Archive for the ‘Pictures’ Category

Root Cause Analysis Day One at Golden Pass LNG, Sabine Pass Texas

Wednesday, September 1st, 2010

Golden Pass LNG Terminal LLC, the owner of the Golden Pass LNG Terminal, is 70 percent owned by an affiliate of Qatar Petroleum, 17.6 percent owned by an affiliate ExxonMobil, and 12.4 percent owned by an affiliate of Conoco Phillips.

Taking the lead before their first shipment of LNG, Golden Pass LNG started the Root Cause Analysis process and training early on. Below are just of few pictures from the first hands-on exercise.

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Root Cause Analysis Tip: “Death by Data” also known as “Data Paralysis”

Wednesday, September 1st, 2010

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Understanding your process data, filtering the good from the bad and detecting when there are true problems coming to light should not be like hand-sorting grains of rice.

Yet I hear this question frequently, “We have a large database and we would like to ……..?”

When I ask what processes are being measured and what data are tied to the process’ outcome, the answers are often very vague if not delayed with a, “I will get back with you, good question.”

Now most of us our good at tracking outcomes (often because we are required by Regulations) like:

… number of defects

… costumer complaints

… OSHA recordables

… Sentinel Events

With tracking outcomes however, comes the data merging error that hides the fact that all rice does not come from the same fields and cannot always be included in the same analysis. For example:

… we had a wonderful month with lower injuries in July per assigned employees.

Problem: Cannot compare the number of employees assigned in July with the other months because we had a 2 week plant shutdown.

… we count all defect opportunities and perform frequent audits but the leading indicators do not seem to predict the change.

Problem: Not all audits are created equal. Often leading indicator metrics are too global and general. In other words, “just plain rice”. When you see indicators change but there is no correlation to your lagging output metrics, stop and Go Out And Look (GOAL) at the tasks being performed to identify the correct leading metrics.

This is just the tip of the iceberg when looking at wrong data collection thoughts. Just remember just because you collect lots of data does not mean this a good thing…. you just get more grains of salt to sift through.

Below are two presentations to dig a little deeper in this thought process.

http://www.taproot.com/wordpress/2009/10/30/trending-with-the-taproot%C2%AE-v5-software/

http://www.taproot.com/wordpress/2009/10/30/proactively-using-leansix-sigma-with-taproot%C2%AE/

Also, check out our metrics course being offered during our October Pre-Summit. It is the only this year it is offered as a public course: http://www.taproot.com/summit.php?t=pre-summit#advancedtrending

Pictures from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course held for Boart Longyear in Santiago, Chile

Sunday, August 29th, 2010

Marco Flores sent these pictures from the class…

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Red Light Cameras – Helpful in Improving Safety or Just a Way to Raise Revenue?

Saturday, August 28th, 2010

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Here’s an interesting article:

http://autos.aol.com/article/red-light-camera-accidents/

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Pictures from the Johannesburg Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

Friday, August 27th, 2010

This was a full course and people had a great time learning advanced root cause analysis.

Pictures from the Cognitive Interviewing Exercise:

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Pictures of the final exercise …

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Class photo …

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Caribbean Nitrogen Company (CNC) Limited holds TapRooT@ Root Cause Courses in Trinidad

Friday, August 27th, 2010

CNC invited System Improvements, Inc. back to Trinidad to teach a 1-Day Refresher and 2-Day Root Cause Analysis Courses this week. It was pleasure for Mark Olson and I to work with their energetic and passionate team.

Here are a few picture from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis:

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A few pictures of life in Trinidad:

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Friday Joke: What’s the Root Cause of this Root?

Friday, August 27th, 2010

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The Associated Press reported that Ron Sveden was worried about cancer when he had increased coughing and an x-ray showed a dark spot in his lungs. Then things got strange. The tests came back negative on the cancer. What was in his lung causing problems?

The doctors decided they had to go in for a look. What was the root cause of his problem? A ROOT! (Well … actually a sprout.)

They removed a mass and sent it to pathology. The report was that he had a vegetable – a pea – sprouting in his lungs!

Now that’s a rooty root cause!

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Talk About TapRooT® and Get a Free Spin-A-Cause™ at the VPPPA Meeting in Orlando

Tuesday, August 24th, 2010

Here are Linda, Ken, and Dave talking about TapRooT® and giving away Spin-A-Cause™s at the VPPPA Conference reception in Orlando.

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If you are at the VPPPA Meeting, stop by booth 503 and say hello. (And get your own Spin-A-Cause™.

