Root Cause Analysis Blog

 

Meet TapRooT® in Milwaukee

Posted: May 30th, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

In two days with TapRooT®, you will learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course can accelerate your career and has proven a professional game changer for many.

TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your expertise and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll meet on July 17 at the Milwaukee Marriott Downtown for the 2-Day TapRooT® Root Cause Analysis Training course. You will likely want to explore Milwaukee so below we’ve included highlights of your host city.

Register here to take the 2-Day TapRooT® Root Cause Analysis Training course in Milwaukee. 

Experience Milwaukee

Milwaukee is known as the “big city of little neighborhoods.” Here, you’ll find friendly folks, delectable cuisine, a Midwestern culture, and unique experiences. Like Lake Michigan, the only Great Lake entirely within the U.S.

Discovery World: Whether you’re awestruck at the Tall Ships or Great Lakes, looking through the Simple Machine Shipyard, or Les Paul’s House of Sound, you’re surrounded by hands-on science, technology, and the environment.

Photo Op: Go around the cool exterior walkway of Discovery World to view Lake Michigan and the downtown area.

Milwaukee Public Museum: You can get lost in the floors of anthropology, geology, botany, history, zoology, and even a vintage European Village.

Sprecher Brewery Tour: See how the brewing process happens, from factory to shelves. Of course, you can sample brews in the mix of activities!

Brady Street: Sense the Midwest atmosphere on this street that offers nightlife, coffee houses, restaurants and ethnic cuisine, and shops.

Riverwalk: Go for the views and great dining along the Milwaukee River.

Historic Third Ward: A jewel in downtown, the Ward is home to a thriving arts community, shopping, restaurants. On the north end, you’ll find Milwaukee Public Market, fully decked out with a wine bar, diverse culinary vendors with vegetarian and vegan options, local swag for sale, something for your sweet tooth, and more. 

The beach: Yes, with sand and water, on beautiful Lake Michigan, which has a water surface of 22,300 square miles. Milwaukee has 1,400 acres of beaches and parkland on the water. Bradford Beach, in downtown Milwaukee, was selected as one of the Travel Channel’s top 11 city beaches.

Best Place at the Historic Pabst Brewery: Fascinating building, with a tour that clues you in on much of Milwaukee.

Did you know: Lake Michigan’s name is derived from an Ojibwa Indian word, “mishigami,” which means “large lake”?

 

Milwaukee eateries

Milwaukee Ale House: Sit on the patio of this microbrewery and restaurant and enjoy the Milwaukee River sights and sounds.

Blue’s Egg: Coffee and carry-out or have breakfast or lunch at this Art Deco eatery.

The Capital Grille: Upscale steakhouse and classic American fare.

Odd Duck: Inventive New American menu with creative cocktails.

AJ Bombers: Happy hour, great burgers and beer, open until late.

Milwaukee Brat House: Great brew selection. Brats, Wisconsin cheese soup, chicken sandwiches, pretzels—all locally popular.

Glorioso’s Italian Market: Shop in the market while waiting for your food. Great meatballs and sauce.

St. Paul Fish Company: Dinner specials nightly. Fresh seafood and a mix of American favorites.

Discover more to explore from our Milwaukee Pinterest board and begin planning your TapRooT® trip to Wisconsin today.

 

 

Join TapRooT® Tomorrow on Facebook Live!

Posted: May 29th, 2018 in Career Development Tips, TapRooT, Topic of the Week, Video

Make plans now to join TapRooT® professionals tomorrow for our Facebook Live discussion. Up next: Corrective Actions.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, May 30

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Sustainable Performance Forum (SPF) EMEA 2018: Paris, France

Posted: May 29th, 2018 in Uncategorized

Are you attending the 2018 SPF EMEA 2018 in Paris, France on June 6 – 7? If so, stop by our booth and say, “Bonjour” to Ken Reed & Dan Verlinde (pictured left to right). They will be answering any questions you have about TapRooT® and what it can do for you.

The first 500 visitors will receive a special prize, so don’t miss out on your free gift! Stop by early to increase your chances in receiving a prize.

Ken Reed will also be presenting at the conference on June 6th at 2:30 PM (CEST).

Hope to see you there!

What does a bad day look like?

Posted: May 29th, 2018 in Bad day

“The challenge? Each year the tree becomes more difficult to get around. By the time the kids are teenagers, they’ll barely be able to get in and out of the garage. It’s a natural deterrent to stop them from going out and partying. Clever parenting technique, eh?”

