Root Cause Analysis Blog


Technically Speaking – November Customer Satisfaction Survey Prize Winner

Posted: December 15th, 2017 in Technical Support, Technically Speaking

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner.

This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a Survey, all respondents are entered into a monthly drawing to win a TapRooT® polo shirt.
Everyone, congratulate Jarrett Marsh, from Noble Drilling Services LLC.  as the winner for the month of November!

Now the Submarine Navy is Having Problems

Posted: December 15th, 2017 in Current Events, Pictures


Can it be true that a Nuclear Navy submarine has sat in port in Guam for six months awaiting repairs while it was suppose to be deployed? Read: “Bizarre Deployment” in Navy Times.

Friday Joke: Priorities

Posted: December 15th, 2017 in Jokes

Secretary of the Navy Strategic Readiness Review – Management System Problems Broke the US Navy

Posted: December 14th, 2017 in Accidents, Current Events, Human Performance, Investigations, Performance Improvement, Pictures

Yes, “Management System Problems Broke the US Navy” is my headline.

The report to the Secretary of the Navy is much worse than I thought. The report outlines how budget restrictions and congressional leadership made the Navy conform to the structures of the Army and the Air Force and de-emphasized the role of providing seapower. That’s how the US Navy was broken. And it will be difficult to fix. (“All the King’s horses and all the King’s men couldn’t put Humpty Dumpty together again!” was a lesson learned in 1648 during the English civil war.)


Many of the problems are Management System problems as outlined in a Navy Times article about the Strategic Review report to the Secretary of the Navy. The good news is … the authors of the Strategic Review get the Management System root causes pretty much right! The bad news is that it is less clear that the Navy has the ability to fix the issues because they are a result of Congressional action (funding, ship procurement, the Defense Officer Personnel Management Act, the Goldwater-Nichols Act of 1986, and National Defense Authorization Act provisions) and the Navy’s response to congressional cutbacks (Optimum Manning, the SWOS-in-a-box, modifications to the surface warfare officer sea-shore rotations and assignments, and the 2001 Revolution in Training for enlisted personnel).

The review says that the Navy must cut back their commitments to operational requirements in “peacetime.” But that is unlikely in the near wartime footing that they Navy faces in their forward deployments.

One of the recommendations made by the Strategic Review is for the Type Commanders to implement the “Rickover Letters” that are part of the Nuclear Navy Commanding Officer reporting structure. This will only work if the Type Commanders maintain strict requirements that Admiral Rickover established in the Nuclear Navy. This has not been the culture in the conventional surface Navy – EVER. Thus this would be a dramatic cultural shift.

Navy brass in the 1980’s and 1990’s wished that sailors at sea could do more with less and that “technology” would make that possible. Unfortunately the cuts were made (Optimal Manning and Continuous Maintenance Plan) without proof of concept testing. Now, over two decades later, the chickens have come home to roost.

The USA is an island nation. We can’t exist in our modern economy without sea trade. Thus, the USA must be the premier sea power. This requirement is independent of the “War on Terror,” the “War on Drugs,” or other missions to support land forces. Somehow past Presidents and Congressional leaders have not funded the seapower mission. Thus, we find ourselves in a bind that will be hard to fix.

The people in senior Navy leadership positions have grown up in a broken system. We must now ask them to fix (restore) the system when they have never seen work properly. The CNO in a Navy Nuke from the submarine fleet that has faced budget reductions but has not faced the same personnel and training issues. He grew up in a completely different culture.

By making the US Navy the “same” as the Air Force and the Army, the unique requirements of the Navy were overlooked and the Navy was broken. Can it be fixed? The recommendations of the Strategic Review could start the repair process. But it is only a start. Many uniquely “Navy” cultural and readiness issues are not addressed in the report. Plus, this report probably will not get the attention it deserves until a failure of our war-fighting ability at sea produces a major foreign policy fiasco or, even worse, economic collapse at home because our island nation is cut off from overseas supplies.

One last comment.

The Strategic Review calls for the establishment of a “learning culture.” The authors of the Strategic Review call for proactive learning instead of the current culture of punishment based reactive learning. They frequently mention the “normalization-of-deviation” as if it a relatively recent US Navy cultural problem rather than being the state of the conventional surface navy for decades (or centuries?). They should read the article about Admiral Rickover and the normalization-of-excellence to better understand the changes that are needed. Also, establishing a proactive, learning culture isn’t possible until the US Navy understands advanced root cause analysis (which current investigations and corrective actions prove that the Navy does not understand).