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System Improvements Celebrates 100th Issue of the Root Cause Network™ Newsletter

Friday, August 20th, 2010

Last night was a great celebration. Here’s the pictures …

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If you don’t already get the Root Cause Network Newsletter (published bi-monthly), register for it here:

http://www.taproot.com/contact.php?news=1

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Pictures from the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Training held at Subsea 7 in the UK

Wednesday, August 18th, 2010

Here’s Roland Reid teaching his first TapRooT® Class at Subsea 7 in the UK with Mhorvan Sherret. Subsea 7 is a licensed TapRooT® User and they do their own 2-Day classes with Certified TapRooT® Instructors that work for Subsea 7.

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Want to find out what it takes to be a Certified TapRooT® Instructor at your company? See:

http://www.taproot.com/wordpress/2005/12/06/process-for-becoming-a-certified-taprootr-instructor/

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Pictures from the on-site 5-Day TapRooT® Advance Root Cause Analysis Team Leader Course held for BoartLongyear in Perth, Australia

Monday, August 16th, 2010

Our instructors at PSG in Perth sent these pictures of the students practicing what they learned …. drawing a SnapCharT® – during the recent 5-Day TapRooT® Course held for BoartLongyear.

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Need an advanced root cause analysis course at your site? Call us at 001-865-539-2139 or contact us by clicking here.

Boiler Blast Damages Hotel in UK – Is Your Boiler Inspection Up-To-Date?

Monday, August 16th, 2010

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Sometimes we take equipment reliability for granted. But equipment failures can cause serious accident.

In this case, no one was hurt when the boiler exploded. But considerable damage was done to the hotel. The root cause analysis of the failure will be interesting.

How do you ensure your equipment is reliable?

How do you troubleshoot equipment problems?

Do you find the root causes of your equipment problems and fix them to prevent future accidents?

Maybe it is time to attend a 3-Day TapRooT®/Equifactor® Course?

For more info on this accident, see:

http://www.meltontimes.co.uk/news/Explosion-in-town-centre-pub.6477199.jp

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UK Rail Accident Investigation Branch Issues Report on the Collision on the Great Orme Tramway

Monday, August 16th, 2010

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See the complete report at:

http://www.raib.gov.uk/cms_resources.cfm?file=/100816_R132010_Great_Orme.pdf

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TapRooT® Summit History

Monday, August 16th, 2010

HOW THE SUMMIT STARTED – 1994 – Gatlinburg, TN

Mark Paradies organized the first Summit (held in 1994) because, after attending, and even helping organize, many conferences between 1983 and 1994, he saw a need for a conference with a focus on performance improvement, human error, incident investigation, and the latest improvement technology. The conference that was NOT oriented toward research and PhD discussions (although this is valuable). The first meeting was oriented toward practical applications that could be implemented at industrial facilities and in service organizations.

The other purpose of that first Summit was sharing information and ideas across industry and organizational boundaries. This couldn’t be done by one professional organization (with a safety, quality, or equipment focus) or by an industry oriented trade group (nuclear, refining, healthcare, aviation, pharmaceuticals, semiconductors, utilities, mining, shipping, oil exploration, …).

And even for that first Summit, we wanted to have international participants.

What a challenge. We didn’t have a society to organize, publicize, and pay for a meeting. But people needed the knowledge, the best practices, the learning, …

So the first Summit was organized and held in nearby Gatlinburg, TN (with 33 participants).

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It was before digital photos and videos so we don’t have a visible record of the lessons that were learned. But after it was over … we knew that we had to do it again.

1995 – Orlando – 72 participants.

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Disney was a great place to hold the Summit. And with more than twice as many people attending, we started to invent ways to maximize the networking.

Orlando was also the first Summit to include a pre-Summit TapRooT® Course (our standard 2-Day).

1996 – Nashville – 85 participants.

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Our social activity? The Grand Ole Opry.

More people … more benchmarking. Also, this was the first Summit with a session dedicated to medical errors at hospitals (an idea ahead of its time).

1997 – San Antonio – 105 participants and growing strong.

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The first Texas Summit. It included more, better networking, some great speakers, and our first reception/party.

This was also the start of “special” pre-Summit courses (additional topics beyond our 2-Day TapRooT® Course).

1998 – Dallas – 119 participants.

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The Southfork Ranch hosted the 1998 Summit. A JR look alike attended the Summit party where everyone had a great time.

This Summit was also the start of TapRooT® Users presenting their Success Stories. A great way to share best practices.

Because we hold the Summit every 14-16 months, after the Summit in the Autumn of 1998, we skipped 1999 Summit and held one in the Spring of 2000.

