Root Cause Analysis Blog

 

Monday Accident & Lessons Learned: RAIB Investigation Report -

Posted: September 1st, 2014 in Accidents, Current Events, Investigations, Pictures

Screen Shot 2014 08 05 at 12 11 11 PM

Here is the summary of the report from the UK Rail Accident Investigation Branch:

At about 03:00 hrs on Sunday 21 April 2013, a road rail vehicle (RRV) ran away as it was being on-tracked north of Glasgow Queen Street High Level Tunnel on a section of railway sloping towards the tunnel. The RRV ran through the tunnel and struck two scaffolds that were being used for maintenance work on the tunnel walls. A person working on one of the scaffolds was thrown to the ground and suffered severe injuries to his shoulder. The track levelled out as the RRV ran into Glasgow Queen Street station and, after travelling a total distance of about 1.1 miles (1.8 kilometres), it stopped in platform 5, about 20 metres short of the buffer stop.

The RRV was a mobile elevating work platform that was manufactured for use on road wheels and then converted by Rexquote Ltd to permit use on the railway. The RRV’s road wheels were intended to provide braking in both road and rail modes. This was achieved in rail mode by holding the road wheels against a hub extending from the rail wheels. The design of the RRV meant that during a transition phase in the on-tracking procedure, the road wheel brakes were ineffective because the RRV was supported on the rail wheels but the road wheels were not yet touching the hubs. Although instructed to follow a procedure which prevented this occurring simultaneously at both ends of the RRV, the machine operator unintentionally put the RRV into this condition. He was (correctly) standing beside the RRV when it started to move, and the control equipment was pulled from his hand before he could stop the vehicle.

The RRV was fitted with holding brakes acting directly on both rail wheels at one end of the vehicle. These were intended to prevent a runaway if non-compliance with the operating instructions meant that all road wheel brakes were ineffective. The holding brake was insufficient to prevent the runaway due to shortcomings in Rexquote’s design, factory testing and specification of maintenance activities. The lack of an effective quality assurance system at Rexquote was an underlying factor. The design of the holding brake was not reviewed when the RRV was subject to the rail industry vehicle approval process because provision of such a brake was not required by Railway Industry Standards.

The RAIB has identified one learning point which reminds the rail industry that the rail vehicle approval process does not cover all aspects of rail vehicle performance. The RAIB has made four recommendations. One requires Rexquote to implement an effective quality assurance system and another, supporting an activity already proposed by Network Rail, seeks to widen the scope of safety-related audits applied by Network Rail to organisations supplying rail plant for use on its infrastructure. A third recommendation seeks improvements to the testing process for parking brakes provided on RRVs. The final recommendation, based on an observation, relates to the provision of lighting on RRVs.

To read the whole report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140717_R152014_Glasgow_Queen_Street.pdf

Monday Motivation: Dale Carnegie

Posted: September 1st, 2014 in Pictures

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Develop success from failures.
Discouragement and failure are two of the surest stepping stones to success. ~ Dale Carnegie

Weekly Wisdom for Career Development and Root Cause Analysis

Posted: September 1st, 2014 in Wisdom Quote

Dhariwal

 

“Drive out fear, work with zest. Be a pioneer, deliver the best!”

- Prateek Dharwal

UK Rail Accident Investigation Branch investigates electrical arcing and fire on a Metro train and parting of the overhead line at Walkergate station, Newcastle upon Tyne, on 11 August 2014

Posted: August 29th, 2014 in Accidents, Current Events, Investigations, Pictures

Here’s the press release …

Electrical arcing and fire on a Metro train and parting of the overhead line
at Walkergate station, Newcastle upon Tyne, on 11 August 2014

RAIB is investigating an accident which occurred on the Tyne and Wear Metro system at Walkergate station on Monday 11 August 2014.