The recommendations of section 6.3 of the Strategic Review are putting the “cart in front of the horse.” The FIRST step in correcting the Navy’s culture is for all naval officers (senior commanders through junior officers) to understand advanced root cause analysis. Without this understanding, learning – either proactive or reactive – is impossible. We have worked with industry leaders and we know of what we speak.

I certainly hope the US Navy makes significant progress in correcting the glaring shortcomings outlined in the Strategic Review. The lives of sailors at sea depend on it. But even worse, a failure to fix the root causes of the Management System problems and the poor understanding of advanced root cause analysis will certainly lead to failures of our seapower and serious foreign policy issues that may cause tremendous economic troubles for the US. I’m old and may not see the day when we discover that under-investment in seapower was a gigantic mistake. But if this problem isn’t fixed rapidly and effectively, certainly my children and grandchildren will face an uncertain, dark future.

I would be happy to discuss the improvements in root cause analysis that are needed with any Navy leader concerned that a more effective approach is needed.

TapRooT® Around the World: Uruguay

Posted: December 14th, 2017 in Courses, TapRooT

Another successful course in Uruguay! TapRooT® instructor, Hernando Godoy Garzón, sent these course photos in from ANDRITZ – Fray Bentos. Contact us at to schedule a course at your facility. We have instructors who are proficient in both Spanish and Portuguese languages.












TapRooT® Around the World: Uruguay

Posted: December 14th, 2017 in Courses, Pictures, TapRooT

TapRooT® Instructor, Hernando Godoy Garzón sent us these great photos from his course at ANDRITZ URUGUAY S.A. | Colonia.

Contact us at to bring a course to your site. We deliver training around the globe.


TapRooT® Around the World: Jeanette PA

Posted: December 14th, 2017 in Courses, TapRooT

TapRooT® Instructor, Heidi Reed sent us these course photos from an onsite course at Elliott Group. If you’d like to host a TapRooT® course for employees at your facility, contact us at


See TapRooT® Explore How They’re Changing the Way the World Solves Problems

Posted: December 14th, 2017 in Media Room, Press Releases, Root Cause Analysis Tips, Root Causes

We’re pleased to announce that Mark Paradies’  interview on Worldwide Business with kathy ireland® is scheduled to air on Fox Business Network as sponsored programming.

CLICK HERE to view the recent press release.

Please reference the broadcast information below. You may also reference the channel finder below for market by market air times.

Air Date
December 17, 2017
Network and Time
Fox Business Network – 5:30pm EST
Channel Finder

Gift yourself! (Santa has your back)

Posted: December 13th, 2017 in Career Development, Career Development Tips, Summit

Do you have the feeling that you have the ability to do more in your career in 2018 but are unsure of how to get going? Why not think about giving a gift to yourself?

Click here to learn more.

TapRooT® for Audits Pre-Summit Course at the Global TapRooT® Summit

Posted: December 13th, 2017 in Summit

“An Ounce of Prevention is Worth a Pound of Cure.”
Ben Franklin

Around the world, professionals and companies have sought to find a better way to perform investigations on problems and losses. Many of the smartest people and leading companies use TapRooT®.

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix simple or complex accidents, difficult quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and the development of effective corrective actions. However, wouldn’t it be better if you never had to do investigations in the first place? Of course, and that is why auditing is so important.

Many companies do perform audits. Unfortunately, in some cases, this work does not yield improvements. Why? There are many reasons, but the primary reason is lack of good root cause analysis. A company can actually be very good at finding problems, but not be effective at FIXING problems.

Beyond auditing, proactive improvement can take many forms, and when effective, becomes an overall mindset and can put an organization on the path to excellence. If that is the case, why are more companies not proactive? Here are just a few reasons:

• Time (perceived at least)
• They don’t have a reason to (not enough pain)
• They do not have the buy-in (management and employee support)
• Procrastination (human nature!)
• They don’t know how (this is where TapRooT® comes in!)

TapRooT®, when used with auditing and proactive improvement programs, can help lead to organizational excellence and reduce the number of investigations required.

To help you in your performance improvement efforts, we created a course entitled “TapRooT® for Audits,” which will be a Pre-summit course at the Global TapRooT® Summit. Why should you attend?

Top 5 Reasons to attend TapRooT® for Audits:
1. You did an audit and found the same thing you did last year!
2. You have used TapRooT® for investigations but never used it for audits.
3. You are an auditor, not an investigator.
4. You are a good investigator, but want to become a better auditor.
5. You want to help your company improve, show your value to the company, and build your expertise level.