2000 – Gatlinburg – 125 participants.

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A Shuttle Astronaut Mike Mullane explained the first Shuttle disaster and what Summit attendees had to do to achieve excellence.

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The great speakers and breakout sessions gave attendees lots to talk about.

2001 – Galveston – 133 participants.

Two days before the Summit, a Tropical Storm dropped 2 feet of rain! Lesson learned: Don’t hold the Summit on the Gulf coast in late June!

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Once again, we had several great keynote speakers.

Plus there were 11 pre-Summit courses to choose from. These pre-Summit Courses give professional accident investigators a way to learn new skills and refresh skills that they don’t get to use very often.

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(Band at the reception.)

2002 – Gatlinburg – 140 participants.

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(Mark at opening talk.)

Participants enjoyed the great speakers …

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Great best practice sharing …

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Participants said it couldn’t get any better. But it did.

2003 – Dallas – 155 participants.

Back to the Southfork Ranch,

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This was the Summit with the first TapRooT® Cup Golf Tournament – something that has become a fixture of Friday afternoon at the Summit and a part of the great networking that every Summit includes.

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We also had the first TapRooT® Advisory Board Dinner.

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And we had a great reception/party!

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On the serious side, we had excellent sharing of knowledge and best practices…

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2005 – San Antonio – 169 participants.

Back to San Antonio again.

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Wow! What amazing Keynote Speakers, networking, and best practice sharing. The Summit that couldn’t get better hit a new high. (Don’t tell Mark Paradies that it can’t be done.)

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Above is a picture of the participants listening to the start of Scott Waddle’s talk. He was the CO of the submarine USS Greeneville when it collided with the Emime Maru (a Japanese fishing vessel). Most of the audience was in tears by the end of his talk. Wow!  Powerful!

The Advisory Board went on a Riverwalk cruise (we are doing it again this year).

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And our golf tournament was held at The Quarry Golf Club (where we are holding this year’s tournament). Half of the course plays around the outside of an old stone quarry. The other half is down in the quarry. A very interesting course to play!

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2006 – Gatlinburg – 175 participants.

Back to Gatlinburg and the Smoky Mountains – this time in the early spring (the leaves were just starting to bud).

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The best Summit so far. Each year we build upon the successes of the past while adding new ideas to improve the best practice sharing and networking.

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(Panel Discussion Debate)

Look at the networking and best practice sharing …
 

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And this was the first Summit Golf Tournament that the Canadian Team was not victorious. Instead, Ken Turnbull’s team had the lowest score.

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2007 – San Antonio – 224 participants.

We’ve found that San Antonio is a great place to hold the Summit. So we are back again in 2007.

Once again, great speakers, networking, best practice sharing, and fun!

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The Summit is a well-oiled networking/benchmarking/best practice sharing machine!

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And again, we had a great reception!

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And how about the golf?

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The Canadians won again …

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2008 – Las Vegas – 259 participants.

The 20th Anniversary of System Improvements …

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The first Summit we’ve ever held in Las Vegas was a real winner!

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First there was touches of Vegas with Elvis and showgirls.

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But before the Summit started, there was great learning in the pre-Summit courses …

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And during the Summit there was serious networking, best practice sharing, and learning from great Keynote Speakers…

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Then we played golf in 100 + degree Fahrenheit heat. But the Canadian team still won!

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2009 – Nashville – 221 participants.

We held the 2009 Summit in the midst of the Great Recession. Who would have guessed that it would be the third biggest Summit of all times.

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We had amazing Keynote Speakers …

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And the networking and benchmarking – the best ever! Maybe you can tell from these pictures …

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Then there was the reception …

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And the TapRooT® Advisory Board Dinner …

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And the almost rained out TapRooT® Summit Charity Golf Tournament …

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And Mark Paradies’ team finally won (beating the Canadians)!

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And the charity golf tournament raised $2,700 for an abused women’s shelter.

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2010 – San Antonio – ??? participants.

What’s in store for the 2010 Summit in San Antonio (October 27-29)?