At 18:56 hrs a two-car Metro train, travelling from South Shields to St James, arrived at Walkergate station. While standing in the station an electrical fault occurred to a line breaker mounted on the underside of the train, which produced some smoke. It also caused the circuit breakers at the sub-stations supplying the train with electricity, via the overhead line, to trip (open). About one minute later power was restored to the train. There followed a brief fire in the area of the initial electrical fault and further smoke. Shortly afterwards, the overhead line above the train parted and the flailing ends of the wire fell on the train roof and one then fell on to the platform, producing significant arcing and sparks for around 14 seconds. Fortunately, there was no-one on the platform at the time. However, there were at least 30 passengers on the train who self-evacuated on to the platform using the train doors’ emergency release handles. The fire service attended but the fire was no longer burning. No-one was reported to be injured in the accident and there was no significant damage to the interior of the train.

NewImageImage courtesy of Tyne and Wear Metro 

RAIB’s investigation will consider the sequence of events and factors that led to the accident, and identify any safety lessons. In particular, it will examine:

  • the reasons for the electrical fault;
  • the response of the staff involved, including the driver and controllers;
  • the adequacy of the electrical protection arrangements; and
  • actions taken since a previous accident of a similar type that occurred at South Gosforth in January 2013 (RAIB report 18/2013).

RAIB’s investigation is independent of any investigations by the safety authority. RAIB will publish its findings at the conclusion of the investigation. The report will be available on the RAIB’s website. 

You can subscribe to automated emails notifying you when the RAIB publishes its report and bulletins.

RAIB would like to hear from any passengers who were on the train. Any information provided to assist our safety investigation will be treated in strict confidence. If you are able to help the RAIB please contact us by email on enquiries@raib.gov.uk or by telephoning 01332 253300

Throwback Thursday: Vegas… Need I Say More?

Posted: August 28th, 2014 in Pictures, Summit

Throwback to the 2012 Las Vegas Summit. System Improvements had a wonderful time preparing and planning for this Summit. The bar has been set very high for next year’s 2015 Las Vegas Summit. Help us make it the greatest Summit ever!

Dan Verlinde hanging out after the Summit.

Dan Verlinde and Summit attendees hanging out after a full day.

System Improvements staff Ken and Michelle hanging out at the 2012 Summit.

System Improvements staff Ken and Michelle at the 2012 Vegas Summit.

Attend the 2015 Summit and have fun while learning. Click on the link below to find out more about the 2015 Global TapRooT® Summit in Las Vegas, Nevada. 

http://www.taproot.com/taproot-summit

What is your favorite Summit memory? Please leave comments below and tell us what you remember…

Root Cause Analysis Training in South America – Lima Onsite Course Photos

Posted: August 28th, 2014 in Courses, Pictures

Our onsite course in Lima, Peru held August 5-6, 2014 was a great success! Thanks to TapRooT® Instructor Piedad Colmenares for these photos and for teaching a great course.

Lima Buenaventura 2014 - 3

Lima Buenaventura 2014 -2

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Want to learn more about how you can bring world-class root cause analysis training to your facility?
Click here to contact us for more information about our onsite courses.

Root Cause Analysis Training in Connecticut – Hartford’s Local Attractions

Posted: August 28th, 2014 in Courses, Local Attractions

Connecticut_State_Capitol,_Hartford

Hartford, Connecticut, in addition to hosting our October 1-2, 2014 TapRooT® Incident Investigation & Root Cause Analysis Training, is home to a rich historical heritage. Authors Mark Twain and Harriet Beecher Stowe hail from this city, as does the country’s first public art museum and oldest newspaper. While you’re attending the course, take some time in the evening to enjoy the food and fun Hartford has to offer.

Food

Salute - Enjoy a classy atmosphere and delicious Italian food. Make sure you get a reservation!

Max Downtown - Seafood, steak, and an excellent wine list will make your dinner at Max comfortable and exquisite.

Firebox - Don’t let the small menu fool you: Firebox’s farm-to-table philosophy brings local charm and amazing quality to dishes like Cast Iron Duck and Black Pearl Salmon.

Chowder Pot IV - Enjoy some inexpensive local chowder and seafood at this unexpected hole-in-the-wall joint.

Black Eyed Sally’s - Get a taste of the South up north with ribs, pulled pork, jambalaya, and blackened catfish.

Woody’s - Kick back and relax with burgers, fries, and their signature all-beef hot dogs with unique toppings like bbq pork, bacon, or cheese.