If any of these 5 reasons apply to you, please attend our course, TapRooT® for Audits, at the Global TapRooT® Summit, February 26-27, in Knoxville, TN. To register for the course (and the summit on February 28-March 2), click HERE

Are you on Santa’s “Naughty” or “Nice” List for investigative interviewing?

Posted: December 12th, 2017 in Best Practice Presentations, Best Practice Presenters, Summit



I’m really excited to share the “Top 7 Secrets of a Great Investigation Interview” during Global TapRooT® Summit Week, February 26 – March 2, 2018 in Knoxville, Tennessee. Meanwhile, in the spirit of the season, I want to share some interviewing tips to keep you on Santa’s “nice” list!


Santa’s Nice List Santa’s Naughty List

Explain to the worker that you want to
interview him/her to find the root causes of
the problem so you can fix them.


Explain to the worker that you want to
interview him/her to find out who is responsible
for the mistake because they deserve to be fired.


Ask the worker open ended questions.
“Tell me about… ” and then listen
to their narrative without


Interrupt the worker whenever you think of a
question or comment he or she may find accusatory,
like, “Mark, isn’t it true that you disregarded company
procedure? Why did you intentionally do that?”
That will pressure him/her to spill the beans!


Tell the worker that you will share information
with only those who need to know.


Promise total and complete confidentiality. You know
you can’t, but they’ll tell you more if you do.


Let the worker know you’ll take notes during
the interview and that you will review them
together upon the conclusion of the interview
to make sure you understood everything

Don’t take any notes. You already know
what happened – you’ve seen it a million times.


What do you think? What best practices do you use for investigative interviewing? What practices do you think lands an investigator on the “naughty” list?

What are the favorite blog posts from this year and from all time?

Posted: December 12th, 2017 in Current Events, Pictures, TapRooT

The end of the year is coming and sometimes it is good to look back and see whats been trending for people who read this blog. Let’s look at the articles posted in 2017 and see what’s been trending …


5. How Far Away is Death? (October – above)

4. Friday Joke: An Old Nuke Navy Joke… (October)

3. US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald (August)

2. What happens when root cause analysis becomes too simple? Six problems I’ve observed. (July)

1. What is the Root Cause of the USS Fitzgerald Collision? (July)

And then let’s look back to the past to see the top five most popular articles of all time:

5. Root Cause Tip: What’s a Causal Factor? (2012)

4. 7 Secretos / secretos del análisis de Causa raíz (2011)

3. Live Your Core Values: 10 Minute Exercise to Increase Your Success (2013)

2. 7 Secrets of Root Cause Analysis (2011)

1. An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts… (2007)

Ten Indicators that your Company may have a Safety Culture Problem

Posted: December 11th, 2017 in Performance Improvement, Summit

What puzzle pieces do you need to put in place to improve your safety culture?

A safety culture is difficult to measure, but there are some indicators that alert us to problems.

  1. There is no visible commitment from leadership.
  2. When there are competing priorities, safety comes in second.
  3. Workers feel uncomfortable reporting safety issues to their supervisors.
  4. Safety is viewed as more of a cost than an investment.
  5. Injuries and illnesses are sometimes swept under the rug.
  6. Safety issues are dealt with in an untimely and inefficient manner.
  7. Workers do not have the power or resources to find and fix problems as they see them.
  8. Managers are never seen on the shop floor with the workers.
  9. Safety is not part of the everyday conversation.
  10. Workers are blamed for accidents.

Do any of these sound familiar? If you identify problems like those listed above, you can improve your facility’s safety culture. We’re excited to welcome Brian A. Tink and Brian W. Tink back to the Global TapRooT® Summit to share their popular 2-day Pre-Summit course, “TapRooT® Analyzing and Fixing Safety Culture Issues.”

Click here to learn more about this course.

Register now for the 2-day course only (Febuary 26 and 27)

Register now for the 3-day Global TapRooT® Summit and this 2-day course (February 26 – March 2)

Job Postings for Candidates with TapRooT® Root Cause Analysis Skills

Posted: December 11th, 2017 in Career Development, Job Postings

Check out the career opportunities below for candidates with TapRooT® skills at facilities around the world

Get trained in 2017 to open up your job opportunities in 2018. Here are some recent postings looking for candidates with TapRooT® Root Cause Analysis skills:

EHS Manager

EHS Manager II

Patient Safety Program Coordinator

ESG Customer Quality Manager

Quality Manager

Quality Advisor

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

Join us LIVE on Facebook December 13

Posted: December 11th, 2017 in Media Room


Click image to go to our Facebook page.