Here’s what we know:

There will be amazing Keynote Speakers

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For the background on these Keynote Speakers, see:

http://www.taproot.com/summit.php?t=keynote

There will also be great knowledge sharing, networking, and best practice sharing  … Picture yourself in San Antonio at the Summit talking about the biggest problems that face your site with some of the world’s best performance improvement experts and a great bunch of very smart peers. Here are some of the experts that are scheduled to participate in the best practice sessions that you could discuss your “potential improvement opportunities” with:

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Dr. John Grout – Mistake Proofing Expert

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Mark Paradies talking about Admiral Rickover’s culture
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Heinz Bloch – Equipment Reliability Expert

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Dan Verlinde – TapRooT® Software Program Manager

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Dr. Beverly Chiodo – Behavior Change & Character Expert

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Brian Crawford – Flight Safety Officer, ExpressJet Airlines

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Captain Vibhas Garg – Sharing a Best Practice for Incident Investigation

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Jennifer Mounce – Coaching Expert

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Major General Doug Rich – Command Surgeon – Air Mobility Command

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George Burk – Airplane Crash Survivor

And that’s just a sample. There are 87 best practice breakout sessions with more than one speaker/facilitator in many of the sessions. For all of the Best Practices Session leaders, see:

http://www.taproot.com/summit.php?t=speakers

And for the complete Summit schedule, see:

http://www.taproot.com/summit.php?t=schedule

There will also be a fun reception featuring exhibits, food, and entertainment!

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Plus you could win an Apple iPad just by being on-time for the sessions and attending the reception (must be present to win).

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For TapRooT® Advisory Board members there will be special sessions and a dinner cruise.

Also, don’t forget to sign up for one of the 12 special pre-Summit Courses. For more information, see:

http://www.taproot.com/summit.php?t=pre-summit

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Finally, there is the TapRooT® Charity Scramble Golf Tournament being held at The Quarry Golf Club where we will see which team can claim the coveted TapRooT® Cup.

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Sign up for the golf tournament here (registration is separate from the Summit registration):

https://taproot.com/summit.php?t=register-golf

Will you help create history by being at the 2010 Summit?

Will you hear best practices that can help your company improve performance?

Will you benchmark your practices against some of the best companies in the world?

Will you discover ideas that could save people’s lives and keep your company out of trouble?

This isn’t idle banter. You can and will learn lessons that could change history because the Summit is that good.

Hope to see you there.

To register, see:

https://taproot.com/summit.php?t=register

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Monday Accident & Lessons Learned: Mine Worker Gets 8 Month Sentence in Fatal Accident in Australian Mine

Monday, August 16th, 2010

A man operating a loader accidentally crushed another worker. He was prosecuted for breaches of the Australian Mining and Quarring Safety and Heath Act 1999.

He was found guilty and given a sentence of 8 months in prison (suspended) and a fine of $13,437.70 to pay for investigation and court costs. The article said that, “Neither the SSE nor the Operator nor Contractor were charged.

To read more about the accident, see:

http://www.sparke.com.au/sparke/news/publications/wrse_publications/qld_first_mining_employee_sentenced_to_imprisonment.jsp

Here are the “key messages” from the lawyer in Australia that wrote the article:

Ensure you have a robust health and safety management system, regardless of your industry.  It needs to be documented and it needs to be followed through, so the reality of what you do matches what’s contained in the documents.

Employers need to be able to demonstrate that employees are trained in and understand the system.  If employers can show that and something goes wrong, they are in a defendable position. It also minimises the possibility of things going wrong.

Take swift action when employees do the wrong thing.  If an employee breaches the safety system, do not hesitate to take severe action against them. In other words, employers should be considering discipline and termination. Courts view such breaches very seriously, and so should employers.

What do you think?

Were the root causes discovered?

Were all the lessons learned that should have been learned?

Would you be sure that this accident won’t happen again?

How would you approach this accident?

Leave a comment here about your approach to this accident. And then think about …

Would you be ready for a fatality investigation at your facility?

Would you know how to handle all the aspects (including police issues) of a fatality investigation?

Perhaps you should consider attending the pre-Summit Course:

A Police Inquiry into a Death
in the WorkPlace – Corporate Responsibility

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UK TapRooT® Instructors Alan Smith and Mhorvan Sherret, the Directors of Matrix Risk Control (UK) Ltd, and former senior Detectives, provide a course that will help you prepare for the worst by participating in realistic police interviews and investigation scenarios. It’s a great chance to get prepared just in case something bad ever does happen.

This course is only offered in the US just prior to the Summit and attendance is limited, so sign up today.

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NTSB Releases Pictures from Alaska Plane Crash

Friday, August 13th, 2010

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Friday Joke: The Real Reason You Topped the Ball

Friday, August 13th, 2010

“When you’re having trouble and topping the ball, it means the ground is moving on you.”  ~ Chi Chi Rodriguez

Don’t forget to sign up for the 2010 TapRooT® Summit Charity Golf Tournament to be held at the Quarry Golf Club on October 29.

Get more info at:

http://www.taproot.com/summit.php?t=golf

Register at:

https://taproot.com/summit.php?t=register-golf

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Summit Recommendations

Thursday, August 12th, 2010

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Have you attended the TapRooT® Summit?

