Root Cause Analysis Blog

 

Kevin McManus receives distinguished Fellows Award

Posted: May 24th, 2016 in Best Practice Presentations, Best Practice Presenters, Summit, TapRooT® Instructor, TapRooT® Instructor Profiles
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Kevin McManus

All of us at TapRooT® would like to extend our warmest congratulations to Kevin McManus who received The Fellows Award among 250 leaders in education and business at the 2016 IISE Honors & Awards Dinner held at the Disneyland Resort.

The Fellows Award recognizes outstanding leaders of the profession (IISE – Institute of Industrial & Systems Engineers) who have made significant nationally recognized contributions to Industrial engineering. A Fellow is the highest classification of IISE membership, and has been given to only 400 individuals globally.

Kevin was nominated and selected for his contributions to Industrial Engineering through his volunteer activities. He has been a supporter of IISE for more than 35 years.  He has written 200 articles for the IISE monthly publication; held workshops; spoke at their conferences; and taught as a guest professor at universities globally.  Kevin is an examiner for the National Baldrige Performance Excellence Award (previously the Malcolm Baldrige Quality Award), a position he has held for 16 years.

Kevin will be co-teaching Advanced Trending Techniques during 2016 Global TapRooT® Summit week (August 1 & 2, San Antonio, Texas) with Mark Paradies, System Improvements’ President.  He will also be presenting “What’s Holding You Back – Common Barriers to Process Excellence” and “Who Really Owns a Quality Defect” at the 2016 Global TapRooT® Summit August 3-5, 2016.

Congratulations, Kevin, on your incredible contributions and hard-earned accomplishments!

Weekly Wisdom: Change your thinking, change the outcome.

Posted: May 24th, 2016 in Wisdom Quote

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“We can’t solve problems by using the same kind of thinking we used when we created them.” – Albert Einstein

What does a bad day look like?

Posted: May 24th, 2016 in Accidents, Video

Near miss!

Monday Accident & Lessons Learned: The Cost of an Accident – BP Pays Out $56 Billion So Far

Posted: May 23rd, 2016 in Accidents, Current Events, Performance Improvement, Summit, Technically Speaking

The Wall Street Journal announced that BP incurred $56 Billion in expenses from the Deepwater Horizon explosion and spill. And the end is still not in sight.

BP’s CFO said “It’s impossible to come up with an estimate [of future costs].”

Of course, those costs don’t include the lives lost and the negative PR that the company has received. 

How much is a best in class process safety program worth? As BP’s CFO says …

It’s impossible to come up with an estimate.

If you would like to learn best practices to improve your safety performance and make your programs “best in class,” the at ten the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.

What? You say YOUR COMPANY CAN’T AFFORT IT? Can it afford $56 Billion? The investment in your safety program is a pittance compared with the costs of a major accident. Your company should put spending on safety improvement BEFORE other investments … especially in difficult times.

If you are a senior manager, don’t wait for your safety folks to ask to attend the Summit. Send them an e-mail. Tell them you are putting a team together to attend the Summit with you to learn best practices to prevent major accidents. Ask them who would be the best people to include on this team. Then get them all registered fot the Summit.

Remember, the Summit is GUARANTEED

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.

Wow! A guaranteed ROI. How can we be so sure that you will return to work with valuable ideas to implement? Because we’ve been hosting these Summits for over 20 years and we know the “best of the best” attend the Summit and we know the value of the ideas they share each year. We’ve heard about the improvements that Summit attendees have implemented. Being proactive is the key to avoiding $56 Billion dollar mistakes.

So don’t wait. Get your folks registered today at:

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

How Does Senior Leadership Affect RCA in Healthcare?

Posted: May 23rd, 2016 in Medical/Healthcare, Root Cause Analysis Tips
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Across industries, senior leadership has some level of impact on every process and system.

I attended the Ohio Association of Healthcare Quality (OAHQ) Conference in Columbus last week and gave a talk on this subject. In any industry there is always some level of impact that senior leadership has on every process and system. From their expectations for the staff through their desire for the organization and business, these expectations become the guidelines within which we work.