Learn TapRooT® in Nairobi

Posted: May 29th, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

In five days with TapRooT®, you will learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course can accelerate your career and has proven a professional game changer for many.

TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper® plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your expertise and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll meet on July 16 for the 5-Day Root Cause Analysis Training course. You will likely want to explore a bit of Nairobi so below we’ve included highlights of your host city.

Register here to take the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Nairobi.

Experience Nairobi
Nairobi is a modern African city with a colonial past. As Kenya’s capital, Nairobi is the most populous city in eastern Africa and a leading business, cultural, and financial hub in Africa.

Nairobi offers parks, shopping, art museums, cultural attractions, restaurants and bars, and opportunities to get close to wildlife.

Wildlife
Giraffe Center: Supported by the American Fund for Endangered Wildlife, the center offers you experiences in feeding, standing face-to-face with the giraffes, and walking the Giraffe Center Nature Trail. An endangered subspecies giraffe, the rare Rothschild, has been successfully bred at Giraffe Center.

Get up close to baby elephants at David Sheldrick Wildlife Trust Elephant Orphanage. Only available for viewing from 11 am to 12 pm, so plan accordingly, the baby elephant orphans are found left behind when the babies fall into watering holes or when their mothers are poached. The handlers bottle feed them the only kind of milk the young elephants can have: elephant milk, of course.

Nairobi National Park: Experience exhibits about Kenyan history and early African ancestry, cultures, and people. Learn about fossils and their names. Next door is Snake Park where some snakes are so poisonous, they are behind double glass! Stroll the botanic garden and trek the nature trail.

Culture
Nairobi National Museum: Explore gardens with sculpture, culture, and history in the midst of Kenya’s rich heritage.

Kenyatta International Convention Centre: View the city from the heights of the conference centre with its dome-shaped tower. The Nairobi skyline is punctuated by the centre’s fusion of African styles, both traditional and contemporary.

Masai Market: On Tuesdays, shop among handicrafts: sculptures, jewelry, batik hangings, apparel, sisal bags, and many other handmade selections. Also, check out the City Market.

African Heritage House: The house overlooks Nairobi National Park and is a combination of diverse mud architectures across Africa.

Karen Blixen Home: Built in the tradition of late 19th-century bungalow architecture, with spacious rooms, verandas horizontally laid out, a roof of tile and stone, at the foot of the Ngong Hills, the home was owned by Danish author Karen and her Swedish husband, Baron Bror von Blixen Fincke. The Academy Award-winning film “Out of Africa” was about their lives in this home on farmland in Kenya.

Nairobi eateries
Carnivore: Set amid tropical gardens, with the rustic feel of a medieval banquet hall, Carnivore offers exotic meats, soups, side dishes and sauces, selection of desserts and Kenyan coffee. Try a classic Kenyan cocktail, Dawa, a blend of vodka, sugar, lime, and honey.

Talisman: A fusion of European, Pan-Asian, and African cuisine and considered one of the best restaurants in Nairobi. Try the grilled filet with a potato patty mixed with vegetables and deep fried, served with a wasabi-mustard sauce.

Wasp & Sprout:  A small cafe in the quiet Loresho area with excellent food and a relaxing ambiance. Visit during breakfast or brunch for ricotta pancakes, eggs Benedict, and baked goods. Bring a book and make yourself at home for a few hours.

The Arbor: Set in a beautiful garden, the cafe is eco-friendly with Southeast Asian and international cuisine.

Brew Bistro & Lounge: A popular restaurant, brewery, and lounge, with rooftop beer garden ambiance and a lively nightlife.

Mama Ashanti: A local favorite with West African and Ghanaian fare.

J’s Fresh Bar & Kitchen: In Westlands, this gastropub has  outdoor seating, a DJ booth, nightlife and a full-service restaurant.

Discover more to explore from our Nairobi Pinterest board and begin planning your TapRooT® trip to Africa today.

Monday Accidents & Lessons Learned: Who’s in Charge?

Posted: May 28th, 2018 in Accidents, Human Performance

An ERJ-145 crew failed to detect a change in its vertical navigation mode during descent. When it was eventually discovered, corrective action was taken, but large deviations from the desired flight path may have already compromised safety.

