Root Cause Analysis Blog

 

Career Development: What *Not* to Say at an Interview

Posted: May 17th, 2013 in Career Development, Career Development Tips

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It takes more than being qualified for a position to win an interview in a competitive market. Here are some common things interviewees say that seem innocent enough, but can be a big turn-off to potential employers. Have you ever said any of these things?

I can do anything …

I can try …

I remember we used to …

Why do you …

I didn’t get an opportunity to grow …

Why are these so wrong? Head over to DailyWorth and read:

5 Things Not to Say in a Job Interview

and some of the answers may surprise you!

 

(Photo courtesy of Dreamstime.)

Course Photos: 5-Day TapRooT® Root Cause Analysis Team Leader Training in Cape Town, South Africa

Posted: May 17th, 2013 in Courses, Pictures

TapRooT® Instructor Sanjay Gandhi sent over these photos of our recent 5-Day course in Cape Town, South Africa.

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Interested in a TapRooT® Root Cause Analysis Course in your area? Check out our courses page at http://www.taproot.com/courses

Final Death Toll at Bangladesh Garment Factory Collapse is 1,127

Posted: May 17th, 2013 in Accidents

1,127 workers were killed in what is reportedly the worst disaster in the history of the global apparel industry.

One survivor said she heard from colleagues that cracks had appeared in the building and was reluctant to enter but was told by management that there was no problem. The building owner had been accused of using shoddy building materials and building extra floors, and then filling them with heavy equipment:

Read more in the Los Angeles Times:

http://www.latimes.com/news/world/worldnow/la-fg-wn-bangladesh-building-collapse-search-for-bodies-20130513,0,3014839.story

Friday Joke: Watch Your Head!

Posted: May 17th, 2013 in Jokes, Pictures

What is wrong with this picture?

Press Release from the US CSB: U.S. Chemical Safety Board Root-Cause Investigation of West Explosion Continues; Board to Examine Ammonium Nitrate Storage, Siting, Fire Protection, and Preparedness Issues

Posted: May 16th, 2013 in Accidents, Current Events, Investigations

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West, Texas, May 16, 2013 – As other agencies wrapped up their on-site investigations into the ammonium nitrate explosion at West Fertilizer in West, Texas, the U.S. Chemical Safety Board (CSB) announced its work to examine all aspects of the tragedy will continue in the town of West, at the Western Regional Office in Denver, and at the agency’s headquarters in Washington, DC.

The CSB deployed a team of approximately 18 investigators and other technical experts within 24 hours of the incident on April 17, and has maintained an almost continuous presence in West since then.  The sudden blast led to at least 14 fatalities, approximately 200 injuries, and widespread damage and destruction in the small town of West, Texas, located between Dallas and Waco. 

CSB Chairperson Rafael Moure-Eraso said, “On behalf of our investigation team and the board, I would like to thank the mayor, fire and police officials, community members and West Fertilizer employees for their outstanding cooperation with the CSB during an extraordinarily difficult period.  Our hearts go out to the residents, employees, and emergency responders and we want everyone to know we are fully committed to providing a thorough public account of all the factors that led to this catastrophe. After a disaster of this scale, it is essential to pursue improved safety as we look toward the future.”

CSB Western Regional Office Director Don Holmstrom said, “The CSB will be examining many issues surrounding the explosion such as the safe storage and handling of ammonium nitrate, the siting of vulnerable public facilities and residential units near the facility, and emergency responder safety. In addition, the investigation will examine the adequacy of national standards, industry practices, and regulations for the safe storage and handling of ammonium nitrate.”

CSB investigation areas of inquiry will include ammonium nitrate safe handling and storage standards here and in other countries such as the UK and Australia; land use planning and zoning practices for high-hazard facilities in relation to schools, public facilities, and residential areas; ammonium nitrate detonation mechanisms; the effectiveness of regulatory coverage including OSHA, EPA, and the State of Texas; whether there are inherently safer products or safer ways to store and mitigatethe damage should a fire or explosion occur. The investigation will examine the emergency response during the fire at West, and practices, including preparedness, fire codes, and guidelines for good practices found in other jurisdictions.