 

Attractions

Mark Twain House – Tour the home in which Mark Twain (Samuel Clements) lived while writing some of his most famous works, along with a museum outlining his life.

Harriet Beecher Stowe Center – See the home of the writer of Uncle Tom’s Cabin, along with a museum celebrating her contributions to equality in America.

Connecticut State Capitol – Join a free, guided tour of the beautiful and historic capitol building of Connecticut.

Cathedral of St. Joseph – No matter your religious affiliation, you’ll be in awe of the gorgeous stained glass windows in this centuries-old cathedral.

Wadsworth Atheneum Museum of Art – Enjoy exhibits of contemporary art or baroque at the first public art museum in the United States.

 

Haven’t registered yet? Want to learn to find and fix the real root causes of problems in your workplace? Click here to learn more about our 2-Day course.

 

Root Cause Analysis Training in Ottawa – Ottawa’s Local Attractions

Posted: August 27th, 2014 in Courses, Local Attractions

Only a couple more weeks until our next 5-day TapRooT® Advanced Root Cause Analysis Team Leader Training Course in Ottawa, Canada! We have a full schedule of great classes planned, but there is also plenty of time to go out and enjoy the wonderful city of Ottawa! Ottawa is packed full of delicious restaurants, casinos, sightseeing opportunities and so much more! Between the beautiful French culture and all the entertainment that Ottawa has to offer, you’re guaranteed to find something fun for you and the family!

Food:

Le Cordon Bleu Ottawa Culinary Arts Institute: Canada’s world-renowned culinary training school, Le Cordon Bleu Ottawa Culinary Arts Institute, includes a Bistro open to the public to sample some exceptional French cuisine.

Town: Town is an excellent, fun restaurant that is full of flavor and style with all of their unique dishes and warm atmosphere!

Fiazza Fresh Fired: This original pizza shop has it all, customizable pizza, fresh ingredients and stone fire grill to make your personalized pizza the best you’ve ever had!

Activities:

Brew Donkey: Enjoy beer tasting and touring the wonderful world of beer breweries? Then the Brew Donkey is perfect for you! Excursions and taste testing make for a great experience!

Parliament Hill: Are you history buff or enjoy gothic style architecture? Take a tour through some of Canada’s heritage at Parliament Hill overlooking the Ottawa River!

Canada’s Aviation and Space Museum: This isn’t your typical museum! With over 50 aircrafts to tour through, you’re in for a fun, educational experience full of history and astonishing aviation facts!

Sign up for the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Ottawa, Canada, September 15-19, 2014.

Register at: http://www.taproot.com/store/5-Day-TapRooT-R-Advanced-Root-Cause-Analysis-Team-Leader-Training-1409OTTA15.html

Root Cause Analysis Tips – Doing Better Investigations (Part 2)

Posted: August 27th, 2014 in Root Cause Analysis Tips, Video

Last week we discussed how to improve your investigation by preparing well. This week we’ll dive into evidence collection.

So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart.

We teach several evidence collection techniques in our courses….

The 3 P’s and the R:
• People
• Plant
• Paper
• Recordings

Interviewing (TapRooT® book, Chapter 3)

Optional techniques:
• Equifactor® (for equipment problems) – TapRooT® book, Chapter 9
• Change Analysis (what has changed or what is different) TapRooT® book, Chapter 11
• CHAP (critical human action profile) TapRooT® book, Chapter 12

Trust me, if you have a good comprehensive SnapCharT® your analysis will be easy and you will find all the root causes. Without that, you will miss something, your corrective actions will be lacking, and your incidents will recur.

Once you have your chart complete, your causal factors identified, and have completed your root cause analysis, it is time for the output of your investigation – corrective actions. Don’t forget our SMARTER technique and use the Corrective Action Helper® for good ideas. Safeguards Analysis is also a great tool for developing corrective actions.

I could go on all day about this, but the key thing I want to bring out here is you MUST have a good SnapCharT®. If you focus on that the rest should fall into place nicely.

Click here to view Part 1.

TapRooT® Around the World: Europe, India, and Africa

Posted: August 27th, 2014 in Courses

Europe

 

Click any of the dates & locations to learn more about the course and its details.