“This event occurred while being vectored for a visual approach. The First Officer (FO) was the Pilot Flying and I was Pilot Monitoring. ATC had given us a heading to fly and a clearance to descend to 3,000 feet. 3,000 was entered into the altitude preselect, was confirmed by both pilots, and a descent was initiated. At about this time, we were also instructed to maintain 180 knots. Sometime later, I noticed that our speed had begun to bleed off considerably, approximately 20 knots, and was still decaying. I immediately grabbed the thrust levers and increased power, attempting to regain our airspeed. At about this time, it was noticed that the preselected altitude had never captured and that the Flight Mode Annunciator (FMA) had entered into PITCH MODE at some point. It became apparent that after the aircraft had started its descent, the altitude preselect (ASEL) mode had changed to pitch and was never noticed by either pilot. Instead of descending, the aircraft had entered a climb at some point, and this was not noticed until an appreciable amount of airspeed decay had occurred. At the time that this event was noticed, the aircraft was approximately 900 feet above its assigned altitude. Shortly after corrective action was begun, ATC queried us about our climbing instead of descending. We replied that we were reversing the climb. The aircraft returned to its assigned altitude, and a visual approach was completed without any further issues.

“[We experienced a] large decrease in indicated airspeed. The event occurred because neither pilot noticed the Flight Mode Annunciator (FMA) entering PITCH MODE. Thrust was added, and then the climb was reversed in order to descend back to our assigned altitude. Both pilots need to reaffirm that their primary duty is to fly and monitor the aircraft at all times, starting with the basics of heading, altitude, airspeed, and performance.”

We encourage you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.We encourage you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Career Opportunities for Candidates with TapRooT® Skills

Posted: May 28th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you are TapRooT® trained, you can rely on your expertise to convey the level to which you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis communicate competency to the potential employer. If you have invested yourself in TapRooT® training and skills, explore professional advancement with confidence through one of these global opportunities.

QHSE Analyst

Associate-Senior Engineer Nuclear (Electrical)

HSE Field Technician

HES Advisor

Senior Process Engineer

Patient Safety Analyst Nurse

Patient Safety Program Coordinator (PSPC)

Safety Professional

Pipeline Risk/Integrity Engineer

Controls Engineer

Group Maintenance Leader

Field Safety Coordinator

If you are not yet TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Gatlinburg, Tennessee, June 4, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

Hamburg, Germany, June 11, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training

Hartford, Connecticut, June 13, 2018: 2-Day TapRooT® Root Cause Analysis Training

Niagara Falls, Canada, June 20, 2018: 2-Day TapRooT Root Cause Analysis Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Lake Tahoe, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT Root Cause Analysis Training

Amsterdam, Netherlands, September 26, 2018:2-Day TapRooT Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139 or 865.357.0080.

Friday Joke

Posted: May 25th, 2018 in Jokes

Join TapRooT® in Niagara Falls

Posted: May 25th, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

In two days with TapRooT®, you will learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and has proven a professional game changer for many.

TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your expertise and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll meet at the Marriott on the Falls Hotel on June 20 for the 2-Day Root Cause Analysis Training course. You will likely want to explore a bit of Niagara Falls so we’ve included highlights of your host city.

Register here to take the TapRooT® course in Niagara Falls. 

 

Experience Niagara Falls

Three waterfalls bridge the international border between Canada’s Ontario province and New York state, forming the southern end of the Niagara Gorge. This is the roar of nature, adventure at its fullest.

Water action
Take a Niagara Hornblower Cruise or cruise via Maid of the Mist close to the bottom of the mighty Niagara Falls and watch the wall of thundering water. Ponchos provided!

Keep the thrills going on another wet visit as you descend an elevator to go through a narrow tunnel—Journey Behind the Falls.

Get close up via a boardwalk. White Water Walk, along the Great Gorge, showcases Class 6 whirlpool rapids in the raging river.

Insider tip: Prepare to get wet (and pack accordingly) for any of the boat adventures!

Want a bird’s-eye view of the falls? Go to the top of Skylon Tower, 775 feet above the falls. There are two fine dining restaurants at the top, a 3D movie theatre, and a Family Fun Centre.

Niagara Gorge Discovery Center is a gateway into short hikes around the falls. Or try Niagara Glen Nature Centre to hike along the Niagara River.

Niagara Adventure Theater is a 45-minute production about settlers, explorers, and the story behind the thundering falls—all within feet of American Falls, Bridal Veil Falls, and the Horseshoe Falls.

Drive over the Rainbow Bridge, an arch bridge across the Niagara River gorge.

Did you know: The Niagara River, along with the Great Lakes Basin, is a legacy of the last Ice Age. 18,000 years ago?

Cycling is a blast here. Take the route along the 56 km path, Niagara River Recreation Trail, connecting Fort Erie to Niagara-on-the-Lake. The route may be started anywhere in the park.