Dr. Moure-Eraso stressed the CSB does not issue fines or penalties of any kind, or seek civil or criminal sanctions. “We do not look for individual fault or blame with regard to actions taken before an accident or in response to them.  Rather, we produce what are called root cause investigations.”

The CSB is in the process of conducting witness interviews and gathering documents and other evidence. It has documented blast damage and patterns in the community, and will engage in testing chemical samples and conducting a thorough analysis of the nature and magnitude of the blast, and its actual and potential consequences.

Chairperson Moure-Eraso said, “This accident produced far more offsite community damage and destruction than any we have investigated since the agency opened its doors in 1998.  We will release information and findings when possible as we continue our work, and in the end will issue a comprehensive root cause report with recommendations.  We also encourage members of the public and stakeholders to share information directly with the CSB as the investigation progresses.”

The CSB established a Facebook page, www.facebook.com/WestExplosion, to exchange information with the public concerning the investigation.

For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496.

What is the Root Cause of Bad Science?

Posted: May 16th, 2013 in Root Causes

Everyone is interested in research statistics but the following infographic asserts that some scientists may make up the data, distort the data … even cook the data!

What would you guess is the root cause of bad science? The infographic suggests that one may be that the scientist changes results due to pressure from a funding source.

And what do you think about the ways to make research more honest at the end of the infographic? Would they work?

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Course Photos: 5-Day TapRooT® Root Cause Analysis Course in Bahrain

Posted: May 16th, 2013 in Courses, Pictures

TapRooT® Instructor Alan Smith sent over these photos from our most recent Bahrain 5-Day course. Looks like a fantastic class.

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Interested in a TapRooT® Course?
Check out our courses page: http://www.taproot.com/courses

Photos: 3-Day Root Cause Analysis Course in Rotterdam, Holland

Posted: May 16th, 2013 in Courses, Pictures

Harry Thorburn sent over these photos from our recent 3-Day TapRooT® Course in Rotterdam, Holland. Enjoy!

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Stand Out in the Job Market: Use Your Valuable Root Cause Analysis Training

Posted: May 16th, 2013 in Career Development, Career Development Tips, Job Postings

7895-327x450Looking for a job where you can use your TapRooT® skills?

If you are not using the skills you learned in training, you are missing key opportunities for professional development. The proactive and reactive tools your training provided will not only enhance your career but will also contribute to the greater good of saving lives and preventing injuries.

If you have been using your root cause analysis skills for awhile and are interested in a career change, one thing that will stand out on your resume is a record of your demonstrated TapRooT® successes. When you share multiple examples of problems solved or leading teams to success, you will have a significant advantage in the job market.

Remember, TapRooT® is not only a valued skill for employers looking for accident investigators, but is also a valued skill for companies that:

  • need to solve quality related issues
  • have equipment downtime problems
  • experience failure to achieve optimal operational success

Keep up with the leading companies looking to hire people with TapRooT® root cause analysis skills by looking at this link:

http://www.taproot.com/archives/category/career-development/job-postings

Need a refresher? We have several 2-day courses coming up in June:

http://www.taproot.com/store/2-Day-Courses/?coursefilter=Incident+Investigation

And finally, if you have been thinking about getting training to become a TapRooT® Team Leader, get more info about our advanced 5-Day Team Leader Course:

http://www.taproot.com/courses/#5-day-root

If you have a success story to share about how TapRooT® has helped your career development, please share it by commenting below.

Root Cause Analysis Tip: Serious Injuries & Fatalities with Mark Paradies – Part 4

Posted: May 16th, 2013 in Root Cause Analysis Tips, Summit, Video

Welcome to our weekly series of Root Cause Analysis Tips from our 2013 Global TapRooT® Summit. This week and the next few weeks following, we’ll be talking about Serious Injuries & Fatalities. At the Summit this year, Mark Paradies gave a great talk about Serious Injuries & Fatalities and how you can prevent them.