When I talk to healthcare professionals I always hear the positive and the negative (usually in reverse order), and it is very rare that anyone is only on one side or the other. There is usually a mix. Some of the things I hear about are as follows:

Negative Impact:

  1. Unreasonable expectations for timelines in determining root causes
  2. Not providing a charter or guideline that provides the responsibilities of the team and communicates the abilities of the team/team leader
  3. Messages communicated from the Administration do not match with the “reality” of our working environment
  4. Corrective Actions that are recommended are not always implemented or followed and are substituted with managements own ideas that are not in alignment with the findings

Positive Impact:

  1. Our team feels like we are provided the necessary support to gather what we need to gather to understand the event
  2. Management supports our efforts to implement corrective and preventative measures following an adverse outcome
  3. The organization is very much a proactive group who truly want and desire to make our systems the best they can be

Now, looking at this list, we truly see how these issues are polar in ways. Different organizations have the opposite opinions from their counterparts. This is to be expected as each organization is different.

Looking at these comments and thinking towards TapRooT® and our Root Cause Tree®/Dictionary, where would these issues (if found to be causal factors) show up in the analysis? Well there is one primary area where I believe these truly match:

Management System – How Policies and the Actions of the Management System Impact the System

Of course this is not the only area that could show up as every investigation is different but these most certainly could have impact. And in addition to that, when investigating events you have to look at the outcomes (not root causes necessarily) from previous similar events. This portion of the analysis will gather data that could lead you to multiple root causes:

Management System->Corrective Actions->Corrective Action NI or Trending NI: If it is found that previous corrective actions were never implemented, or were not as effective as they could be you might be led to and those decisions were directly related to management decisions to change alter or not follow-up to see if the actions worked.

Management System->SPAC Not Used->Enforcement and/or Accountability: When examining events, if it is found that due to a lack of support from senior leadership to uphold investigative charters or uphold the level of responsibility given to the investigative team, then this could most certainly be a Management System issue.

These are just a few examples of how past performance can impact the events you investigate today. My recommendation is to always talk to people in your Management System to understand their expectation and compare that expectation to the actual messages received and heard throughout the organization. Then compare those messages to what happened during the event analysis to assess the actual impact. You might be surprised at what you uncover.

If you would like to know more about the TapRooT® process and our investigative philosophy please contact me directly at skompski@taproot.com or attend one of our training courses held worldwide www.taproot.com/courses and learn how TapRooT can help you improve performance. Thank you for reading!

Monday Motivation: Get busy!

Posted: May 23rd, 2016 in Career Development, Career Development Tips, Wisdom Quote

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Research indicates that the happiest people are the busiest.  What’s the key to wanting to stay busy? Find justification for being busy; otherwise, we tend to remain idle.  Learn more.

Chris Vallee invites you to the Quality Track at the 2016 Global TapRooT® Summit

Posted: May 20th, 2016 in Best Practice Presentations, Best Practice Presenters, Summit, Summit Videos, Video, Video Depot

The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Quality Track. Come to the Summit and maximize improvement at your company!


Starring Chris Vallee. Produced by Benna Dortch.

 

Interested in the Investigation Track? Learn about it here!

Interested in the Asset Optimization Track? Learn about it here!

Interested in the Safety Track? Learn about it here!

We can’t wait to go to Connecticut!

Posted: May 20th, 2016 in Courses, Local Attractions

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Like many things in your professional life, there’s no black and white when it comes to making bold career-changing decisions, but this training might just be the thing you need to breathe new life into your career and open up your opportunities!

Learn to analyze problems, identify causes and stop them from happening again.

TapRooT® is not just a root cause analysis system but is a complete investigation process that helps investigators collect the information they need to find root causes. This course offers all of the TapRooT® essential techniques and information you need to conduct a root cause analysis.

There’s so much to do in Hartford! You can bring the family during summer break and check out the Mark Twain Museum or the Connecticut Science Center or enjoy some downtime strolling Elizabeth Park Conservancy with dinner at Salute or Max Downtown.

We can’t wait to head up to the Northeast United States to Hartford, Connecticut!

LEARN MORE

Common Wind Turbine Equipment Failure Modes

Posted: May 19th, 2016 in Equipment/Equifactor®

Turbine failure

I found this article discussing some common failure modes for wind turbines. While not completely new, it does give you some things to consider when performing maintenance on turbine equipment.

Which Pre-Summit Course Should You Choose???

Posted: May 19th, 2016 in Courses, Pictures, Summit, TapRooT

Each year Mark Paradies, President of System Improvements, picks courses to hold prior to the TapRooT® Summit. He chooses the courses to help TapRooT® Users learn even more about root cause analysis and performance improvement. :lessons that go beyond the standard 2-Day and 5-Day TapRooT® Courses.

Chris

What are the courses scheduled for August 1-2?