2-Day TapRooT® Incident Investigation and Root Cause Analysis Course

Stavanger, Norway September 2-3, 2014

Aberdeen, Scotland | September 16-17, 2014

Johannesburg, South Africa | September 4-5, 2014

 

3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Stavanger, Norway | September 2-4, 2014

Aberdeen, Scotland | September 16-18 2014

 

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Manchester, England | September 29-October 3, 2014

How Far Away is Death?

Posted: August 26th, 2014 in Accidents, How Far Away Is Death?, Video

Compilation of aviation crashes … some fatal, some not.

To See the Best in Others Will Help Them Become the Best by George J. Burk

Posted: August 26th, 2014 in Career Development, Career Development Tips

“Treat people as if they were what they ought to be, and you help them to become what they are capable of being.” Johann Wolfgang von Goethe

Imagine for as moment where we actually treated one another with such an unbiased respect and unconditional belief in them that we were able to elevate each other to be the best we can be. It’s not just a military slogan. It can and does happen. I’ve experienced this kind of respect, belief and positive reinforcement in my own life.

I’ve heard and witnessed many incredible stories of how people, given little chance to live or to walk again, overcame their physical and emotional injuries to lead positive, productive lives. They, in turn chose to “Pass the salt and make a difference in other people’s lives.” One particular story I read about recently, where a man who was barely able to read was given an assignment that required him to not only read, but to speak in public and exhibit leadership skills. (I know from personal experience that man’s greatest fear is NOT standing in front of a crowd and speaking. Man’s greatest fear IS walking (or crawling) through a wall of fire.) The man’s personal transformation was called miraculous.   He was told that GOD inspired his assignment, and he took it quite seriously. He became an eloquent speaker and leader and that helped him to prosper in other areas of his life and provided a better life for his family. How can this be done you ask? Glad you did and here are some tips:

Release the prejudice. The first step is we must relieve ourselves of the limitations we place on others. Eradicate (I like the word) negativity about ours and others limitations from our mind and memory; erase the mental models and phrases like, “She’s only” or “He’s always” or “They never,” or “He can’t.” We need to stretch our mind and our imaginations and visualize, “see”, them doing something great or being something great. Change our thought patterns from the negative to think “Just because he (or she) never did that before doesn’t mean that he (or she) can’t. It just means that he (or she) has never tried before because no one really believed he (or she) could.”

“None can be more negative on its impact than the limitation on human resource capacity.” Said Musa

Forget the past. Car windshields are larger than the rear view mirror because it’s far more important to see the ‘highway’ ahead than the ‘road’ travelled. Look where you’re headed, not where you’ve been. Whatever mistakes you and others have made and wherever you and they have failed before, or the horrible way you or they have been treated, leave it go! Those issues are totally irrelevant for today. The past is the past. It’s over! Everyone has a story. Choose to change your mental models. ‘See’ yourself and them as winners, not whiners and treat yourself and others that way. It’s sequential, inside out, not outside in. You and then others. Get your own ‘house’ in order first.

“Life is divided into three terms-that which was, which is and will be. Let us learn from the past to profit by the present, and from the present to live better in the future.” William Wordsworth

Remember your roots. We’ve developed and grown into the person we have become because someone, or in my case, many someone’s, believed in us. It was our parents, mentors, teachers, friends, God, all the above and many others. Along the way, there were (and are) people who believed in us and that belief helped us to believe in ourselves. When we stop, pause and reflect on where we began and where we are now and all those who’ve helped us and believed in us and then apply that same belief in others, the results can be (and are) amazing. Like all meaningful change, it has a beginning and middle but no end. It’s continuous.

“Believe in yourself and stop trying to convince others.” James De La Vega

Use words that encourage and inspire. Positive affirmations. A few examples like, “If I can, you can.” “You will succeed.” “You’re potential is endless.” “You’re more than capable.” “You’re smart and articulate.”

Assist them through the setbacks. I’ve discovered that few things in life have a trajectory that’s straight up. On the contrary, there are many issues from our choices that are often straight down. There are times when we ask, “What am I doing? Am I crazy for trying this? “What was I thinking?” “I should have asked for help?” Don’t let the negative thoughts get in the way. Bring them out. Talk about them with people you trust. Share your thoughts and then dismiss them. Vent! It’s healthy. Then continue with your encouragement and prayers. Caution: prayers work! Be careful for that which you pray. You might just receive it.