This is the first part of the Q & A portion at the end of the session, in which participants discuss SIF situations in their workplace with Mark.

Watch it here:

Interested in attending our 2014 Global TapRooT® Summit?

Visit our Summit page here: http://taproot.com/summit

Watch Part 1 here: http://www.taproot.com/archives/37877
Part 2: http://www.taproot.com/archives/37972
Part 3: http://www.taproot.com/archives/38015

Root Cause Analysis Tip: Don’t Ask “Why” During an Interview

Posted: May 15th, 2013 in Root Cause Analysis Tips

Why NOT Ask Why?

Some people teach the “5-Why” technique for root cause analysis as their preferred method to solve problems. If you have read this blog for very long, you’ve probably been convinced that 5-Whys is at best a rudimentary technique with many inherent flaws. But you may not know that asking “Why” during an investigation interview is also a mistake.

In the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, we spend a majority of the second day teaching fact finding and interviewing. This section of the course highlights an advanced interviewing technique called “Cognitive Interviewing”.

Cognitive Interviewing helps the interviewee recall information that they might have otherwise forgotten or thought too unimportant to share. The Cognitive Interviewing training in our course emphasizes that the interviewer should not ask the interviewee “Why?” during the interview.

Why not ask Why? Because the question elicits justifications from the interviewee rather than getting them to share additional information from their long term memory. The “Why?” question is seen by the interviewee as accusatory (Why did you do that?) rather than a request for more information.

What should the interviewer do? Cognitive Interviewing teaches a systematic process to get the interviewee to tell their story, recalling as much as they can from their long term memory. It also teaches the interviewer to ask “What” and “How” questions to get additional information (instead of “Why?”).

Find out more about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course by CLICKING HERE.

2 Day TapRooT® Incident Investigation and Root Cause Analysis Course in Pittsburgh, PA

Posted: May 15th, 2013 in Courses

Ken Scott and I teaching the two day course this week, here are some pictures of the students working on their first exercise:

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Sorry if you missed us on this one, the course filled up several weeks out. We have been experiencing high demand for our training, so if you want to attend, you should enroll as soon as possible. To view the schedule and register, click HERE

Mark Paradies Talks About Rickover, Process Safety, and Fatality Prevention

Posted: May 15th, 2013 in Accidents, Human Performance, Performance Improvement, Presentations

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There are too many major accidents due to failures in process safety. These accidents go beyond the regulations written by OSHA and EPA (and the regulators in other countries). They go beyond the chemical industry and include the nuclear industry, oil exploration and production, fertilizer storage and distribution, grain elevators (and other dust explosion examples), aviation, shipping, utilities, and even hospitals.

How can these accidents be prevented? First one has to understand process safety and fatality prevention. Unfortunately, many senior managers don’t understand it. And that’s why Mark Paradies started giving talks about this topic at the TapRooT® Summit. Unfortunately, even though the Summits are well attended, thousands need to hear what Mark has to say, but don’t get the chance. That’s why we decided to post links to some of Mark’s Summit talks here.

Of course, attending the sessions at the TapRooT® Summit is much better than looking at slides and watching videos. But the information in these talks needs greater dissemination to help prevent major accidents around the world. Therefore, we’ve selected video clips, slides from mark’s talks, and Admiral Rickover’s testimony before Congress after TMI (written remarks) to provide an overview of some of the concepts that senior managers need to consider to prevent major process safety accidents.

Here are the links:

Mark’s General Session Talk About Fatality Prevention from the 2013 Summit

Marks Talk About SIF Prevention from the 2013 Summit (Part 1)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 2)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 3)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 1)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 2)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 3)

Mark’s Slides About Rickover & Process Safety from the 2010 Summit

Rickover’s Testimony to Congress About Reactor Safety (Process Safety)

I know this is a lot of information and the videos are long, but the lives lost each year are a preventable tragedy. Please pass this information on to those that you think many need it.

For those who would like to get Mark to talk to your senior management about management’s role in process safety and how the lessons from Admiral Rickover apply to your facilities, call us at 865-539-2139 or e-mail us by CLICKING HERE.