Noon Eastern

11:00 a.m. Central

10:00 a.m. Mountain

9:00 a.m. Pacific


Santa Accidents 2

Posted: December 11th, 2017 in Current Events

My 20+ Year Relationship with 5-Why’s

Posted: December 11th, 2017 in Accidents, Career Development, Great Human Factors, Human Performance, Investigations, Performance Improvement, Quality, Root Cause Analysis Tips, Root Causes, TapRooT

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Monday Accident & Lesson Learned: Near Miss Incidents at Camden Junction South London

Posted: December 11th, 2017 in Accidents


The RAIB recently published an investigation report concerning track worker near miss incidents at Camden Junction South, London. Click here to view the report.

Dennis Osmer – RIP

Posted: December 8th, 2017 in Current Events, Meet Our Staff, Pictures


Dennis Osmer, 70, TapRooT® User/Instructor and safety and ergonomics expert died on December 1, 2017 from bladder cancer.

Dennis started using TapRooT® at Novartis and became the worldwide head of occupational health, safety, environment, and emergency management at CIBA Vision.

After he retired from CIBA Vision in 2008, he became a TapRooT® Instructor and for five years helped students learn to apply TapRooT® to improve safety and quality. In addition, he helped clients by facilitating difficult investigations to stop future safety issues.

Dennis was one of our first clients to show how TapRooT® could be used to investigate and prevent ergonomics issues while working for CIBA Vision. Here is a link to the success story that he presented at the Global TapRooT® Summit: This work saved many workers the pain and suffering from ergonomic injuries in the facilities customer support and distribution departments and saved the company over $6 million dollars in workers compensation costs in the six years after the program was implemented.

Some people just have an ability to make positive change happen and Dennis was one of those people. Everyone here at System Improvements and all of his students and co-workers, as well as his family, will miss him.

See this link:, for his obituary and memorial.

Advance the Quality of your Risk Assessments: A Q & A with Jim Whiting

Posted: December 8th, 2017 in Summit

Would you like to add “RA Workshop facilitator” to your resume? Are you interested in improving your current risk matrix tool in a way that achieves dramatic results? We were excited to talk to Jim Whiting about his upcoming Risk Management – Best Practices & Risk-Based Thinking course, at the 2018 Global TapRooT® Summit, February 26-27, 2018 in Knoxville, Tennessee and learn that these objectives are within your reach.

Q:  What are the main benefits of attending this course for a newcomer or a very experienced professional?

A: Regardless of your current level of experience, the main benefit you will gain is learning how to use and adapt new practical and effective RM approaches, methods and tools which are now required in managing all types of risk in general, and particularly as specified in new HSEQ System Standards.

Q. What is an example of one such approach that I could learn & derive benefit?

A: The workshop training will describe and provide hands-on practice with a proven Likelihood Estimation Guidance tool which significantly reduces variability of risk assessors’ estimates of the likelihood / probability / frequency of any specific risk scenario. After the workshop, the 100’s of past attendees describe how they are much more confident of the consistency and accuracy of likelihood estimation and hence risk assessments.

Q: Why do Risk Assessments always seem to be very subjective and depend on personal opinions, biases and perceptions?

A: YES many risk assessments in the past have led to widely variable estimates of risk which then cannot help in our HSEQ decision making. That is why the Workshop concentrates on improved facilitation techniques which minimize the effects of those factors. You will learn how to become a very effective RA Workshop facilitator.

Q: What are some examples of these improved facilitation techniques?

A: To achieve better results from a RA team, you will learn about optimizing control and design of facilitation factors such as number, composition, types, profiles, interpersonal dynamics and consensus techniques including the Delphi technique.

Q: What are other beneficial take-aways from the training?

A: You will learn how to avoid common RM traps such as – arguing unnecessarily about consequence severity; mixing different scenarios and attempting to assess them together at the one time; misinterpretation of effective applications of the Hierarchy of Risk Controls; not using formal criteria for making consistent decisions re risk tolerability; not recognizing when everyday risk mythology is influencing assessments; etc.

Q: Can I get a better understanding of RBT Risk Based Thinking and what I would need to do to conform with RBT aspects of ISO / ANSI Standards?