Then I’d like to hear what you think. Leave a comment here.

I think the TapRooT® Summit is the best conference for sharing best practices and benchmarking with industry peers and experts.

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Of course, I’m biased because I’m the conference chair and I’ve helped organize this meeting since 1996.

I’ll post my comment below WHY I think this is the best conference. So if you are interested, see the comments.

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For more Summit info and to register for the Summit, see:

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

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Pictures from the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Sao Paulo, Brazil

Tuesday, August 10th, 2010

Boris Resnic, out TapRooT® Instructor in Brazil, sent these pictures from the recent 2-Day Course in Sao Paulo.

Where is our next public course in Brazil? MACAÉ

When is it? November 8-12

See our complete public course schedule at:

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

To schedule an on-site course for your facility, contact us by clicking here.

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First Exercise

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Pictures from the First TapRooT® Root Cause Analysis Course Held in Libya

Monday, August 9th, 2010

Mhorvan Sherret, on of our UK instructors, sent these pictures from Libya where we held a 5-Day TapRooT® Advanced Root Cause Analysis Course for Suncor.

Lifting of restrictions on Libya now allow us to provide on-site training so people can use TapRooT® to improve performance and save lives in Libya.

Here are the class photos …

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If you need a course at your facility anywhere in the world, click here for a quote.

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Pictures from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Angola for ExxonMobil

Monday, August 9th, 2010

Companies hold TapRooT® Courses around the world. here are pictures from a special 5-Day TapRooT® Course with a day of Equifactor® Training (equipment troubleshooting) built in.

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If you need some TapRooT® Root Cause Analysis Training for your site, call us at 865-539-2139 or e-mail us by clicking here.

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NTSB Press Release: Photos of Michigan Pipeline Rupture

Monday, August 9th, 2010

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National Transportation Safety Board
Washington, DC 20594

August 8, 2010

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NTSB RELEASES PHOTOS OF
PIPELINE OIL SPILL IN MICHIGAN

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The National Transportation Safety Board today released the following photographs of the pipeline that ruptured and spilled oil into a river last week in Marshall, Michigan.

On the evening of Sunday, July 25th, a 30-inch crude oil pipeline, operated by Enbridge Energy Partners/Pipeline, experienced multiple low pressure alarms near the Marshall City Pump station during a planned shutdown.  By 11:45am (EDT) the following morning Enbridge employees confirmed an oil leak extending into nearby Talmadge creek, a tributary to the Kalamazoo River.

Two sections of the pipe, 23 feet, 4-inches and another 26 feet, 10-inches, have arrived at the NTSB for further examination.

The photographs show the length of the fracture which extends approximately 6 1/2 feet longitudinally with the widest portion of the opening measuring 4 1/2-inches.  The fracture was located approximately 25 feet from the upstream joint in a 40 foot section of 30-inch pipe.

The photographs may be viewed by clicking on the following link http://ntsb.gov/Pressrel/2010/100807.html

The NTSB’s investigation continues.

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Monday Accident & Lessons Learned: UK RAIB Report on the Derailment at Windsor & Eton Riverside Station

Monday, August 9th, 2010

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This track maintenance related derailment was investigated by the UK Rail Accident Investigation Branch. See the following report for the causes of the accident and the UK RAIB recommendations:

http://www.raib.gov.uk/cms_resources.cfm?file=/100805_R112010_Windsor.pdf

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Class Photos from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course Held for Vestas in Portland

Friday, August 6th, 2010

Dennis Osmer (one of our TapRooT® Instructors) sent these cell phone pictures from the course…

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Do you need at TapRooT® Root Cause Analysis Course at your site?

Call us at 865-539-2139 or click here to e-mail a request.

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Pictures from “After Hours” Activities at the Seattle 5-Day Advanced Root Cause Analysis Team Leader Course

Thursday, August 5th, 2010

Sorry I didn’t post these earlier … but I just found them on my cell phone today!

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Canary in a Coal Mine – Manager’s in China’s Coal Mines Haven’t Stopped Accidents

Wednesday, August 4th, 2010

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Associated Press reports that China’s mines have not suddenly become “safe” after China’s Premier ordered mining managers to go down in the mines with the miners.

The article says:

State media have noted with surprising sharpness that none of the dead seemed to have been mine managers or bosses.”

“‘Who knew that every boss who goes into the shaft is a god: Flooding, explosions, whatever it is, they can always fly free,’ the official Xinhua News Agency said in a pointed commentary Tuesday.”