Fancy a wine tour and tastings in Niagara Falls? Two popular opportunities are Winery Tours of Niagara and Discovery Tours Unlimited.

 

Visit Niagara Parks Butterfly Conservancy for a walk through a rainforest setting, viewing over 2000 butterflies.

Did you know: The Niagara River supplies the water for  the falls and its dissolved minerals and limestone create the green color you see?

Niagara Falls eateries
BlueLine Diner, 4424 Montrose Ave.: Huge, delicious pancakes, perfect bacon, wonderful coffee, and more. Bonus: Browse the hockey store attached to this diner.

Flying Saucer, 6768 Lundy’s Ln.:  Up late? Flying Saucer is open until 4 am!  Indulge in eggs, fries, toast, and more.

Koutouki, 5745 Ferry St.: Chicken souvlaki, moussaka, lemon potatoes—great Greek fare.

Fun fact: Niagara Falls State Park is the oldest state park in the nation.

Piccadilly Restaurant, 5501 Ferry St.: Traditional English pub fare and the owners are from the UK. Great fish and chips and chicken curry.

Weinkeller, 5633 Victoria St.: With fare such as house-made wine and fried goat cheese, Weinkiller is upscale and farm-to-table.

Frijoles Fresh Mex Burritos, 3465 Portage Way: Open until 8 pm, this burrito establishment makes everything in house, including all the sauces. Customize your order any way you like. Vegan and vegetarian options.

Tide & Vine, 3491 Portage Rd. or 1523 Niagara Stone Rd.: The freshest oysters and great seafood. Serves local beer and wine.

PhoXyclo, 6175 Dunn St.: You can get a great steaming bowl of pho here, with an sweetness to the broth.

Queen Charlotte Tea Room, 5689 Main St.: The desserts are made from scratch, and tea is always ready. You can also feast on bangers & mash, mushy peas, and  fish & chips.

AG, 5195 Magdalen Ave., Named for silver on the periodic table, this farm-to-table experience is sophisticated, made with fresh ingredients harvested from the AG farm.

Good to know:  U.S. driver’s licenses are valid in Canada, but if you’re visiting from other countries, you’ll need an international driver’s license. A seatbelt must be worn at all times, for both drivers AND passengers. Hand-held electronic devices are banned while driving.

Discover more to explore from our Niagara Falls Pinterest board and begin planning your TapRooT® trip today.

TapRooT® Around the World: Sao Paulo, Brazil

Posted: May 24th, 2018 in Career Development, Courses, TapRooT, Training

This group has been busy this week! Just look at the wall behind them! TapRooT® Instructors Boris Risnic and Marcelo Marquez are shown here with students from the 5-Day TapRooT® Root Cause Analysis Team Leader Training class in Sao Paulo, Brazil.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Below is a sample of our upcoming courses.We are global to meet your needs. If you need other times or locations, please see our courses.

Gatlinburg, Tennessee, June 4, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

Hamburg, Germany, June 11, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Lake Tahoe, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139 or 865.357.0080.

Avoid Big Problems By Paying Attention To The Small Stuff

Posted: May 24th, 2018 in Career Development Tips, Investigations, Topic of the Week, Video

If you didn’t catch the Facebook Live discussion yesterday, join in now to hear TapRooT® professionals Mark Paradies and Benna Dortch discuss this week’s topic: Avoid Big Problems by Paying Attention to the Small Stuff. After you’ve listened to the discussion via the Vimeo below, go to Mark’s article here for further exploration of the precursor mindset.

Avoid Big Problems By Paying Attention To The Small Stuff from TapRooT® Root Cause Analysis on Vimeo

The 2-Day TapRooT® Root Cause Analysis Course is a good choice to send folks to for learning how to investigate precursor incidents. Your best problem-solvers need to learn more to gain the necessary skills for coaching others, and to investigate significant incidents and major accidents; they would attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. And, we can always come to your workplace to teach your team, just let us know or call us: 865.539.2139.

We look forward to being with you on Wednesdays! Here’s how to connect with us for our weekly Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Every Wednesday

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Let us host your TapRooT® VI software!

Posted: May 24th, 2018 in Software, Technically Speaking

Let us take the burden off your company and manage your TapRooT® VI software with our hosting services.

  • We upgrade you to the latest versions, no hassle
  • 3 websites (Prod, Test, and Training)
  • Data Backups and security protection
  • High availability server with 99.9% uptime
  • Https ensures extra layers of security
  • Disaster rollover to another city in the event of a natural disaster
  • 24/7 onsite security and secured access to climate controlled facility
  • SAE 16 Soc type II certification
  • Live US support Monday through Friday
  • Multi-Device and browser support (Firefox, IE, Safari, Chrome)
  • No client-side installations required

Please reach out to us at sales@taproot.com or support@taproot.com to get started!

