Root Cause Analysis Blog

 

Friday Joke

Posted: January 19th, 2018 in Jokes

When you don’t want to go along with your wife’s New Year’s Resolution to take up a new hobby together but she makes you…

Safety Fines Double in One Year in UK

Posted: January 18th, 2018 in Accidents, Current Events, Performance Improvement, TapRooT, Video

In the UK, fines related to safety doubled from 2016 to 2017. Here is a video from Safety & Health Practitioner (SHP) that provides more details…

Perhaps now is the time to invest in improved root cause analysis as part of your safety improvement efforts?

CLICK HERE for more information about TapRooT® Root Cause Analysis or CLICK HERE for information about TapRooT® Training.

CLICK HERE to see a list of public TapRooT® Courses in Europe.

CLICK HERE to contact us for information about training at your site.

Is your travel planing done for the 2018 Global TapRooT® Summit?

Posted: January 18th, 2018 in Current Events, Pictures, Summit

Step 1: REGISTER for the 2018 Global TapRooT® Summit.

Step 2: Do your travel planning and get a hotel booked.

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And don’t miss the activities the week of the Summit.

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Miranda Lambert is performing at Thompson-Boling Arena on Thursday, March 1, 2018.

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Tape Face, the Comedian, is performing at the Bijou Theatre on Sunday, February 25, 2018.

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Jonny Lang with Tony Lucca Solo is performing at the Bijou Theatre on Tuesday, February 27, 2018.

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Beth Hart is performing at the Bijou Theatre on Thursday, March 1, 2018.

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The Wizard of Oz national tour will be starring at The Tennessee Theatre on Friday, Saturday and Sunday, March 1, 2 and 3, 2018.

Who’s Coming to the 2018 Global TapRooT® Summit in Knoxville, TN?

Posted: January 18th, 2018 in Uncategorized

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It’s still to early to make a final attendance list but I thought people might be interested in a list of the companies who have signed people up early to attend the 2018 Global TaoRooT® Summit.

American Water
APS
Asplund
BG&E
Champion Technologies
Encana
Energy Systems Group
ExxonMobil
First Energy
Flint Hills Resources
IAP Worldwide
INEL
Lotte Chemical
Marathon Petroleum
Matrix North American Construction
Monsanto
Nalco Chemicals
Nine Energy Services
North Star Generation
Nutrien
Oceaneering
Oxy
Parker Drilling
Patten Energy
PNM Resources
PPL
Prairie State Generating
SAExploration
Saudi Aramco
SBM Offshore
Suncor
TD Williamson
Terango Gold
TransAlta
TransCanada
United Tehnologies
Vancouver Airport Authority

That’s a sample (not a complete list). The list grows every day.

If you are waiting to sign up, STOP waiting. CLICK on this LINK and register NOW!

What do people who have attended the Global TapRooT® Summit in the past have to say about it? here are just a few people sharing their experience…

Is this a good idea? … Navy to have “Article 32” hearings for COs involved in collisions at sea.

Posted: January 17th, 2018 in Accidents, Current Events, Investigations, Performance Improvement, Pictures

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Didn’t I just read (see this LINK) a Navy investigation that implied there were Management System causes of the two collisions in the Pacific? Didn’t the report suggest that the Navy needed to change it’s culture?

An article in USNI News says that both Commander Alfredo J. Sanchez and Commander Bryce Benson will face Article 32 hearings (the prelude to a court martial) over their role in the ships’ collisions in the Pacific.

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Will punishment make the Navy better? Will it make it easier for ship’s commanding officers to admit mistakes? And what about the crew members who are facing disciplinary hearings? Will that make the culture of the Navy change from a reactive-punitive culture to a culture where mistakes are shared and learned from BEFORE major accidents happen?

What do you think…

Here is the press release from the Navy’s Consolidated Disposal Authority (Director of Naval Reactors Adm. James F. Caldwell):

On 30 October 2017, Admiral William Moran, Vice Chief of Naval Operations, designated Admiral Frank Caldwell as the Consolidated Disposition Authority to review the accountability actions taken to date in relation to USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) collisions and to take additional administrative or disciplinary actions as appropriate.

After careful deliberation, today Admiral Frank Caldwell announced that Uniform Code of Military Justice (UCMJ) charges are being preferred against individual service members in relation to the collisions.