The other way the government has chosen to improve safety is to arrest management at mines with accidents.

Since neither of these tactics have improved safety … maybe it is time that someone try advanced root cause analysis? Perhaps Chinese mines could learn from this TapRooT® Success Story:

http://www.taproot.com/about.php?s=1

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What a 5-Day TapRooT® Class in Gatlinburg, TN! Is your Industry really that different?

Saturday, July 31st, 2010

This 5-Day Root Cause Course was definitely an adventure. When you start with a class of combined industries such as Mining, Military Health, Manufacturing, Nuclear, Power Generation, Drilling, Oil, Gas, and Chemical, day one starts off like this…..

“Our Industry is different than ________ (fill in the blank).”

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Can you point out who is from what Industry? At the end of the 5-day, all industries were having the same conversations and sharing best practices…. I love TapRooT® Public Courses!

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An evening with the Military Health Group above…. great discussions with members’ assignments spreading from Texas all the way to Korea.

Some more pictures from the course below.
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Pictures from Day 3&4 of the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Seattle

Friday, July 30th, 2010

Here’s more pictures from the Seattle public TapRooT® Course …

Pictures from “After the Class”

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We had a post class meeting at Kells Irish Pub for class attendees and my Seattle LinkedIn contacts. Guinness was very popular!

More shots from the class…
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“Hands-only CPR, pushy dispatchers are lifesavers”

Wednesday, July 28th, 2010

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Read more here: http://news.yahoo.com/s/ap/20100728/ap_on_he_me/us_med_hands_only_cpr

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Pictures from Day 2 of the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Seattle

Wednesday, July 28th, 2010

Another great day at the Seattle 5-Day TapRooT® Course. Here are pictures of people learning and practicing their root cause analysis, interviewing, and corrective action development skills.

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For more about the course, see:

http://www.taproot.com/courses.php?d=2

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Pictures from the Seattle Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

Monday, July 26th, 2010

People worked had in exercises at Day 1 of a 5-Day TapRooT® Root Cause Analysis Course in Seattle.

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If you are interested in our upcoming public TapRooT® Courses around the world, see:

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

To get a quote for a course at your site, contact us at:

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

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PRESS RELEASE from the Chemical Safety Board: CSB Issues Report on 2009 Explosion at Veolia ES Technical Solutions, L.L.C. Hazardous Waste Facility; Waste Industry Urged to Improve Safety Standards; Recommendations Issued to Ensure Safer Siting of Buildings

Friday, July 23rd, 2010

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Washington DC, July 21, 2010 – A U.S. Chemical Safety Board (CSB) case study released today on the 2009 explosion and fire at the Veolia ES Technical Solutions L.L.C. facility in West Carrollton, Ohio, calls on the industry to improve safety standards covering hazardous waste processing, handling, and storage facilities. The Board also recommended that fire protection codes be revised to require companies to determine safe distances between occupied buildings and potentially hazardous operating areas.

The accident occurred on May 4, 2009, when flammable vapor was released from a waste recycling process, ignited, and violently exploded. The blast seriously injured two workers and damaged 20 nearby residences and five businesses. CSB investigators found that the north wall of the lab and operations building – where the victims were injured – was less than 30 feet from the waste recycling processing area where the flammable vapor was released. 

CSB Chairman Rafael Moure-Eraso said, “This accident should not have happened. Our report notes that OSHA cited the company for inadequate attention to process safety management practices in the handling of flammable liquids. But in case of an accident, I believe it is absolutely critical that buildings at chemical facilities be sited safe distances from process equipment to maximize the safety of workers. We are making recommendations that would help ensure that operating areas with occupied buildings such as control rooms be sufficiently separated from process areas containing flammable liquids and gases that have the potential to explode.”

The Board issued a recommendation to the National Fire Protection Association (NFPA), which develops codes and standards for industry, urging NFPA to require companies to perform engineering analyses to determine safe separation distances between buildings occupied by administrative and other personnel not essential to process operations, and buildings housing the potentially hazardous process equipment.

The Board also revised a previous recommendation to the Environmental Technology Council, a hazardous waste industry trade group, to petition the NFPA to develop a standard specific to hazardous waste treatment, storage and disposal facilities. This would include guidance on reducing the likelihood of fires, explosions, and releases of hazardous waste.

Dr. Moure noted, “The Environmental Technology Council did not respond adequately to our 2007 recommendation, which we issued following an explosion and massive fire at the Environmental Quality hazardous waste facility in Apex, North Carolina, to work for more stringent standards in the hazardous waste industry. I strongly urge the industry to act now. These facilities, by their nature, contain wide varieties of flammable and toxic materials that can cause significant injury to workers and threaten the well being of nearby communities. Facility owners and operators need stricter technical requirements to improve the safety of life and property.”