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Get TapRooT® Trained in Hartford

Posted: May 23rd, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

In two days with TapRooT®, you will learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and has proven a professional game changer for many.

TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your wheelhouse and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll meet at the Hilton Garden Inn Hartford North/Bradley Int’l Airport for the 2-Day Root Cause Analysis Training course.

Register here to take the TapRooT® course in Hartford. 

 

Experience Hartford
Connecticut’s capital, Hartford, is home to beautiful parks, a choice of unique museums, attractions, performing arts and restaurants. See the stunning Connecticut State Capitol, visit the Wadsworth Atheneum, one of the oldest art museums in the U.S., and stroll through the Rose Garden in Elizabeth Park. Best things to do in Hartford include the Connecticut Science Center, the Mark Twain House & Museum and the carousel in Bushnell Park.

Connecticut State Capitol: At 210 Capitol Ave., the marble and granite state capitol building dates from 1871 and is a U.S. National Historic Landmark.

Mark Twain House & Museum: This Victorian Gothic house on Farmington Avenue has 19 rooms and is where Samuel Longhorne Clemens wrote The Adventures of Huckleberry Finn and The Adventures of Tom Sawyer, and where he raised his family.

Wadsworth Atheneum Museum of Art, 600 Main St., was founded in 1842 and opened in 1844, one of the oldest art museums in the U.S. You’ll see French and American Impressionist collections, works by contemporary and modernist artists, landscapes by members of the Hudson River School, American decorative arts, and furniture. The Wadsworth Atheneum is the largest art museum in Connecticut and is listed on the U.S. National Register of Historic Places.

Lincoln Financial Sculpture Walk: Created to honor Abraham Lincoln, the walk includes sculpture installations, murals, and artwork. Noted historian and biographer Doris Kearns Goodwin was instrumental in the launch of the mobile tour, and is the narrator.

Connecticut Science Center: At 250 Columbus Blvd., the Connecticut Science Center is a nine-story science museum with 40,000 square feet of interactive exhibits.

A city park on Asylum Avenue, 102-acre Elizabeth Park is the oldest municipal rose garden in the U.S., with 15,000 rose bushes representing 800 varieties. The Park is also home to an outdoor concert series in the summer, and contains greenhouses, lawns, pathways, a pond, and tennis courts.

Bushnell Park, 30 Arbor St., has its own summer concert series. The park also offers visitors a tour of the Soldiers and Sailors Memorial Arch or a historical tour.

Hartford eateries 
At Bushnell Park (see above), you will find food trucks at the park year round with fare such as the bacon marmalade grilled cheese from Whey Station.

Salute, 100 Trumbull St., in downtown Hartford, is a great “meet and eat” spot, with a robust bar and a creative menu.

BBQ Bear’s Smokehouse, 25 Front St., smokes meats Kansas City-style and boasts “the best ribs in Connecticut,” along with its delicious sides and desserts.

The Capital Grille, 44 Front St., is a great steakhouse with classic American fare in an upscale setting.

The Trumbull Kitchen, 150 Trumbull St., is a stylish eatery featuring a inventive menu—from tasters and tapas to soothing comfort food.

Firebox Restaurant, 539 Broad St., is set in a renovated forge, with an upscale-casual atmosphere and a farm-to-table New American menu.

Sarah’s Coffee House, 257 Asylum St., is farm-to-table and a local charity supporter along with having terrific coffees, teas, smoothies, and pastries.

Homemade doughnuts, breakfast sandwiches, coffee, and more—Tastease, 70 New Park Ave.—is a local favorite.

Family-owned Tangiers, 550 Farmington Ave., is a restaurant and a grocery, specializing in Middle Eastern and Mediterranean fare, such as spicy falafel, chicken gyro, tabbouleh, baklava.

Mozzicato DePasquale Bakery and Pastry Shop, 329 Franklin Ave., is ideal for cocktails, an espresso, a pastry.

Sample a German-Polish smokehouse/deli, Adolf’s Meats & Sausage Kitchen, 35 New Britain Ave., for brats, hams, Canadian bacon, kielbasa, and more.

Stop in at Spigot Cafe, 468 Prospect Ave., for ice-cold brews from around the world. Cash only. Feel free to bring food in to have with your beer!