USS Fitzgerald: Courts-martial proceedings/Article 32 hearings are being convened to review evidence supporting possible criminal charges against Fitzgerald members. The members’ ranks include one Commander (the Commanding Officer), two Lieutenants, and one Lieutenant Junior Grade. The charges include dereliction of duty, hazarding a vessel, and negligent homicide.

USS John S. McCain: Additionally, for John S. McCain, one court- martial proceeding/Article 32 hearing is being convened to review evidence supporting possible criminal charges against one Commander (the Commanding Officer). The charges include dereliction of duty, hazarding a vessel, and negligent homicide. Also, one charge of dereliction of duty was preferred and is pending referral to a forum for a Chief Petty Officer.

The announcement of an Article 32 hearing and referral to a court-martial is not intended to and does not reflect a determination of guilt or innocence related to any offenses. All individuals alleged to have committed misconduct are entitled to a presumption of innocence.

Additional administrative actions are being conducted for members of both crews including non-judicial punishment for four Fitzgerald and four John S. McCain crewmembers.

Information regarding further actions, if warranted, will be discussed at the appropriate time.

Why do people try to make root cause analysis so difficult?

Posted: January 17th, 2018 in Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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I read a comment string on LinkedIn about root cause analysis. People made the concepts and techniques so hard to understand.

First, there was an argument over what is a root cause. One person argued that there was no such thing because EVERY cause had another deeper cause. Someone else argued that there wasn’t a root cause because most incidents had multiple causes. Someone else introduced the idea of root causes, contributing causes, causal factors, and initiating events. Someone else brought up the concept of latent causes and Swiss cheese.

If that wasn’t enough disagreement, another side argument started over what was an incident, and accident, a near-miss, and a significant incident. This lead to a discussion of what needed investigation and how good an investigation was good enough.

At SI, we too had discussions about these topics 30 years ago. However, in the TapRooT® System, these arguments are settled and the terminology is either settled or irrelevant.

Perhaps it is my engineering and Nuclear Navy training that lead me away from philosophical discussions and turned me toward practical solutions to problems.

Perhaps it was my human factors training that made it easy to see why people made mistakes and what we could do to prevent them.

Perhaps it is my ability to take complex subjects and make them understandable that lead to the development of a systematic, practical, repeatable system to find the root causes of problems – the TapRooT® System.

So, if you are tired of debate and just want a system that has been proven around the world to find and fix the root causes of safety, quality, equipment, and production issues, learn about TapRooT® and save lot’s of time by avoiding needless arguments.

CLICK HERE to find out more about our 2-Day and 5-Day TapRooT® Training.

CLICK HERE to see where our upcoming public TapRooT® Training is being held.

Or CLICK HERE to contact us about having a course at your site.

Why are the SMARTEST people going to the 2018 Global TapRooT® Summit?

Posted: January 17th, 2018 in Performance Improvement, Pictures, Summit, TapRooT, Video

SummitHands

About three Summits ago, I had a Summit attendee come up to me and say:

Mark, it is amazing the quality of speakers and topics you put together for the Summit.
But even more amazing is the networking. The people at this Summit are some of
the smartest people working on real life performance improvement in industry!
I just wanted to tell you thanks for making this happen.

 How do we get such high quality attendees? That’s the kind of people who use TapRooT® Root Cause Analysis to stop accidents, improve quality, reduce risk, and improve equipment reliability.

If you haven’t registered for the 2018 Global TapRooT® Summit yet, GET HOT! Visit the Summit web site and get registered TODAY!

Don’t Miss the TapRooT® Family Reunion

Posted: January 17th, 2018 in Performance Improvement, Pictures, Summit, TapRooT

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The Global TapRooT® Summit was almost named the TapRooT® Family Reunion. Why? Because that’s the way it feels.

Friendly folks getting together to say hello and get reacquainted.

Unless you belong to a dysfunctional family, you know what I mean.

This family has a common goal. They to share best practices and learn how to achieve outstanding performance. TapRooT® Root Cause Analysis is a part of that effort. But there is so much more to learn and share at the reunion (Summit). And that’s why we sponsor the Summit and spend lavishly on speakers.

We want to provide the opportunity for our best clients to meet face to face, develop relationships, and get new ideas to make safety, quality, equipment reliability, patient and process safety, and productivity even better. And leave the Summit inspired to go back home and make performance great.