 

WHICH OF THESE IS RIGHT FOR YOU?

I’ll provide some background on each course so that you can choose the course that will provide the knowledge you need to help your facility reach the next level in improving safety, quality, patient safety, root cause analysis, trending, or equipment reliability.

 

TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis

Are you responsible for equipment troubleshooting and root cause analysis?

Do you need to improve your plant’s equipment reliability?

This course has been completely redeveloped and focused on solving equipment problems. Ken Reed, Vice President at System Improvements and lead for Equifactor® will be one of the instructors.

The course is equipment focused, but you don’t have to be an engineer to attend. Anyone who looks into the causes of equipment failures as part of:

 

  • equipment troubleshooting
  • safety investigations
  • environmental releases
  • quality issues

can benefit from this systematic approach to discovering why equipment failures occur.

The course teaches techniques for equipment troubleshooting developed by equipment expert Heinz Bloch. It combines those techniques with the world-renowned TapRooT® Root Cause Analysis System to make a best-of-class system for finding the causes of equipment troubles.

The text for this course is the new book: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability

 

2-Day TapRooT® Root Cause Analysis Training (The revised course)

The 2-day TapRooT® Course has been around for over 20 years. This year we decided to go back to the basics and focus the course on performing investigations of low-to-medium risk incidents. We developed a new 50 page book (Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents) that goes with the course. 

The course teaches the essential TapRooT® Techniques in an easy to use new simplified 5-Step Investigation Process. You will learn to:

  • Use the SnapCharT® Diagram to collect and organize information and understand what happened.
  • Identify Causal Factors using the new, simplified three question method 
  • Use Safeguard Analysis to help quickly identify Causal Factors.
  • Find root causes using the latest TapRooT® Root Cause Tree® and Dictionary.
  • Develop effective but simple fixes to improve performance.
  • Identify Generic Causes if you want to go beyond the simple process.

You will practice each of these skills to become proficient. In this new course you get more practice than you did in the old course. And each team will take one of their own incidents through the process to find root causes and develop effective fixes.

If you want to learn to use a state-of-the-art root cause analysis process to perform quick investigations of low-to-moderate risk incidents, THIS COURSE IS FOR YOU.

If you are a Certified TapRooT® Instructor, you may want to attend this course to see all the new things you will be teaching (including new animated examples).

 

Understanding and Stopping Human Error

Dr. Joel Haight, a TapRooT® User since 1991 and a Professor at the University of Pittsburgh, will teach you to analyze and understand human error. This course teaches many of the techniques covered in a university human factors course in a modified short course format.

Topics covered in the course include:

  • Basic understanding of visual, auditory, tactile and vestibular senses.
  • Understanding reaction time and decision making.
  • Understanding physical human performance (ergonomics).
  • Factors that influence human error (stress, fatigue, equipment design,/automation, training, and social factors)
  • Nuclear industry human performance tools (attention to detail, questioning attitude, and error traps/precursors, peer checking, 3-way communication, procedure use, peacekeeping, pre-job brief/SAFER, post-job brief, observation/coaching, STAR, and time out)
  • Practical questions for incident investigators
  • Quantitative/Qualitative methods (THERPS, MAPPS, OAT, and FTA)

If you are interested in an overview of techniques focussed on human error to augment your standard incident investigations, this course is for you.

To continue to the other course descriptions click on the link MORE below.

(more…)

TapRooT® Around the World: Onsite course at Geisinger Medical

Posted: May 19th, 2016 in Courses, Pictures

Thanks to Tommy Garnett for sending pictures of the recent Onsite course at Geisinger Medical.

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Interested in bringing TapRooT® to your company for an Onsite course? Click here for more details.

Root Cause Analysis Tip: Use the Dictionary!

Posted: May 19th, 2016 in Courses, Pictures, Root Cause Analysis Tips, Root Causes, TapRooT

TapRooT® Users have more than a root cause analysis tool. They have an investigation and root cause analysis system.

The TapRooT® System does more than root cause analysis. It helps you investigate the problem, collect and organize the information about what happened. Identify all the Causal Factors and then find their root causes. Finally, it helps you develop effective fixes.

But even that isn’t all that the TapRooT® System does. It helps companies TREND their problem data to spot areas needing improvement and measure performance.

One key to all this “functionality” is the systematic processes built into the TapRooT® System. One of those systematic processes is the Root Cause Tree® and Dictionary.