The report notes that after a normal run of the tetrahydrafuran (THF) solvent recovery process at the Veolia facility, the unit operator began a routine shutdown. Completing the process required blowing nitrogen back through the circulation piping to clean it, prior to closing valves.

CSB lead investigator Johnnie Banks said, “At the time of the shutdown, witnesses reported hearing the sound of a sudden, loud vapor release and smelling a very strong odor of THF solvent which knocked several employees to their knees. It was a matter of just a couple of minutes until the highly flammable vapor ignited.”

The vapor drifted to the laboratory and operations building and found an ignition source inside the building. A worker in the control room reported being enveloped in a fireball that went through the building. The first explosion knocked over a bank of lockers, severely injuring an employee and pinning him underneath.

Because of the extensive fire damage, the CSB was unable to conclusively determine the exact initiating event for the vapor release, concluding one of two possible scenarios likely occurred. In the first scenario, air may have been drawn into a tank containing THF residue and peroxides, causing increased pressure in the tank and forcing flammable vapor from the tank to escape through a manway cover or a vacuum breaker.

In the second possible scenario, CSB investigators believe a line hose, intended to send pressurized nitrogen into a different tank, may have instead been connected to a tank containing unprocessed, flammable liquid. When the nitrogen was applied, it forced flammable vapor out through the tank vent. In either scenario, the vapor drifted to the operations building and ignited, causing the injuries.

In addition to issuing recommendations to NFPA and the hazardous waste industry, the Board also issued recommendations to Veolia, which is rebuilding the plant. The CSB called on the company to restrict occupancy in buildings in close proximity to the operating plant to personnel trained in the safe operation and orderly shutdown of the plant. The Board also called on the Center for Chemical Process Safety, a division of the American Institute of Chemical Engineers, to revise control room siting guidelines to address the characteristics of all Class 1B flammable liquids.

For more information, contact Public Affairs Specialist Hillary Cohen, 202-261-3601, or Sandy Gilmour, 202-261-7614, cell 202-251-5496

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Pictures from the Public 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in San Francisco (Tiburon)

Tuesday, July 20th, 2010

Dana Barclay, one of our TapRooT® Instructors, sent these pictures from the Public San Francisco 2-Day TapRooT® Course …

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Pictures from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course for Fenner Dunlop

Monday, July 19th, 2010

Dennis Osmer, one of our TapRooT® Instructors, sent these pictures from the 5-Day Course for Fenner Dunlop. Students hard at work learning by doing (an exercise).

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Need training at your site? Please call us at 865-539-2139 or click here to e-mail your request.

Finally Success: Oil Flow Stopped!

Friday, July 16th, 2010

I heard it yesterday afternoon but I waited until this morning just to be sure…

Looks like the well in the Gulf is finally capped.

Here’s the picture from the site:

http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/incident_response/STAGING/local_assets/html/Skandi_ROV2.html

Here’s a picture from that site:

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The worry now is that pressure will build and rupture the well casing. This could make future efforts to use relief wells to finally permanently stop the flow more difficult or impossible. But government scientist approved this latest effort.

Let’s cross our fingers and pray this goes well!

Don’t Wait! TapRooT® Courses Fill Up and Have Waiting Lists. Sign that the Economy is Picking Up.

Friday, July 16th, 2010

If you are “thinking” about attending a TapRooT® Course … Don’t wait too long. Many of our courses are filling up and then have a “wait list” for those who call to late because the course is full.

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What courses have filled up lately?

  • Johannesburg, South Africa
  • Edmonton, Canada
  • San Francisco, USA
  • Calgary, Canada
  • Houston, USA

Don’t miss out. Register well ahead of a course that you want to attend to make sure you get your first pick for a location and date.

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Happy Independence Day!

Sunday, July 4th, 2010

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Here is a reminder that the freedoms we enjoy in the US aren’t “free.” They came at a cost. I’ve seen this article reprinted several places and have seen some research on some of the claims. The reason I pass it along is to remind everyone of the responsibility we have to support continued freedom.

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Have you ever wondered what happened to the 56 men who signed the Declaration of Independence?

Five signers were captured by the British as traitors, and tortured before they died.

Twelve had their homes ransacked and burned.

Two lost their sons serving in the Revolutionary Army; another had two sons captured.

Nine of the 56 fought and died from wounds or hardships of the Revolutionary War.