Discover more to explore from our Hartford Pinterest board and begin planning your TapRooT® trip to Connecticut today.

Why is TapRooT® Root Cause Analysis Software the Best Choice?

Posted: May 23rd, 2018 in Software, TapRooT

Screen Shot 2018 05 04 at 12 23 16 PM

If you are looking for the best root cause analysis software, here are some things to consider:

  1. How the software works is important, but the root cause analysis system that the software uses is probably THE MOST IMPORTANT part of picking your software. No matter how well a bad root cause tool is implemented in software … it is still a bad root cause analysis tool. Therefore, you should look for a world-class root cause analysis tool.
  2. It’s all in the cloud, baby! The days of software just working on one operating system are over. Now your software should be cloud-based and available on a multitude of devices. Mac or PC, laptop or tablet, even phones should be supported.
  3. Able to connect with other software. Does the software play well with others? The root cause analysis software should be able to connect with other ESHQ (Environment, Safety, Health, Quality), human resource, or performance monitoring systems.
  4. Custom reports. Reports the way that you and your management want them. Easy to develop and save. No special software required.
  5. Trends. Advanced trending techniques that help you measure and predict performance.

Sounds great. But where can you find these features? The TapRooT® Version VI Software (of course).

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First, the TapRooT® VI Software is based on the world-class TapRooT® Root Cause Analysis System. If you don’t know why TapRooT® stands head and shoulders above other root cause systems, you should attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and find out. Learn to use SnapCharT® to investigate what happened and organize your evidence. Use Equifactor® to troubleshoot equipment failures. Use Safeguard Analysis to find all the Causal Factors. Use the Root Cause Tree® to find the real, fixable causes of human performance and equipment issues. and use the Corrective Action Helper® Module to develop effective fixes.

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Second, TapRooT® VI Software is cloud-based. You can subscribe as an individual; you can host the TapRooT® VI Software on your network; or we can host the software for your whole company. TapRooT® VI is device independent. Mac, tablet, smartphone. No problem. CONTACT US for more information.

Third, TapRooT® VI Software has an API. This allows easy connections to other software. Talk to our IT guys to find out more. Call 865-357-0080 or CLICK HERE.

Fourth, need a custom report? No problem when you are using TapRooT® VI Software. Have a look at this link to get some ideas … http://www.taproot.com/?s=custom+report.

Fifth, we have been teaching advanced trending techniques for 20 years and they are built into the TapRooT® VI Software. Here’s a short video on exporting trending data to Excel.

But there is more to consider when picking your root cause analysis software. Consider this:

How good is the training?

How good is the software support?

TapRooT® Training is highly rated by students around the world. See samples of what they have to say HERE.

What abut our software support? Outstanding! Our knowledgeable support staff is happy to help you figure things out.

Want more information about TapRooT® VI Software? Let’s do an online demo. CONTACT US to learn more.

“People are SO Stupid”: Horrible Comments on LinkedIn

Posted: May 23rd, 2018 in Accidents, Human Performance, Root Cause Analysis Tips

 

 

How many people have seen those videos on LinkedIn and Facebook that show people doing really dumb things at work? It seems recently LinkedIn is just full of those types of videos. I’m sure it has something to do with their search algorithms that target those types of safety posts toward me. Still, there are a lot of them.

The videos themselves don’t bother me. They are showing real people doing unsafe things or accidents, which are happening every day in real life. What REALLY bothers me are the comments that people post under each video. Again concentrating on LinkedIn, people are commenting on how dumb people are, or how they wouldn’t put up with that, or “stupid is as stupid does!”

Here are a couple examples I pulled up in about 5 minutes of scrolling through my LinkedIn feed.  Click on the pictures to see the comments that were made with the entries:

 

 

 

 

 

 

 

 

 

 

 

Click on picture to watch Video

 

 

 

 

 

 

 

These comments often fall under several categories.  We can take a look at these comments as groups

“Those people are not following safety guideline xxxx.  I blame operator “A” for  this issue!”

Obviously, someone is not following a good practice.  If they were, we wouldn’t have had the issue, right?  It isn’t particularly helpful to just point out the obvious problem.  We should be asking ourselves, “Why did this person decide that it was OK to do this?”  Humans perform split-second risk assessments all the time, in every task they perform.  What we need to understand is the basis of a person’s risk assessment.  Just pointing out that they performed a poor assessment is too easy.  Getting to the root cause is much more important and useful when developing corrective actions.

“Operators were not paying attention / being careful.”