Carl Dixon Confirms for the 2014 Global TapRooT® Summit

Posted: May 15th, 2013 in Best Practice Presentations, Best Practice Presenters, Summit

We are pleased to announce that Carl Dixon has confirmed to speak at the 2014 Global TapRooT® Summit, April 7 – 11 in Horseshoe Bay, Texas.

Carl Stool Tornado PicCarl Dixon is a Canadian musician, singer and songwriter. More than that, he is an entertainer who has performed for audiences around the world for many years. A presence on stage, screen, radio and print (and now the internet), which he’s maintained for over three decades has created a following of people who care about the man and his music.

The career of the good-natured native of Northern Ontario includes his beginnings as lead singer/songwriter of Coney Hatch, lead singer of the Guess Who for eight years, and member of April Wine for four years. A run of album releases with all the above-named bands and his solo work, along with concert appearances around the globe, has made Carl internationally known.

Musically these days Carl either performs a solo acoustic show or tours with his Carl Dixon Band. Speaking appearances are his latest passion, a chance to share his thoughts and experiences in a direct connection to an audience.

In April 2008 Carl’s career path was disrupted by a catastrophic car accident in Australia. This left him in coma with terrible injuries and a poor prognosis from the trauma doctors. To general amazement Carl pushed himself toward recovery with a “No weakness, no fear” motto. He overcame the adversity and eventually made a full return to performance and life. This experience and the lessons gained through it form a large component of Carl’s speaking presentation.

His book Strange Way to Live is being published, an account of Carl’s experiences and impressions of his life and musical adventures to date.  The book details the path which led Carl to here and the factors which helped him overcome the accidents’ effects.

Residing in the forests and hills of Haliburton, Ontario, “Lucky Dog” Carl has a charmed life with his wife and two daughters.

And to those who enjoyed his performance at the Summit reception in Gatlinburg in 2013 — he has agreed to play an acoustic set for us again in 2014!

Learn more about the Summit: http://www.taproot.com/products-services/summit

Press Release from the UK Rail Accident Investigation Branch: Runaway of a road-rail maintenance vehicle near Glasgow Queen Street High Level station, 21 April 2013

Posted: May 15th, 2013 in Accidents, Current Events, Investigations, Pictures

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The RAIB is investigating a serious accident caused when a road-rail maintenance vehicle ran away and struck scaffolding in a tunnel near Glasgow Queen Street High Level station on Sunday 21 April 2013.

The maintenance vehicle was a mobile elevating working platform (MEWP) that was equipped with both rubber wheels for road running and steel rail wheels for operation on the railway. It was intended to be used for engineering work on a section of track which was under possession (temporarily closed to normal train services).

The runaway started at the Keppochhill road-rail access point, a location within the possession where boarding laid between, and to either side of, the rails provides a flat surface allowing road-rail vehicles to be manoeuvred onto the track. This access point is on a section of railway which slopes downwards at a gradient of about 1 in 45 towards, and through, Queen Street High Level Tunnel before running onto level track as it enters Queen Street High Level station. Shortly before 03:00 hrs the MEWP was being transferred from its rubber tyred road wheels onto its rail wheels. During this manoeuvre the machine operator was controlling the machine by means of a remote control unit which was connected to the machine by a length of cable. As the rail wheels were lowered onto the track the MEWP started to run down the gradient, through the tunnel and into the station where it stopped about one mile (1.6 km) from the access point (and before reaching the buffers at the end of the platform).

No-one was onboard the MEWP as it ran away. However, while passing through the tunnel, the MEWP struck some scaffolding which was being erected as part of the planned engineering work and a person working on this scaffolding was seriously injured. Other members of staff working on the track were able to move clear of the runaway vehicle because they either heard its approach or were warned by mobile telephone.

A preliminary examination by the RAIB has shown that the runaway occurred because the brakes acting on the rail wheels were inadequate to stop the vehicle on the gradient and the road to rail transfer was not carried out correctly. The examination also showed that the MEWP ran through the tunnel without lights.