Encourage others to play it forward. Regardless of when and where I’m greeted by others, my reply is always, “I’m vertical, take nourishment and play it forward when God provides the opportunities.”

After a goal’s achieved, encourage others (and yourself) to establish and seek more goals and continue that pattern. I believe we have an obligation, or errand to help those around us; those who seek our help and are truly committed and enrolled in the process. What we don’t want to I do is become an enabler and weaken them emotionally, spiritually and physically. When we see others as better than they are or were and help them on their journey of self-realization and self-improvement it is one of the noblest things we can do for others. When they achieve success, it’s a win-win. Many, many others have done that for me and for you too, I suspect and often without us even knowing it. So…”Pass the salt and make a difference in all you choose to do. Make a person, place or thing a little better for your having been there.”

“Correction does much but encouragement does more.” Johan Wolfgang von Goethe

Becky Hammon was recently hired as the first female basketball coach in the National Basketball Association (NBA) by the San Antonio Spurs. She’s played professionally here in the U S and overseas for 17 years and begins her new position as an assistant coach next year.

In the Tuesday, August 12, 2014 edition of “USA Today Sports” an article written by Nancy Armour shares her exclusive interview with female basketball player Becky Hammon. “Even after all these years, Becky Hammon hears the voices in her ear,” she said. “The assistant coach at Colorado State University was constantly on Hammond telling her she was going to be the school’s first All-American. How she was going to do this. How she was going to do that,” she said. In the interview Becky Hammond said, “but when she started speaking all that, she started planting seeds. ’Yeah, maybe. Maybe I could do that if I worked really hard,’ Hammon said. “You have those people speaking really good things in your life and it grows and produces fruit later on,” she said. “But somebody had to initially plant those good seeds.”

”Hope and encouragement, especially hope, is probably one of the greatest things you can give another person,” Hammond said. “I mean, what a gift to allow that person to be able to dream, to be able to say, ‘Why not me?’ ‘Why couldn’t I be the first?’”

Hope is the thing that perches in the soul-and sings the tunes without the words-and never stops at all.”   Emily Dickinson

Life really IS like a roll of toilet paper. The closer to the end the faster it goes. When you leave this life, what will be your epitaph? What do you want others to say about you? How do you want to be remembered? When our time’s up, it’s up. No more make-ups or second chances. So…take time to be the person who others hear in their ears. Tell them how they’re going to do this and how they’re going to do that. Make the choice to become a planter of positive seeds then stand back and watch the ‘plant(s)’ grow. I know it works!!

This article was submitted by “Captain George”J Burk, USAF (Ret).Vietnam Veteran, Plane crash & burn survivor, motivational speaker, author & writer | www.georgeburk.com | gburk@georgeburk.com

Root Cause Analysis Training in South America – Chile Course Photos

Posted: August 25th, 2014 in Courses, Pictures

We held an on-site course in Santiago, Chile on July 30-31, 2014, with Piedad Colmenares as the TapRooT® Instructor. She sent us these photos of the class. Enjoy!

Barrick Santiago de Chile Julio 2014 -1

Barrick Santiago de Chile Julio 2014 -3

Barrick Santiago de Chile Julio 2014 -2

Interested in bringing root cause analysis training to your facility?

Click here to contact us for more information about our onsite training.

Monday Accident & Lessons Learned: OPG Safety Alert #259 – FATALITY DURING CONFINED SPACE ENTRY

Posted: August 25th, 2014 in Accidents, Current Events, Investigations, Pictures

 

FATALITY DURING CONFINED SPACE ENTRY

  • Two cylindrical foam sponge pads had been inserted in a riser guide tube to form a plug. Argon gas had been pumped into the 60 cm space between the two sponges as shielding gas for welding on the exterior of the riser guide tube.
  • After completion of the welding, a worker descended into the riser guide tube by rope access to remove the upper sponge. While inside, communication with the worker ceased.
  • A confined space attendant entered the riser guide tube to investigate. Finding his colleague unconscious, he called for rescue and then he too lost consciousness.
  • On being brought to the surface, the first worker received CPR; was taken to hospital; but died of suspected cardio-respiratory failure after 2 hours of descent into the space. The co-worker recovered.