No kidding.  Humans are NEVER careful for extended periods of time.  People are only careful when reminded, until they’re not.  Watch your partner drive the car.  They are careful much of the time, and then we need to change the radio station, or the cell phone buzzes, etc.

Instead of just noting that people in the video are not being careful, we should note what safeguards were in place (or should have been in place) to account for the human not paying attention.  We should ask what else we could have done in order to help the human do a better job.  Finding the answers to these questions is much more helpful than just blaming the person.

These videos are showing up more and more frequently, and the comments on the videos are showing how easy it is to just blame people instead of doing a human performance-based root cause analysis of the issue.  In almost all cases, we don’t even have enough information in the video to make a sound analysis.  I challenge you to watch these videos and avoid blaming the individual, making the following assumptions:

  1.  The people in the video are not trying to get hurt / break the equipment / make a mistake
  2.  They are NOT stupid.  They are human.
  3.  There are systems that we could put in place that make it harder for the human to make a mistake (or at least make it easier to do it right).

When viewing these videos in this light, it is much more likely that we can learn something constructive from these mistakes, instead of just assigning blame.

Join TapRooT®’s Facebook Live Today at Noon EST!

Posted: May 23rd, 2018 in Career Development Tips, Topic of the Week, Video

Join TapRooT® professionals Mark Paradies and Benna Dortch today for our Facebook Live discussion: Avoid Big Problems by Paying Attention to the Small Stuff.

Here’s a sample of the content: What is a precursor incident? A precursor incident is an incident that has low to moderate consequences but could have been much worse if . . .

Join Mark and Benna today to see what comes after the “if.”

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, May 23

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Two Incidents in the Same Year Cost UK Auto Parts Manufacturer £1.6m in Fines

Posted: May 22nd, 2018 in Accidents, Investigations, Performance Improvement, Pictures

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Faltec Europe manufactures car parts in the UK. They had two incidents in 2015 related to health and safety.

The first was an outbreak of Legionnaires’ Disease due to a cooling water system that wasn’t being properly treated.

The second was an explosion and fire in the manufacturing facility,

For more details see:

http://press.hse.gov.uk/2018/double-investigation-leads-to-fine-for-north-east-car-parts-manufacturer-faltec-europe-limited/

The company was prosecuted by the UK HSE and was fined £800,000 for each incident plus £75,159.73 in costs and a victim surcharge of £120.

The machine that exploded had had precursor incidents, but the company had not taken adequate corrective actions.

Are you investigating your precursor incidents and learning from them to prevent major injuries/health issues, fires, and explosions?

Perhaps you should be applying advanced root cause analysis to find and fix the real root causes of equipment and human error related incidents? Learn more at one of our courses:

2-Day TapRooT® RooT® Cause Analysis Course

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

Want to see our courses in Europe? CLICK HERE.

You can attend our training at our public courses anywhere around the world. See the list by CLICKING HERE.

Would you like to sponsor a course at your site? Contact us for a quote by CLICKING HERE.

Connect with TapRooT® in Hamburg

Posted: May 22nd, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

In five days with TapRooT®, you can learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

From beginners to experts, TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper® plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your expertise and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll gather and kick off the 5-Day TapRooT® Advanced Root Cause Analysis Training at the Courtyard by Marriott Hamburg Airport on June 11. You may want to make plans to explore your host city while you’re there. See our travel tips below.

Register here for the course.

Hamburg—Germany’s second-largest city and seaport—offers you lots to explore. Walk along the harbor, see the sights, and plot your Hamburg game plan.

Hamburg highlights
Visit the port. See Hamburg and feel its maritime vibes on a boat tour. View the fish market, pass contemporary seaside architecture and the Elbe beach, touring across the port and back.

Honored as a Historic Landmark of Civil Engineering in Germany, the Old Elbe Tunnel was the first river tunnel on the European continent. Access the entry point from the harbor, walking to Steinwerder and back to St. Pauli in a few minutes.

Marvel at the Museum Ships—such as Rickmer Rickmers and Cap San Diego—Hamburg’s heralded historical ships, moored by the harbor.

If you’re a fan of model ships, U-boats and military history, visit International Maritimes Museum Hamburg, with the world’s largest private collection of maritime treasures, in historic Speicherstadt.

Appreciate the art and architecture of the oldest parish church in Hamburg, St. Peter’s Church, just a few blocks from Town Hall. Bronze lion-head door handles grace the west portal and date from 1342. A gothic mural that dates from 1460 is in the north portion of the church. The bell tower is up 544 steps and offers a grand view over Rathausmarkt, the Town Hall market, and Alster Lake.

