Root Cause Analysis Blog

There are eight great pre-Summit courses to pick from on April 23-24, 2007, in San Antonio, Texas. They are:

• Getting the Most from Your TapRooT® Software
• TapRooT®/Equifactor® Equipment Failure Root Cause Analysis
• TapRooT® Incident Investigation & Root Cause Analysis
• Advanced Trending Techniques
• Stopping Human Error
• Risk Analysis & Risk Management
• How to Interview & Gather Evidence
• Innovation & Creative Solutions

What one should you attend? That depends on which one will provide you and your company with the most value (ROI). To help you decide, I’ve provided a short course description for each course and some ideas how each course could help you improve performance at your site.

Just click on the “continue” link below to learn more…

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Are you looking to improve the performance of your equipment? Are you tired of seeing the same equipment failures happening over and over again? Would you like to get out of the “break and fix” cycle at your facility? Try applying the easy to use Equifactor® Equipment Troubleshooting module of the TapRooT® Root Cause Analysis System to your machinery problems. Equifactor®, in concert with the rest of the TapRooT® System, will help you find and fix the real root causes of those failures, instead of just fixing the same symptoms time and time again.

We will be holding Equifactor® courses throughout the world in 2007:

Jan 29-31 - Galveston, TX
Feb 26-28 - Halifax, Nova Scotia, Canada
Apr 11-13 - Gothenburg, Sweden
April 23-24 - San Antonio, TX (Pre-Summit course)
May 9-11 - Calgary, Alberta, Canada
June 13-15 - Aberdeen, Scotland
Jul 25-27 - Dallas, TX
Aug 8-10 - Lake Tahoe, NV
Nov 19-21 - Edmonton, Alberta, Canada
Nov 28-30 - New Orleans, Louisiana

Get those travel budgets in place now! And don’t forget about the Summit in San Antonio, TX April 25-28 (during the Fiesta!!).

Yes - I’m on the road teaching with Ken Reed and Tommy Garnett.

We deserve hardship pay. It was partly cloudy and in the low 60’s today. Too cool to swim in the pool today… Eat your heart out Canadian TapRooT® Users!

The course is going great!

Here’s a picture of Ken explaining a point to attendees.

Ken and Tommy deciding who teaches next…

Here I am teaching…

Here are pictures of students working on examples and discussing concepts in groups…

The day-1 course critiques say that the students are learning what they need to find the real root causes of accident, incidents, quality issues, equipment problems, environmental incidents, …

If you are interested in attending TapRooT® Training and learning the latest in root cause analysis, see:

http://www.taproot.com/courses.php

2007 is closer than you think. Check out our schedule of courses around the world and register for January courses at http://www.taproot.com/courses.php.

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What’s it like to be in a TapRooT® Course?

The critiques tell us that it is a very positive experience.

Most people find it hard to believe how much they have learned in 5 days of a 5-Day TapRooT® Course..

Many come to the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training wondering how we will keep them busy for 5 days. Will they be bored to tears? Will the instructors know what they are talking about?

The answers are:

- You won’t be bored at all. The course is described by attendees as being action packed - very busy! Time seems to fly by. Many tell us that they wished they had more time to absorb all that we teach even though every major learning objective is reinforced with a hands-on exercise.

- The instructors are very knowledgeable. They have extensive experience doing investigations. Attendees report they are pleasantly surprised by the extensive knowledge of the instructors and the attitude and enthusiasm they bring to the course.

I’ve had investigators with 20 years of experience come to the course who were surprised by how much they learned from the course. Their only comment - THEY WISHED THEY HAD CONE SOONER.

Here are some class photos from the first day of the course in Aberdeen:

Team discussed incident.

Team builds their SnapCharT®

More discussion around a SnapCharT®.

Another team discussing an incident.

Barry explaining a point to team members.

And don’t forget - many courses are held in resort locations. (Unfortunately - Aberdeen in November really doesn’t qualify as a peak season for a resort). So plan to come early and stay a few days after the course is over.

