniques

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TapRooT® Analyzing and Fixing Safety Culture Issues

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Risk Assessment and Management Best Practices

IMG 6458

 

TapRooT® Quality Process Improvement Facilitator Course

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Getting the Most from Your TapRooT® VI Software

IMG 6472

 

TapRooT® for Audits

IMG 6452

 

Effective Interviewing & Evidence Collection Techniques

IMG 6443

 

Understanding and Stopping Human Error

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