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The Root Cause Tree® Dictionary is a detailed set of questions that helps you consistently identify root causes using the evidence you collected and organized on your SnapCharT®.

For each node on the TapRooT® Root Cause Tree® Diagram, there is a set of questions that define that node. If you get a yes for any of those questions, it indicates that you should continue down that path to see if there is an applicable root cause. Atr the root cause level, you answer the questions to see if you have the evidence you need to identify a problem that needs fixing (needs improvement).

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For example, to determine if the root cause “hot/cold” under the Work Environment Near Root Cause under the Human Engineering Basic Cause Category is a root cause, you would answer the questions (shown in the Dictionary above):

  1. Was an issue cause by excessive exposure of personnel to hot or cold environments (for example, heat exhaustion or numbness from the cold)?
  2. Did hurrying to get out of an excessively hot or cold environment contribute to the issue?
  3. Did workers have trouble feeling items because gloves were worn to protect them from cold or hot temperatures?

If you get a “Yes” then you have a problem to solve.

How do you solve it? You use Safeguards Analysis and the Corrective Action Helper® Guide. Attend one of our TapRooT® Root Cause Analysis Courses to learn all the secrets of the advanced TapRooT® Root Cause Analysis System.

The TapRooT® Root Cause Tree® Dictionary provides a common root cause analysis language for your investigators. The Dictionary helps the investigators consistently find root causes using their investigation evidence, This makes for consistent root cause analysis identification and the ability to trend the results.

The expert systems built into the Root Cause Tree® Diagram and Dictionary expand the number of root causes that investigators look for and helps investigators identify root causes that they previously would have overlooked. This helps companies more quickly improve performance by solving human performance issues that previously would NOT have been identified and, therefore, would not have been fixed.

Are you using a tool or a system?

If you need the most advanced root cause analysis system, attend one of our public TapRooT® Courses. Here are a few that are coming up in the next six months:

2-Day TapRooT® Root Cause Analysis Training

 Dublin, Ireland      June 8-9, 2016

Pittsburgh, PA   June 20-21, 2016

Hartford, CT       July 13-14, 2016

San Antonio, TX   August, 1-2, 2016

Copenhagen, Denmark September 22-23, 2016

 

2-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Training

San Antonio, TX   August 1-2, 2016

 

5-Day TapRooT® Advanced Root Cause Analysis Training

Houston, TX           June 13-17, 2016

Gatlinburg, TN          June 20-24, 2016

Niagara Falls, Canada July 11-15, 2016

Monterrey, Mexico   August 22-26, 2016

Mumbai, India   August 29 – September 2, 2016

Aberdeen, Scotland  September 19-23, 2016

For the complete list of current courses held around the world, see: http://www.taproot.com/store/Courses/.

To hold a course at your site, contact us by CLICKING HERE.

(Note: Copyrighted material shown above is used by permission of System Improvements.)

TapRooT® Around the World: 2-Day course in Dallas

Posted: May 18th, 2016 in Courses, Pictures

Take a look at these pictures from a recent 2-Day TapRooT® course in Dallas.

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Register for a TapRooT® near you! Click here to see all Public Course options around the world.

Using TapRooT® for Audits

Posted: May 18th, 2016 in Courses, Quality, Root Cause Analysis Tips, Summit

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Happy Wednesday, and welcome to this week’s root cause analysis column.

This week I wanted to share an excerpt from our new book which will be coming out on August 1st, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. I hope this small part of the book will help you start to think about being more proactive.

“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?

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.

Would you like to be one of the first people to get the new book? If so, attend our new course, TapRooT® for Audits, at the Global TapRooT® Summit, August 1-2, in San Antonio. To register for the course (and the summit on August 3-5, click HERE

What does a bad day look like?

Posted: May 17th, 2016 in Accidents, Human Performance

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A lot of bad days start with bad decisions.  For example, when you decide to take a selfie with a 4-foot rattlesnake… (Read story.)

Weekly Wisdom: Create Your Own Happiness.

Posted: May 17th, 2016 in Wisdom Quote

happiness

“Happiness is not something readymade. It comes from your own actions.” -Dalai Lama

About Us

Posted: May 17th, 2016 in TapRooT

About Us

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When the Message does not Communicate the Message in Healthcare

Posted: May 16th, 2016 in Medical/Healthcare, Root Causes

This week’s article is not so much based on RCA principles but on the decisions that senior leaders make and the consequences of those actions. I always highlight from an RCA perspective the impact of the messages and communications from senior leadership down through the organization and the possible negative consequences. But this takes the cake… or the donut, if you will.