To see the locations for upcoming courses, go to:

http://www.taproot.com/courses.php

Over the next two days (Wednesday/Thursday) I’ll be teaching a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Class at Woodland Grange’s Facilities in England.

This is the first time that System Improvements has teamed up with Woodland Grange to teach TapRooT® in the UK.

I am impressed with Woodland Grange’s facilities in Leamington Spa, England. They are about a 20 minute taxi ride south of the airport in Birmingham, England - so travel arrangements are fairly easy from anywhere in Europe.

The staff is friendly and very competent and the rooms are quite nice. And the room rate includes all meals (I just ate a wonderful supper from an excellent menu). And they have an on-site pub.

Nearby is Warwick Castle. If you have an extra day, it is well worth the visit.

Also nearby is Stratford-upon-Avon - The birthplace of William Shakespeare.

So if you are looking for a place to attend a course in Europe next year, I highly recommend this location.

The 2007 courses scheduled for Woodland Grange’s facilities in Leamington Spa include:

2-Day TapRooT® Incident Investigation and Root Cause Analysis Course - January 29-30.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training - June 18-22 and November 19-23.

Hope you or someone from your staff can make a course.

Here’s a note for people at Licensed TapRooT® Sites. Do you know:

• About the TapRooT® Licensed Client Discount for public 5-Day TapRooT® Courses?
• How to get an additional multi-attendee discount?
• The benefits of attending a 5-Day Course?

First, the licensed client discount. The regular tuition for a 5-Day TapRooT® Course is $2,295 US Dollars. But people from licensed sites can attend for just $1,795. That’s a $500 savings.

Second, if you sign up 3 or more people at one time, you can get an additional $100 off for each attendee. So their tuition would be only $1,695 each.

Third, here are the benefits of attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. People attending the 5-Day TapRooT® Course have these advantages over those who just attend just the 2-Day TapRooT® Course:

• They get much more practice with the software and come away with an excellent understanding of how to apply it when investigating an incident. This improves the efficiency and consistency of their investigations.
• They learn about the optional TapRooT® Techniques that aren’t taught in the 2-Day: Change Analysis, Equifactor®, and CHAP. This helps them solve especially difficult equipment and human performance problems more creatively.
• They get much more practice with the standard TapRooT® Techniques (SnapCharT® and the Root Cause Tree®) and with Safeguards Analysis. This helps make them be more efficient and effective when performing an investigation.
• They learn much more about improving human performance and changing behavior. This helps them tackle the most challenging investigations stemming from human errors. information and more accurate information when they perform interviews.
• They learn how all the TapRooT® Techniques work together in an investigation process which will help them feel confident that they can lead even difficult investigations.
• They learn more about using the TapRooT® System proactively to improve performance. They can help your company become more proactive in solving problems by seeing and fixing problems before they can become accidents and incidents.

So if you know people that frequently lead difficult investigations or people who need a refresher from their 2-Day TapRooT® Course, you should get them registered for the 5-Day TapRooT® Course. They will come away with the knowledge required to be a TapRooT® Champion at their site. I guarantee it will be money well spent.

To see the list of upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses, see:

http://www.taproot.com/courses.php#c1

Best Regards,

Mark

San Antonio offers the world to its visitors . . . and TapRooT® Training in October is a perfect excuse to be one!

If you appreciate culture and history, San Antonio’s Market Square is an ideal representation of preserving the City’s Spanish and Mexican culture for present and future generations. And who can think of San Antonio without thinking of The Alamo? A visit to The Alamo’s Shrine and Long Barrack Museum will also introduce you to the rich heritage of the City.

Just around the corner from The Alamo is the Rivercenter Mall (located on San Antonio’s famous River Walk). The Mall offers 125 stores, dining and entertainment. Register for a free membership in the Concierge Club and receive a free gift plus special values. (Visit The Shops at LaCantera and North Star Mall for other upscale shopping experiences!) While you are at the Rivercenter Mall, you can purchase tickets for a boat tour (provided by Rio San Antonio Cruises) or you may choose to enjoy the natural beauty of the “Paseo del Rio” (Walk of the River) by foot.