A: A significant issue covered in the workshop is how to clarify the degree of formality of RM processes and tools needed to conform with RBT requirements of ISO Management System Standards 9001, 14001 and the new OHSMS ISO 45001.

Q: Can I learn how to make our current risk matrix work better and more effectively without major changes?

A: Many past attendees were pleased that they were shown how to consider dramatic improvements to their existing risk matrix tool without necessarily complete replacement and the often accompanying trauma of major change.

We’re looking forward to Jim Whiting sharing all these valuable risk management best practices at the 2018 Global TapRooT® Summit!

CLICK HERE to learn more 









Friday Joke: Nuclear Winter Wonderland

Posted: December 8th, 2017 in Documents, Jokes, Video

Winter wonderland

Click on the links below for a Nuclear Winter Wonderland (either a Quicktime movie or a PowerPoint)

Nuclear Winter Wonderland


The PPTX is the best quality.

Or try this YouTube video…


TapRooT® Certified Instructor Recertification Track

Posted: December 7th, 2017 in Summit

Certified TapRooT® Instructors: Your 2018 Summit attendance is required!


It is time to renew your Certification status so that you can continue teaching TapRooT® within your company. Join Linda, Ken and Michelle as they answer your questions and provide important information about changes and new TapRooT® products. Most importantly, your certification status will be extended for two more years.

Here’s what you can expect:

10 2-day Pre-Summit courses to choose from and expand your knowledge.

8 Best Practice Sessions

  1. TapRooT® Users Share Best Practices, Linda Unger, Michelle Wishoun & Benna Dortch
  2. Defining Better Causal Factors, Ken Turnbull
  3. What’s New in TapRooT® Software, Dan Verlinde
  4. TapRooT® Certified Instructor Recertification Workshop, Ken Reed, Linda Unger, Michelle Wishoun
  5. Top 7 Secrets of a Great Investigation Interview, Barb Carr
  6. Taking Your Investigation Communication Skills to a Dynamic New Level, Vincent Phillips
  7. Best Practices for Sharing Lessons Learned, Pat Fortune
  8. Performance Improvement Gap Analysis


Software Track at the 2018 Global TapRooT® Summit

Posted: December 7th, 2017 in Best Practice Presentations, Best Practice Presenters, Current Events, Software, Summit, Uncategorized


We’re getting closer to the 2018 Summit in our hometown of Knoxville, TN on February 28th -March 2nd (Pre-summit courses February 26th-27th)!

Here’s what you can look forward to in our Software Track sessions:

The TapRooT® Software Sandbox – Dan Verlinde and Angie Comer

In this session, you will have access to the latest TapRooT® VI Software and have an opportunity to navigate throughout the application. You can ask questions and learn tips and tricks from the designer of the software himself!

Instructor Software Updates – Dan Verlinde and Ken Reed

This session is intended for certified TapRooT® Instructors and will provide important updates and information on the software.

What’s New in TapRooT® Software – Dan Verlinde

Learn what’s new in the TapRooT® Software and get a sneak peek at what’s coming soon in 2018!

Building Your Software Incident Report – Dan Verlinde

In this session, you will learn how to create customized reports and templates in the software that you can easily use to effectively share your incident, investigation and audit findings with others.

Software Advisory Board – Dan Verlinde (and Software Advisory Board Members)

A discussion on current software topics will be held in this session with members of the Software Advisory Board.

What is a Trend and How Can You Find Trends in the TapRooT® Data – Chris Vallee

You have invested in TapRooT® and have root cause data, but do you know what the data tells you? Do you know if what you are measuring has changed for the good or the bad? Do you know how to access your trend-able data in your VI Software? Learn what to look for, what needs to be acted on and how to access the data on VI Software.

Best Practices for Sharing Lessons Learned – Pat Fortune

Learn best practices for sharing lessons learned from an experienced TapRooT® Investigator.

Performance Improvement Gap Analysis – TapRooT® Instructor Team

Meet with other TapRooT® users from world leading companies and discuss lessons learned, best practices and favorite takeaways that you can apply to your business and share with team members once you leave the summit.

And of course, all tracks attend the inspiring KEYNOTE SPEAKER sessions.

Also, don’t miss a chance to learn even MORE about the software in our Pre-Summit, Getting the Most from Your TapRooT® VI Software course.

We can’t wait to see you there! To register for the Summit, click HERE.

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Garrett BoydGarrett Boyd

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Success Stories

As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section: “Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 …

In 2002, we decided that to reduce accidents, prevent…

Greater Cleveland Regional Transit Authority
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