The learning that takes place is one of the reasons that we require Certified TapRooT® instructors to attend the Summit at least once every two years. We think that keeping up to date on the latest improvement ideas is that important.

So don’t miss the reunion (the Summit) and your chances to make your performance improvement efforts that much better. Register for the 2018 Global TapRooT® Summit (February 26 – March 2, Knoxville, TN) TODAY by CLICKING HERE.

TapRooT® Root Cause Analysis Training Offers Hands-on Learning

Posted: January 16th, 2018 in Courses, Success Stories, Training


Hands-on learning is so important when learning something new. We keep this in mind when developing root cause analysis training and our course attendees appreciate it too. Here’s some feedback we’ve received lately:

“Great hands on exercise [for developing Corrective Actions] and great class involvement.” ~ D. Rind

“Very good to get a feel of how to put all the investigation together [on final team exercises] using a group and the challenges of getting everyone on the same page.” ~ P. Loudat

“Hands-on is always useful.” ~ G. Magee

“I appreciate the balancing of lecture and hands-on content.” ~ J. Nelson

What are some of the benefits of hands-on learning?

Increased retention of what is taught. Research indicates that learners retain 5% of material presented through lecture and 30% taught through demonstration. Hands-on participation can help learners retain 75% of the information presented.

Increased engagement. Hands-on learning keeps learners interested in what is being taught.

Opportunities for critique. Learners can get instant feedback from the instructor or others attending the course that reinforces learning.

Risk mitigation. Hands-on learning allows the course attendee to practice a new skill prior to working in real-world environments.

Advanced problem solving. Hands-on learners can work through scenarios in the training room and become better equipped to deal with problems back at their facilities.

Extra practice. It’s true what they say… practice makes perfect!

See for yourself! We have upcoming courses in these locations:

San Antonio, Texas, January 29, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Aberdeen, Scotland, February 1, 2018, 2-Day TapRooT® Root Cause Analysis Training

Corpus Christi, Texas, February 5, 2018, 2-Day TapRooT® Root Cause Analysis Training

Amsterdam, The Netherlands, February 5, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Johannesburg, South Africa, February 19, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Monterrey, Mexico, March 5, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Come be INSPIRED by Inky at the 2018 Global TapRooT® Summit

Posted: January 16th, 2018 in Summit, Video

Het more information HERE.

Register HERE.

Job Postings

Posted: January 15th, 2018 in Career Development, Career Development Tips, Job Postings

Discover the career opportunities below for candidates with TapRooT® skills at facilities around the world.

Get trained soon to open up your job opportunities for the new year. Here are some recent postings looking for candidates with TapRooT® Root Cause Analysis skills:

EHS Manager II

EHS Manager

Reliability Engineer

Reliability Engineering Supervisor

Electronic Specialty Gas Customer Quality Manager

HSE Site Supervisor

Check out our complete listing of 2-day TapRooT® trainings around the world here and register today!

Time for some advanced root cause analysis?

Posted: January 15th, 2018 in Accidents, Current Events, Human Performance, Pictures, TapRooT

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What do you think? Does someone in the Hawaii government need to attend TapRooT® Training?

Which Summit Track Should You Attend?

Posted: January 15th, 2018 in Current Events, Pictures, Summit, Video

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There is so much to new information to learn and so many best practices being shared that the hardest question you have to answer is:

“What Best Practice Track should I attend at the 2018 Global TapRooT® Summit?”

 That’s a tough question to answer. Maybe you should bring enough folks so that some attends each track?

If you have to pick just one, watch these videos and read the information at the links below to help you select the right track that will help you improve performance at your company.

Quality

http://www.taproot.com/archives/61257

Patient Safety

http://www.taproot.com/archives/61721

Human Performance

http://www.taproot.com/archives/60950

Investigator

http://www.taproot.com/archives/61241

Asset Optimization

http://www.taproot.com/archives/61327

Safety

http://www.taproot.com/archives/60790

Software

http://www.taproot.com/archives/61000

Some info about the new software …

 

TapRooT® Certified Instructor

http://www.taproot.com/archives/61023

General Discussion and Keynote Speakers

Now REGISTER! 

Friday Joke

Posted: January 12th, 2018 in Jokes

What Will You Learn in the Patient Safety Best Practice Track at the Summit?