You may also want to visit The King William Historic District which covers a 25 square block area and is Texas’ first Historic Neighborhood District. In the King William area you’ll find the Blue Star Arts Complex, a unique group of contemporary and non-traditional art studios and galleries.

You will be delighted at your choices of restaurants. Chuys, Biga on the Banks, EZ’s Brick Oven and Grill and, for Texas-sized portions, Lulu’s Bakery & Cafe are just a few recommended to me by a friend and local resident.

Arrive in San Antonio a day or two early, and you’ll have time to spend at your choice of several popular tourist attractions including:

SeaWorld San Antonio,

Six Flags Fiesta Texas, and the

San Antonio Zoo

And don’t leave the Alamo City without a final spectacular view from the 750-foot high deck of The Tower of the Americas.

Stay tuned . . .the 2007 TapRooT® Summit will also be held in San Antonio, and I’ve got some wonderful travel ideas to share with you about this exciting event in my upcoming posts.

I’ve been away for a few weeks, visiting our Aussie neighbors. Capability Resources, one of our new partners in Australia, sponsored a 3-Day Equifactor® course in Singleton, NSW, just a few hours north of Sydney. The course was a great success, and I had the opportunity to meet equipment operators from several different segments of the mining and drilling industries.

Amazingly enough, the southern hemisphere has many of the same attributes we see here in the north. Highly safety-oriented, hard-working people, with great attidudes (and cool regional accents!). Unfortunately, they also have many of the same problems: equipment operated beyond its intended design, people making honest mistakes while trying to do the “right” thing, poorly analyzed “root causes” of equipment failures, and “break and fix” repair strategies.

Equifactor® and TapRooT® are an excellent complement to the Australian mining industry. Their high-volume and high-tech mining operations demand highly reliable equipment operation, and Equifactor® is an obvious choice for their troubleshooting toolboxes.

Thanks to Greg, Peter, and Ross for a truly enjoyable trip. I look forward to working with them again in Singapore in November!

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BP shuts down a pipeline that feeds 400,000 barrels per day of crude oil to the Trans-Alaska pipeline and crude prices shoot up 3%. This could translate to a 5¢ to 10¢ per gallon increase at the pump.

We all know that the price of oil effects the economy, but who would have guessed that equipment reliability (system integrity) on a 20 mile long pipe would impact the whole US (and thereby the global) economy?

As production capacity and the world economy get more closely linked, the ability to keep everything functioning smoothly (reliably) becomes more and more important. That’s why tools like Equifactor® and TapRooT® are used by industry leaders to troubleshoot and understand the root causes of equipment problems and improve equipment reliability.

To learn more about equipment troubleshooting and root cause analysis, attend a TapRooT®/Equifactor® Course. For more information see:

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

San Antonio, TX October 11-13,2006

Edmonton, Alberta November 20-22

Dubai, UAE November 28-30

Charleston, SC December 6-8

Don’t wait until reliability problems at your plant impact the global economy. Attend a course and learn how the combination of TapRooT® and Equifactor® can help you use advanced equipment troubleshooting and root cause analysis to improve equipment reliability.

SKF is sponsoring two more Equifactor® Courses in 2006.

2-Day Equifactor® - UTRECHT, The Netherlands - September 14-15, 2006

The first is a 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course that will be held at SKF’s facilities in Utrecht, The Netherlands. This is a special version of the Equifactor® Course that concentrates on Equipment Troubleshooting, understanding what happened using SnapCharT®, and using the Root Cause Tree® to identify the root causes of human errors and equipment failures. This course includes an Individual User version of the TapRooT® Software for each attendee (a $1495 value without the class). This software includes computerized versions of Heinz Bloch’s equipment troubleshooting tables. Course attendees also get a copy of Heinz Bloch’s book, Machinery Troubleshooting and Failure Analysis (a $115 value) and a copy of the TapRooT® Book (a $195 dollar value). The course cost is $1690 US Dollars (or $1190 US Dollars for people attending from a company that has a TapRooT® Software License). E-mail info@taproot.com to register for this special course.