They signed and they pledged their lives, their fortunes, and their sacred honor.

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What kind of men were they?

Twenty-four were lawyers and jurists.

Eleven were merchants.

Nine were farmers and large plantation owners:

men of means, well educated.

But they signed the Declaration of Independence knowing full well that the penalty would be death if they were captured.

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Carter Braxton of Virginia, a wealthy planter and trader saw his ships swept from the seas by the British Navy. He sold his home and properties to pay his debts and died in rags.

Thomas McKeam was so hounded by the British that he was forced to move his family almost constantly. He served in the Congress without pay, and his family was kept in hiding. His possessions were taken from him, and poverty was his reward.

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Vandals or soldiers looted the properties of Dillery Hall, Clymer, Walton, Gwinett, Heyward, Ruttledge, and Middleton. At the battle of Yorktown, Thomas Nelson, Jr. noted that the British General Cornwallis had taken over the Nelson home for his headquarters. He quietly urged General George Washington to open fire. The home was destroyed, and Nelson died bankrupt.

Francis Lewis had his home and properties destroyed. The enemy jailed his wife, and she died within a few months. John Hart was driven from his wife’s bedside as she was dying. Their 13 children fled for their lives. His fields and his gristmill were laid to waste. For more than a year he lived in forests and caves, returning to find his wife dead and his children vanished. A few weeks later he died from exhaustion and a broken heart. Norris and Livingston suffered similar fates.

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Such were the stories and sacrifices of the American Revolution. These were not wild-eyed, rabble-rousing ruffians. They were soft-spoken men of means and education. They had security, but they valued liberty more. Standing tall and straight, and unwavering, they pledged:

“For the support of the declaration, with firm reliance on the protection of the divine providence, we mutually pledge to each other, our lives, our fortunes and our sacred honor.”

They gave you and me a free and independent America. The history books told you a lot of what happened in the Revolutionary War. We didn’t fight just the British. We were British subjects at that time and we fought our own government!

Some of us take these liberties so much for granted, but we shouldn’t. So take a few minutes while enjoying your 4th of July holiday and silently thank these patriots. It’s not much to ask for the price they paid.

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Remember: Freedom is never free! I hope you show your support by sharing this with as many people as you can. It’s time we get the word out that Patriotism is NOT a sin, and the Fourth of July has more to it than beer, picnics, and baseball games.

~Author Unknown~

Also, here is another interesting web site with facts about the American Revolution:

http://americanhistory.si.edu/militaryhistory/printable/section.asp?id=1

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When is the last time you have Experienced Riyadh, Saudi Arabia?

Tuesday, June 29th, 2010

While this was my third tour to Saudi Arabia, this was my first true Saudi Culture experience while in Riyadh. My first two trips were with the United States Air Force for two tours of duty. These pictures are posted with great appreciation to the employees (my friends) from the Saudi Food and Drug Authority.

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Until recently, skyscrapers were not allowed to be built (a night time picture from the skybridge)…..

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Experiencing Authentic Arabic Cuisine

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History of and formation of a Unified Saudi Arabia
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The first Medical Devices in Saudi Arabia
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Saudi Food and Drug Authority take the Lead in Investigating Medical Device Failures

Tuesday, June 29th, 2010

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The newly developed SFDA (Saudi Food and Drug Authority) located in Riyadh, Saudi Arabia, has taken the lead in medical oversight of conformity; not only by creating a Medical Devices Sector, but also by ensuring that their Medical Device team has a thorough understanding of human error and equipment failure and has the best tool to investigate it with, TapRooT® Root Cause Analysis.

Here are few pictures taken during the onsite 2-Day TapRooT® Incident Investigation and Root Cause Analysis, 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis, Stopping Human Error, and 1-Day Evidence Gathering Courses held in June.

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If you look closely you can see that they are using the new individual software… (another user test to make sure it is ready to go out to all users)
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Rent a TapRooT® Trained Senior Detective to Help Facilitate A Tough Accident Investigation

Tuesday, June 29th, 2010

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Alan Smith and Mhorvan Sherret are retired Senior Detectives located in Scotland. They are also Certified TapRooT® Instructors. That makes a great combination if you need unbiased help facilitating a difficult investigation. Mhorvan and Alan are close by for any investigation in Europe & the Middle-East. But they will travel anywhere you need them around the world.

Need someone closer to your site? We have excellent TapRooT® Facilitators in:

Africa,
Australia,
Brazil,
Canada,
Columbia,
Korea,
Mexico, and
the United States.

To get help fast, call 001-865-539-2139. Or e-mail info@taproot.com.

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