Posted: January 12th, 2018 in Best Practice Presentations, Best Practice Presenters, Medical/Healthcare, Pictures, Summit

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Since 1994, System Improvements has included information about improving Patient Safety in the Summit. This year we have a whole best Practices Track dedicated to improving patient safety and a Keynote Speaker talking about a fatal sentinel event.

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Let’s start by telling you about Dr,. Carol Gunn, one of our Keynote Speakers. She is a medical doctor who was trained to use the TapRooT® Root Cause Analysis System before she became a doctor. While she was a doctor, her sister died in a hospital from “complications.” It turns out that those complications were a result of a medical error. She will tell the story of her sisters death and what can be learned when root cause analysis is used properly and what happens when sentinel events are covered up.

Now let’s look at what’s covered in the Patient Safety Best Practices Track:

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Improving Patient Safety – Gaining a Win from a Loss (Michel Lindsay): Michele will share the evolution and success of their system for managing patient safety incidents and the expanded role of the Quality of Care Committee (QCC) on its journey to a high reliability organization at Southlake Regional Health Centre. A serious incident can have devastating outcomes to patients, their families, and to the caregivers involved. Even errors that result in no or mild harm to the patient can be devastating and career changing for staff and physicians. We have created structures and supports for immediate and long term organizational learning and improvements from incidents while maintaining a culture of care. Learn how the process QCC role has assisted in removing the shame and blame from an incident and turned it into a powerful lever for caring, sharing and repairing. Michele will describe the investigation processes using illustrations and case studies to describe how patient safety, learning, performance and culture has been positively impacted by their approach. The presentation includes the input from the COO & SVP Operations, Director of Surgery, the Director of Risk, the Manager of Risk, the Manager of a Cardiac Clinical Program, a Physician and the Quality Specialist.

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Improving Sentinel Event Investigations (Ken Turnbull): Ken is one of the authors of the new book, Improving Patient safety with TapRooT® Root Cause Analysis (to be released somewhere around the time of the Summit) and will share some of the new ideas presented in the book.

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Using Wearables to Minimize Daily Human Errors (Kevin McManus): Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.

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Deep Dive Into the Procedures Basic Cause Category (Ralph Brickey): Procedures (checlists) are almost a new concept being used to improve patient safety. Learn from the TapRooT® procedures best practices including: Learn: the philosophy and practice of using procedures; different types of procedures and how they are addressed in the TapRooT® Root Cause Dictionary and the Root Cause Tree®; and two human performance tools to aid in proper procedure use

Influencing Change (Jonathon Kennedy): Change is what improving performance is all about. What is the best way to influence change? Hear what Jonathan Kennedy has to say.

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Top 7 Secrets of a Great Investigation Interview (Barb Carr): Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.
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TapRooT® Users Share Best Practices (Linda Unger): Share best practices about root cause analysis, investigations, and performance improvement with industry leaders from around the world.

Performance Improvement Gap Analysis (Linda Unger): Evaluate where you are and where you want to go and how you will apply what you have learned at the Summit to improve performance at your facility. The goal of this session is to go back to work with a plan to improve patient safety.

That an impressive list of breakout sessions.

So are you really interested in improving patient safety? Then you should attend the 2018 Global TapRoot® Summit. Register HERE!

Technically Speaking – Helpdesk Humor

Posted: January 12th, 2018 in Technical Support, Technically Speaking

Using the TapRooT® VI software is a HOOT!

With all the updated features in the TapRooT® VI software, working through the 7 steps of a TapRooT® investigation is a breeze and we hope our customers get owl they need out of the software! 

Please remember if you have any questions about the software you can call us directly at (865)357-0080 or email us at support@taproot.com.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor. Remember, just because it’s technical, doesn’t mean it has to be complicated!

 

Why does your site need someone (or a team) at the 2018 Global TapRooT® Summit?

Posted: January 10th, 2018 in Current Events, Performance Improvement, Pictures, Summit, TapRooT, Video

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Since there are so many high-quality conferences and events put on each year, you really need to think about which ones you should go to. If you haven’t signed up for the 2018 Global TapRooT® Summit yet, here are four top reasons to attend.

REASONS TO ATTEND THE SUMMIT

1. SAVE MONEY

You can’t afford a major accident, a fatality, a serious quality defect, a sentinel event or an unexpected equipment failure.