Saw an article today about the University of North Carolina’s decision to remove the name of their newest (7-month-old) corporate sponsor off of their UNC Children’s Clinic. That corporate sponsor… wait for it…

“Krispy Kreme”

Now, I am surely no marketing genius (my strengths are more in the training and RCA world) but could anyone associated with the organization see past the $$$$ to know that this was not a good idea? In today’s money driven society there are reasons that sponsors are invited, and in most cases these are due to a lack of funding and a desire to continue doing good deeds and good work. But sometimes the word “NO” is very much underutilized.

What message was sent to all those Doctors and Nurses? To all the parents bringing their children for care to the clinic? Is it the health, care and safety of their young loved ones? Or is it something else? I certainly don’t want to be treated for a clogged artery in the “Beef it’s What’s For Dinner Cath lab”, or be treated for a peanut allergy in the “Peanut M & M’s Allergy Center.”

Now if you read the full article the name was tied to a fund-raising race and the Clinic and UNC’s dedication to it. But always remember that what you perceive the message to be may not be what is received. I have worked with investigations where too many times the Administration says one thing and a totally different message is received. From an RCA perspective in the diagram below you will see that the Administration/Management interview circle is dotted… in TapRooT® circles that means an assumption or unknown.  

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From a data gathering perspective, this means that I need to compare what Administration/Management believes/says/communicates is what is understood by the masses. To understand if the true message has reached those who need it. And in the case of this article I believe that they totally missed the mark with all the right intentions. Let me know what you believe in the comments below.

If you would like to know more about TapRooT® or if you have any questions you can contact me at skompski@taproot.com or you can find out about our public course offerings at:

www.taproot.com/courses.

 

Monday Accident & Lessons Learned: What Not To Do During Flooding

Posted: May 16th, 2016 in Accidents, Human Performance, Video

The following is a video of a fatal accident. The vehicle drove around a tow truck sent to block the underpass and past a worker waiving his arms to stop her. She drove into water about 17 feet deep. DON’T watch the video if it will upset you. For others, hopefully you can use this to teach others to avoid standing water during flooding.

Monday Motivation: Courage

Posted: May 16th, 2016 in Career Development, Career Development Tips, Wisdom Quote

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True story! “You get in life what you have the courage to ask for.” Other people do not really think about what you need. Whether it’s a boss, co-worker, spouse or friend, if you feel frustrated, overwhelmed or resentful of the relationship it is usually because you are not asking enough of the relationship. People are not mind readers, and they miss subtle cues.

How can you practice courage? Be specific about what your unmet expectations are, “Would you please do x by y?” If you are allowing others to encroach on your personal boundaries, you are complicit in it. Set boundaries — and be clear about what you can’t tolerate. “When you x, I feel y.” Don’t try to be all things to all people. “I’m sorry, I’m not available to help you with x today.”

No need to act in an aggressive or entitled way to get what you want. Courage is a manner of conveying that you know your worth, and while you may not always get what you asked for, you will command more respect than if you had not been bold enough to make your request.

You Still Have a Chance to Win if You Register Now!

Posted: May 16th, 2016 in Summit

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Register now! It only takes one ticket to win!

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We are giving away an Fitbit Blaze Smart Fitness Watch to the 2016 Global TapRooT® Summit early bird prize drawing winner and you still have a chance to win!

Here’s how it works: Register after May 15 but on or before June 15 and receive ONE ticket in the drawing.

The early registration drawing will be held at the Kickoff Session, Wednesday, August 3, 2016 at 8:00 a.m. at The Westin Riverwalk (You must be present to win!). This drawing is in addition to the other prize giveaways we have planned for the 2016 Summit.

If you are planning to register for the Summit, don’t delay!

REGISTER NOW for the 2016 Global TapRooT® Summit!

Heavy Equipment Maintenance Tips

Posted: May 13th, 2016 in Equipment/Equifactor®

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I saw this entry today, highlighting some great ideas on maintaining your heavy equipment. I think what caught my eye was the very first tip: “Stay on top of large machinery operator training.” Any plan to keep your equipment operating at top performance must include the operators and maintenance personnel. It doesn’t matter if you have the very best maintenance plans and schedules if the operators don’t understand how to properly start, operate, and secure the equipment. And maintenance techs must also be properly trained; otherwise, the best preventative maintenance plan will be poorly implemented.
Training of your staff should ALWAYS be a top priority!

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