3-Day Equifactor® - DUBAI, UAE - November 27-29, 2006



The 3-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course that will be held at SKF’s facilities in Dubai, UAE. This 3-Day version of the Equifactor® Course includes everything in the regular 2-Day TapRooT® Course plus a day that concentrates on Equipment Troubleshooting. This course includes an Individual User version of the TapRooT® Software for each attendee (a $1495 value without the class). This software includes computerized versions of Heinz Bloch’s equipment troubleshooting tables. Course attendees also get a copy of Heinz Bloch’s book, Machinery Troubleshooting and Failure Analysis (a $115 value) and a copy of the TapRooT® Book (a $195 dollar value). The course cost is $1890 US Dollars (or $1390 US Dollars for people attending from a company that has a TapRooT® Software License). E-mail info@taproot.com to register for this special course.

MOVED FROM MANCHESTER TO WOODLAND GRANGE’S FACILITIES IN LEAMINGTON SPA



Woodland Grange (http://www.wgrange.com/), one of the UK’s most respected providers of management and safety training, is partnering with System Improvements to provide the 2-Day and 5-Day TapRooT® Courses in England.

The first course will be a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course that will be held on November 8-9 at their facilities in Leamington Spa, England.

Woodland Grange’s facilities are great! See:

http://www.wgrange.com/experience/guests.php

And the first course will be taught by Mark Paradies, founder and President of System Improvements and one creators of the TapRooT® System.

Register for this course at the TapRooT® web site:

http://www.taproot.com/store.php?e=129

Don’t wait. Space in this course is limited. Register today.

This is the busiest summer that we’ve ever had.

Despite expanding our staff of instructors, we’ve had a hard time accommodating all the root cause analysis course requests. The fall schedule is already starting to fill up. So if you are thinking about having on-site TapRooT® Courses at your facility during 2006,

PLAN AHEAD AND CALL NOW!

Linda Unger, Ken Reed, Ed Skompski, or I (Mark Paradies) will be glad to help you get a course set up. Just call 865-539-2139. Or e-mail us here.

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Interested in troubleshooting equipment failures and analyzing their root causes?

Live in Europe?

Then you should start planning to attend the special 2-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting & Root Cause Analysis Course that is being sponsored by SKF (and held at their facilities) in Utrecht City, The Netherlands on September 14-15, 2006.

This course isn’t on our registration pages yet, so if you want to register now you will have to call our offices in the US at 865-539-2139 or use the e-mail link.

The cost for this 2-Day Equifactor(R) Course is $1690 US Dollars.

This price includes:

1. An individual user version of the TapRooT(R) Software (priced at $1495 without the course).
2. Heinz Bloch’s book - Machinery Failure Analysis and Troubleshooting (a $115 value) - and
3. The TapRooT(R) Book (a $195 value) by Mark Paradies & Linda Unger.

That’s $1805 of software and books in a course that only costs $1690. What a deal!

Space in the course is limited so register by phone or e-mail today.

click to open (pdf)

Would you be interested in sending someone to a Public TapRooT(R) Root Cause Analysis Course (probably a 5-Day) in South Africa or Singapore?

Let me know by sending me an e-mail. If we get enough response, we’ll hold one later this year.

Thanks

Mark

You won’t get this one unless you have attended a TapRooT(R) Course.

VACATION & GREAT ROOT CAUSE ANALYSIS TRAINING

Remember your SUMMER VACATION!

Combine great root cause analysis training with an excellent location.

Consider …

2-Day in Virginia Beach - June 5-6 - Recently saw Virginia Beach on a list of best economical vacation sites with a great beach.

5-Day in Niagara Falls, Canada - June 5-9 - Honeymoon or just look at the falls. Plus there are casinos and winery tours.

5-Day in San Antonio - June 12-16 - Riverwalk is great!

5-Day in Seattle - July 31 - August 4 - August is great weather in Seattle … a great city!

5-Day in Amsterdam - September 11-15 - Amsterdam is definitely different!

2-Day in Prauge, Czech Republic - September 18-19 - A great place to spend 2 days in late Summer!