Rail wheel brakes on MEWPs of the type involved in the accident were intended to be effective on gradients of up to 1 in 29. Testing carried out to date suggests that the brakes may not always perform to this standard. Consequently additional restrictions have been placed on the use of this type of MEWP.

The RAIB’s investigation will identify:

- the sequence of events that led to the runaway;
- the factors influencing the actions of those involved in the operation of the machine as it was being placed onto the track;
- the actual capability of the rail wheel brakes;
- the design, approval, maintenance and/or testing processes that were applied to this type of MEWP; and
- the reasons for the loss of lighting on the runaway vehicle.

The RAIB’s investigation is independent of any investigations by the safety authority (the Office of Rail Regulation).

The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

Rocky Bleier Confirms for the 2014 Global TapRooT® Summit

Posted: May 14th, 2013 in Best Practice Presentations, Best Practice Presenters, Summit

Rocky Bleier (2)We are pleased to announce that Rocky Bleier has confirmed to speak at the 2014 Global TapRooT® Summit, April 7 – 11 in Horseshoe Bay, Texas.

Rocky Bleier’s life story–a gripping tale of courage on both the football fields of America and the battlefields of Vietnam–has held audiences in rapt attention for years. Yet, the motivational message behind it, detailing how ordinary people can become extraordinary achievers, defines success in the new American century.

With the same optimism, sense of humor and steadfast determination that were his trademarks as a Pittsburgh Steelers running back, Rocky Bleier takes audiences from his early years through his professional career and talks about the lessons he learned along the way…lessons that we all can benefit from.

Not falling within the ideal of what a running back should look like, Bleier had to run harder and play smarter to be able to stand out. Despite his drive and ability to make the big play, the Pittsburgh Steelers only considered him a late round pick. But before the season ended that first year, he was drafted again–this time by the United States Army. At the height of the Vietnam War, Bleier was thrust into combat early and was seriously wounded when his platoon ran into an ambush. Receiving wounds from both rifle fire and grenade fragments in his legs, he was barely able to walk and his professional football career seemed to have ended before it began.

For more than two years, he drove himself. Little by little he overcame obstacles and fought his way back. He not only made the Pittsburgh Steelers, but also eventually became a starting running back on a team that won four Super Bowls and became the greatest football team of the 20th century.

The hard lessons Rocky Bleier learned early in his life that helped him overcome adversity and reach his goals, have paid off after football. Some of those lessons are seen between the lines in the popular book on his life, Fighting Back , and an ABC-TV movie of the week by the same name.

Rocky is active in the Veteran’s Administration–Abraxas, the National Multiple Sclerosis Society, the United Way, the Pennsylvania Association for Retarded Children; he serves as honorary chairman of the Special Olympics and supports the Civic Light Opera. As a board member of the Vietnam Veterans Memorial Fund, Rocky helped make possible the erection of a monument in Washington, D.C. to the servicemen and women who died in Vietnam.

Rocky’s special qualities have been recognized by colleagues as well as others who have honored him with awards too numerous to list in detail. Among them are the Whizzer White Humanitarian Award, the Vince Lombardi Award and the Most Courageous Athlete of the Decade Award. He has also received awards from the USO and been named one of the Ten Outstanding Young Men in America by the U.S. Jaycees.

Today, Rocky Bleier shares his expertise and insight as the sports anchorman at the NBC affiliate in Pittsburgh, WPXI-TV. He is in demand as a speaker, motivating audiences in a wide variety of organizations, corporations and universities. And several companies, such as Uniroyal Tires, Sports Illustrated, Soloflex, Bradford-White, Swanson Dinners and First Federal Savings of Pittsburgh have benefited from his televised endorsements of their services and products.

Learn more about the Summit: http://www.taproot.com/products-services/summit

How Far Away is Death?