 

NewImage

 

What Went Wrong?

  • Exposure to an oxygen-deficient atmosphere: The rope access team members (victim and co-worker) were unaware of the asphyxiation risk from the argon gas shielding.
  • Gas test: There was no gas test done immediately prior to the confined space entry. The act of removing the upper foam sponge itself could have released (additional) argon, so any prior test would not be meaningful.
  • Gas detectors: Portable gas detectors were carried, but inside a canvas bag. The co-worker did not hear any audible alarm from the gas detector when he descended into the space.
  • Evacuation time: It took 20 minutes to bring the victim to the deck after communication failed.

Corrective Actions and Recommendations

Lessons:

  • As a first step: assess whether the nature of the work absolutely justifies personnel entering the confined space.
  • Before confined space entry:
    - identify and communicate the risks to personnel carrying out the work
    - define requirements, roles and responsibilities to control, monitor and supervise the work
    - check gas presence; understand how the work itself may change the atmospheric conditions
    - ensure adequate ventilation, lighting, means of communication and escape
  • Ensure step by step work permits are issued and displayed for each work phase, together with specific job safety analyses
  • During confined space entry:
    - station a trained confined space attendant at the entrance to the space at all times
    - ensure that communication and rescue equipment and resources are readily available
    - carry and use portable/personal gas detectors throughout the activity 

ACTION

Review your yard confined space entry practice, keeping in mind the lessons learned from this incident.

safety alert number: 259 

OGP Safety Alerts http://info.ogp.org.uk/safety/

Disclaimer
 
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Monday Motivation: Bruce Lee

Posted: August 25th, 2014 in Pictures

 

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The successful warrior is the average man, with laser-like focus. ~ Bruce Lee

Weekly Wisdom for Process Quality & Root Cause Analysis

Posted: August 25th, 2014 in Wisdom Quote

Krumm

 

“There is more than one way to skin a cat – but it matters to the cat.”

- Doug Krumm

Friday Joke: Walk Lines for Those Under the Influence?

Posted: August 22nd, 2014 in Jokes, Pictures

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Or do they need better painter quality control?

Root Cause Analysis Training in Ohio – Dayton’s Local Attractions

Posted: August 21st, 2014 in Courses, Local Attractions

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Dayton, Ohio may seem like your average midwestern town, but look a little closer and you’ll find a life and personality all its own. Dayton is the home of the Wright Brothers, so the history of aviation permeates the town. It’s also got a strong arts, dining, and craft beer scene, with Warped Wing brewery located in Oregon Historic District. While you’re in town attending our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course this September 15-16, 2014, stop by a few of these restaurants and take a little bit of time to enjoy the fun Dayton has to offer:

 

Food

Voltzy’s Weiner World - Hot dogs, root beer, coneys, and burgers are the casual fare of this hometown joint.

The Paragon Supper Club - A great place to sit down for a nice steak dinner after the course.

Lucky’s Taproom - A fantastic selection of craft beer, including the local Warped Wing brand.

Slyder’s Tavern - Hailed as “the best burger in town” by locals.

Marion’s Piazza - Voted Dayton’s #1 pizza, this place has been around since 1965.

 

Activities

National Museum of the US Air Force - America’s oldest and largest military aviation museum in the world, with over 100 aircrafts to see and 11 exhibits separated by era.

Warped Wing Brewery - Stop by for a tasting at Dayton’s local brewery.

The Neon - Enjoy independent movies with a beer or cocktail at this eclectic movie theatre.

America’s Packard Museum - Located in the former Packard auto factory, this museum holds over 50 beautifully restored historical cars.

Riverscape MetroPark - Relax and unwind after the TapRooT® course with a stroll in the park along the Miami River.

Would you like to learn to find and fix the real root causes of problems in your workplace? Click here to register or find out more information: 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OH.

Throwback Thursday: Scotland

Posted: August 21st, 2014 in Pictures, Root Causes, TapRooT, Training

Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!

Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!

SnapChartExercise2

Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.

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