Here’s the complete Summer TapRooT(R) Training schedule…

http://www.taproot.com/courses.php

I’m in Gothenburg, Sweden teaching a 3-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting and Root Cause Failure Analysis Course that is co-sponsored by SKF. More than half of the students in the course are SKF manufacturing, customer service, and application design engineers - a really smart bunch of people. It’s day 2 of a 3 day course.

It really is humbling teaching root cause analysis to people who know so much about bearings and equipment. But as usual, the TapRooT(R) System helps even experts do better root cause analysis.

The TapRooT(R) System “expands the universe” of potential ideas for correcting serious problems by giving experts additional ideas of potential root causes. And I see this happen in all kinds of industries all around the world.

I think that’s why it is such a good job being a TapRooT(R) Instructor. TapRooT(R) comes through in every case to help experienced and inexperienced investigators find root causes that the previously would have overlooked.

Another strength of the TapRooT(R) System that comes across in this course is the ability to analyze the causes of equipment problems that are causes by human performance of the operators, installers, or maintainers. Often machinery experts know an amazing amount about the engineering of the machine. But they really appreciate the root cause analysis assistance they get analyzing human performance problems.

Tomorrow they get the Equifactor(R) part of the class and I really look forward to the “lightbubs turning on” as they realize how advanced root cause analysis and advanced equipment troubleshooting fit together.

If you have already attended the 5-Day TapRooT(R) Course but you would like to learn MORE advanced investigation and root cause analysis skills, what should you do?

Attend the Advanced Investigation Skills Track at the TapRooT(R) Summit on April 5-8, 2006, in Gatlinburg, TN.

First, you can attend the following sessions to provide advanced root cause analysis and incident investigation skills:

• Investigation/Corrective Action Best Practices
• Best Practices for Managing Investigations with Potential for Litigation
• Innovative Thinking and Creative Corrective Actions
• Evaluating the Effectiveness of Your Investigations
• Analyzing Fatigue as a Cause of Errors
• Best Practices for Fast Analysis of Small Problems
• New SnapCharT(R) Software

You will also hear the following Keynote Speakers and Sessions:

• Panel Discussion - What is the Most Important Factor in Leading an Investigation
• Mike Kelley - VP, TODCO - A Corporate Vision for Performance Improvement
• Bob Nelson - Guru of Rewards - Rewards, The Secret of Success
• Mark Paradies - President of System Improvements - Getting Beyond Slips, Lapses, Mistakes, and Latent Errors
• Jim Whiting - Principal, risk@workplaces - Changing the Way North Americans Manage Safety
• Mike Durant - Blackhawk Down Pilot - In the Company of Heroes
• Vincent Phipps - TLC LLC - Better Communications to Improve Safety, Quality, Productivity, and Morale!

And if you want even more, attend the pre-Summit Course (April 3-4) titled “How to Interview and Gather Evidence“.

This special opportunity only happens once this year so don’t miss your chance, register today!

There’s the:

5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Training

2-Day TapRooT(R) Incident Investigation and Root Cause Analysis Course

3-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting and Root Cause Failure Analysis Course

What Course should you attend?

Read this page at the TapRooT(R) Web Site to get a better idea:

http://www.taproot.com/about.php?s=pickcrs

Question 1: Is this an accident or an “on-purpose”?

Question 2: Will this truck have future equipment reliability problems?

Lesson Learned:

If your root cause analysis tools don’t help you look at equipment problems caused by human performance, you are probably missing a MAJORITY of the root causes.

That is why TapRooT(R) and Equifactor(R) are such a powerful combination.

Equifactor(R) - the best equipment troubleshooting tools from Heinz Bloch.

TapRooT(R) - the best human performance troubleshooting and root cause analysis system from System Improvements.

If you want to find the real root causes of equipment failures, then the 3-Day TapRooT(R)/Equifactor(R) Course is the root cause failure analysis course that you must attend.