Posted: May 14th, 2013 in Pictures

Let’s hope he’s wearing rubber boots…

Weekly Wisdom for Root Cause Analysis

Posted: May 14th, 2013 in Wisdom Quote

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To expect the unexpected shows a thoroughly modern intellect.
- Oscar Wilde

Christine Holton Cashen Confirms for the 2014 Global TapRooT® Summit

Posted: May 13th, 2013 in Best Practice Presentations, Best Practice Presenters, Summit

Cashen_Christine Headshot1We are pleased to announce that Christine Holton Cashen has confirmed to speak at the 2014 Global TapRooT® Summit, April 7 – 11 in Horseshoe Bay, Texas.

Christine Cashen delivers a fast–paced, hilarious program with useful content that makes her a sought after speaker worldwide.  For more than 10 years, she has jazzed an amazing variety of audiences throughout the United States, Canada, South Africa and Australia. Christine is an authority on sparking innovative ideas to handle conflict, reduce stress and energize employees.

Before hitting the speaking scene, CC was a university admissions officer, corporate trainer and broadcaster. Hey—she even votes.   Christine holds a Bachelors Degree in Communication and a Masters Degree in Adult Education. She is a member of the National Speakers Association and is a Certified Speaking Professional (CSP).  CSP is an earned designation awarded by the National Speakers Association and the International Federation for Professional Speakers to recognize demonstrated commitment to the speaking profession through proven speaking experience.  Fewer than 10% of the speakers on the planet hold this designation.

Christine has been featured as a creativity expert in HOW Designs at Work magazine and is a co-author of the book Mission Possible, Volume Eight. She has also developed the A Dynamic Speaker series of learning resources:  Get What You Want With What You’ve Got DVD, Why Can’t Everybody Just Get Along CD and Got Humor Video. Christine resides in Dallas with her husband and their two children.

She will present

Why Brainstorm When You Can Brain El Niño?

Have you run out of ideas? Is your team having a brain drizzle rather than a brainstorm? Discover the tools to weather creative blocks, solve problems and get great ideas in half the time!  Learn specific strategies to put the “storm” back into brainstorming.  Increase effectiveness and productivity, boost group morale and relieve workplace tension with this program. Get ready to have a brain El Niño!

Learn more about the Summit: http://www.taproot.com/products-services/summit

Career Development: How to Give Effective Feedback

Posted: May 13th, 2013 in Career Development, Career Development Tips

Feedback makes all the difference in performance improvement, but giving constructive feedback can be difficult. Many managers have a tendency to give feedback that makes the employee feel good instead of helping the employee to improve. So, how can we give honest feedback in a way that doesn’t defeat an employee’s efforts but helps them improve?

Research has found that giving feedback to help people see their progress toward their goals is one way to give effective feedback and stay neutral. It is not necessary to highlight what is “good” or “bad” but simply examine the employee’s road map to the goal, and determine how to help them get there efficiently. Employees are often frustrated by professional goals because they know the goals they’ve set, but are unsure of what progress is being made, if any, or what specific actions can be taken to get them there.

This was one tip of four that I learned by reading Time Ideas “Four Ways to Give Good Feedback.” Check out the other three tips here:

http://ideas.time.com/2013/03/18/four-ways-to-give-good-feedback/

Course Photos: TapRooT® Root Cause Analysis in Bogota, Colombia

Posted: May 13th, 2013 in Courses, Pictures, TapRooT

Course planner Diana Munevar shared these photos with us from our recent course in Bogota, Colombia.

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Want to learn how to find and fix the incidents & near misses that are costing your company time and money? Attend a TapRooT® Root Cause Analysis course. Learn more at http://www.taproot.com/courses.

If you’re interested in a South America course, feel free to call Diana Munevar at 57 3203429267.

Course Photos: 5-Day TapRooT® Root Cause Analysis in Monterrey, MX

Posted: May 13th, 2013 in Courses, Pictures, TapRooT

Marco Flores sent over these photos from out 5-Day TapRooT® Course in Monterrey, Mexico.

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Looking for a world class root cause analysis system that will help you find the real root causes of problems in your workplace? Try TapRooT®.

Learn more here: http://www.taproot.com/courses

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