The TapRooT® Summit is a unique gathering of people intent on improving performance. They share ideas across companies, disciplines, and continents. The sharing of new ideas and best practices will help you develop ideas to stop accidents, fatalities, quality issues, sentinel events, and equipment failures.

What you may not have thought of is how much money this could save your company. Do you know the costs of human errors that occurred at your site? What were your workman’s comp costs? How much does unexpected downtime and lost production cost your site? What were the costs of legal issues due to mistakes and the resulting lawsuits? You will be far ahead financially if you stop just ONE major issue.

2. GET A PROMOTION

What will happen to your career is you are seen as an essential problem solver that leads the sites improvement efforts?

But where will you get the skills and ideas to lead improvement at your site? That’s easy. Attend the 2018 Global TapRooT® Summit.

When we plan the Summit we take the lessons we learn from teaching root cause analysis around the world and build sessions that we know will help solve frequently occurring issues that we have observed at courses. You will be surprised how many people face issues similar to the ones that you face and how there are people who have figured out how to improve performance and stop those problems. Don’t reinvent the wheel. Attend the Summit and learn from the success of others.

3. GET FIRED UP!

Improving performance requires constant attention. Working hard to constantly improve performance can wear you down. Where do you get the motivation to continually challenge the status quo? Attend the TapRooT® Summit!

Most people we talk to before the Summit say that they are attending to learn new skills and get new ideas and best practices to help their site improve performance. And after the Summit they agree that they learned valuable information well worth the time and expense of attended. But they are surprised that they got an unexpected benefit that was even more valuable. They left the Summit FIRED UP to go back to work and make things happen.

Why is motivation so valuable? Because an unmotivated person is unlikely to have the stamina to see an improvement effort through to completion. They get started but they don’t get things done.

We understand motivation and making improvements happen and that’s why we know that motivation is important. That’s why we build in events to motivate you throughout the Summit. Attend the 2018 Global TapRooT® Summit and go back to work CHARGED UP to make improvement happen.

4. HAVE FUN

What? How can fun be an important reason to attend the TapRooT® Summit? We have learned that people learn more, retain more, and bring more and better ideas back to work from the Summit if they have fun learning and sharing.

After all, who says that work and learning have to be dull and boring? We have discovered how to make the Summit an activity that you will find valuable and ENJOYABLE every time you attend.

ONE MORE IDEA…

Have you ever noticed how an effective team accomplishes much more than a single motivated individual?

That’s why we recommend that a site truly interested in achieving excellence send an improvement team to the TapRooT® Summit.

A team can spread out across the various sessions (there are tracks with various topics to pick from). Someone might attend the Safety Track while someone else attends the Quality Track, while someone else attends the Human Factors Track, while someone else attends the Asset Optimization Track. See the schedules for the various tracks by CLICKING HERE.

GUARANTEE

We know that you will find the 2018 Global TapRooT® Summit a valuable experience. We know that you will have a great return on your investment of time and money. And we provide you with this guarantee:

Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

So don’t wait. REGISTER TODAY!

Want to see what people who attend the Summit have to say after they attend? Here’s a video I made a few years ago and it sure is a blast from the past that still applies today…

Sorry, we won’t be having golf at this Summit (the first week in March in Tennessee just doesn’t work) but we will have a great reception and a lot of sharing.

TapRooT® is going to Dubai March 18, 2018

Posted: January 9th, 2018 in Courses

 

We’re looking forward to our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Dubai, March 18 – 22, 2018.

Register early because seats in our last Dubai course sold out! 

In just 5 days, learn TapRooT® to find and fix the root causes of incidents, accidents, quality problems, near misses, operational errors, hospital sentinel events and other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper® plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement.

Dubai is an exciting location with golden sunshine all year round. We hope that you’ll join us for training and also plan to explore a few of the extraordinary attractions this destination offers.

REGISTER NOW

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Chris ValleeChris Vallee

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Dan VerlindeDan Verlinde

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Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

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Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

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Mark ParadiesMark Paradies

Creator of TapRooT®

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Susan Napier-SewellSusan Napier-Sewell

Marketing & Communications Strategist

Wayne BrownWayne Brown

Technical Support

Success Stories

Fortunately, I already had a plan. I had previously used TapRooT to improve investigations…

Bi-State Development Corporation

If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to: Save lives Prevent injuries Improve product/service quality Improve equipment reliability Make work easier and more productive Stop sentinel events Stop the …

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