Here’s a list of upcoming TapRooT(R)/Equifactor(R) Courses:

2-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting & Root Cause Analysis Course

April 3-4 Gatlinburg, Tennessee

3-Day TapRooT(R)/Equifactor Equipment Troubleshooting & Root Cause Failure Analysis Course



March 15-17 Brussels, Belgium

May 3-5 Houston, Texas

Meet Mark Paradies, Co-Creator of the TapRooT(R) System, at the IOSH Conference in London on March 13-14.

Mark will be representing TapRooT(R) in booth 131 in the exhibit area.

Of course, if you have the time, it would be much better to attend one of the courses Mark is teaching in Europe in March:

Aberdeen, Scotland - March 6-10, 2006

5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Course

Brussels, Belgium - March 15-16

2-Day TapRooT(R) Incident Investigation & Root Cause Analysis Course

Brussels, Belgium - March 15-17

3-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting & Root Cause Failure Analysis Course

If you are in Europe, try to get to one of these courses.

If your company has facilities in Europe, recommend that they attend this outstanding root cause analysis training with the special opportunity to be taught by one of the co-creators of the TapRooT(R) System.

Creative Solutions

Do you have repeat incidents?

Did you try the same corrective action that you put in place last time, and it still didn’t work?

How do we break through the mindset, “This is the way we’ve always done it?”

Maybe you need some help… Here is a practical idea.

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If you are already planning to attend a 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Course, register NOW and get the lower 2005 price and save $100.

As of April 1, 2006, the 5-Day Course price will increase to $2,295.

There will still be a $500 discount for previous 2-Day or 3-Day Course attendees who attend a 5-Day Course. Also, attendees from licensed sites will also still receive the $500 discount.

Yes, we teach TapRooT(R) all over the world in all types of cultures.

Brian Locker, one of our Canadian Instructors, recently did several courses in the Middle East. He sent me pictures from the course and stories (including his camel riding experience at one of the attendee’s camel ranch).

Class Graduation Photo (Brian’s the guy sitting in the chair in the middle of the front row in the picture above.)

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2005 has ended with full TapRooT(R) Courses.

Unfortunately that means that several people hoping to go to a course heard:

“I’m Sorry, that course is full. Can I add you to the waiting list?”

Because 2006 looks to be equally busy, we have added a few courses to the schedule. But you still might want to sign up early (more than a month in advance) to make sure that you get a seat.

This is especially true if you want to sign up multiple people (3 or more at one) to take advantage of the $100 discount per attendee.

For a list of our upcoming public courses just click on the Courses button above.

What do TapRooT(R) Course attendee think about their experience at a TapRooT(R) Course?

The feedback is often extremely positive.

Here is what one attendee wrote to our Australian instructor, Jim Whiting:

From: Greg Boyce

Sent: Thursday, 10 November 2005 3:11 PM

To: JIM WHITING

Subject: TapRooT Course 3-4 Nov 05

Hi Jim,

I read your response sheet (critique form) - didn’t like it!! So here is my reaction to the TapRoot Pubic Course:

Over my 33 odd years in the Aircraft Industry I have undertaken a huge variety of training courses from simple inductions, 3 month long aircraft specific, Supervisor Training, Personnel Management/Development, DuPont Safety, Problem Solving, just to name a few.

I can, without any fear of contradiction, state that the course you ran was the best I have ever participated in. (Please note participated)

At no time, even after lunch, was I even tempted to nod/switch off.

The presentation and content were interesting.

The methods explained were logical and non judgmental.

I felt connected and involved with my group and the whole experience left me feeling that I had really learnt something useful.

Sincere thanks and regards

Greg Boyce

Supervisor Base Maintenance

QANTAS Airways Ltd

PS my certificate arrived today - thanks.



- - -

One more comment.

We guarantee our courses.

Attend a TapRooT(R) Course. Participate and take back the techniques and apply them at your facility. If you don’t find root causes that you previously would have overlooked OR if you and your management don’t agree that you develop corrective actions that are much more effective than you previously recommended, just let us know and return the course materials, and we will refund the entire course fee.

How can we offer such an iron-clad guarantee?

Because we know you will be pleased with your course experience.

So don’t wonder if a TapRooT(R) Course would help your facility. Go to a course and you will see.