Impressive sandstone Town Hall, also called Rathaus or City Hall, houses the senate and parliament among its 647 rooms. Note the staircase made of Sardinian marble, a commentary on the course of human life.

Check out Miniatur Wunderland, the largest model railway in the world. Close to the miniature wonderland, the canal of Nikolaifleet is one of the oldest spots in Hamburg, where you can see well-preserved Old Hamburg townhouses.

St. Pauli is a unique quarter in Hamburg, a great place to walk around and absorb the street art, get a drink, and shop.

Fun fact: Hamburg has more bridges than Venice.

Hop on a double-decker bus for a fun city tour. Take in the Landungsbrücken, the breathtaking harbor, historical Speicherstadt, modern HafenCity, famous Reeperbahn, the ‘Michel,” the Alster, Town Hall, museums, and villas.

Want more action? Take a beach walk on the Elbstrand, bike by Alster Lake, and kayak Hamburg’s canals.

Relax in the Rissen district, by the Elbe River on the Wittenberg shore. Nearby, explore the Wittenberg lighthouse.

Relish the views from the bistro and the collections in noted art museum, Hamburger Kunsthalle.

Taste Hamburg
Nosh at Barefood Deli. This bright, cozy atmosphere was introduced by a famous German actor and is family-owned. Homemade beer and wine, Sunday brunch, DJs in the evening—food and fun for everyone.

Dine with a view of Hamburg harbor at Fischereihafen, where fish dishes rule the day.

Another great fish eatery is Schabi’s Fischimbiss, where you can pick your own fish, eat inside or out, and enjoy the experience.

Insider tip: If you’re more interested in exploring than sitting down to dine, pop into a Hamburg grocery store for cheap-and-go items. Groceries often give out generous samples, so keep your eyes open!

You can see it from the Elbe bridges: Entenwerder 1. What a view from this pontoon eatery! Public Coffee Roasters is next door, so the cappuccino, espresso and coffee are amazing.

In a former pharmacy, the Brooklyn Burger Bar’s offerings are fresh and homemade.

Taste chocolate at Chocoversum. Learn about the process and create your own chocolate bar.

Enjoy Luicella’s Ice Cream in the St. Georg or St. Pauli locations.

Taste Scandinavia at Karlsons, where the Norwegian apple pancake is but one of the offerings you’ll long remember.

Klimperkiste is a bar and an eatery, so you don’t have to choose. Good for all night or a nightcap.

Discover more to explore from our Hamburg Pinterest board and begin planning your TapRooT® trip to Germany today. Download the handy, free Hamburg app here.

Join TapRooT®’s Facebook Live tomorrow!

Posted: May 22nd, 2018 in Career Development Tips, Topic of the Week, Video

Join TapRooT® professionals Mark Paradies and Benna Dortch tomorrow for our Facebook Live discussion: Avoid Big Problems by Paying Attention to the Small Stuff.

Here’s a sample of the content: What is a precursor incident? A precursor incident is an incident that has low to moderate consequences but could have been much worse if . . .

Join us tomorrow for what comes after the “if.”

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, May 23

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

What does a bad day look like?

Posted: May 22nd, 2018 in Bad day

“When you don’t consult an architect, designer or contractor, this is the type of home renovation you’re bound to get. Did it never occur to them to match the exteriors?”

ASSE (Safety 2018) is almost here!

Posted: May 22nd, 2018 in Current Events

The best safety conference of the year. I can’t wait.

If you are attending the conference, please stop by and see us at booth 843. Barb and I will be there. The first 500 people will get a special gift, so don’t miss out!

See you in San Antonio!

Thanks to all my Linkedin Connections

Posted: May 22nd, 2018 in Current Events

I have reached 20,000 Linkedin connections! Thank you for your support!

If we are not yet connected, please send me a REQUEST

Technically Speaking – Helpdesk Humor

Posted: May 21st, 2018 in Software, Technical Support, Technically Speaking

Would you consider this a good Safeguard? Of course not! Thinking of implementing new safeguards at the company you work for? Get some great ideas at one of our upcoming TapRooT® training courses. Take a look at your next course here.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, it doesn’t mean it has to be complicated!

Monday Accidents & Lessons Learned: The Worst U.S. Maritime Accident in Three Decades

Posted: May 21st, 2018 in Accidents, Great Human Factors, investigation, Investigations

The U.S.-flagged cargo ship, El Faro, and its crew of 33 men and women sank after sailing into Hurricane Joaquin. What went wrong and why did an experienced sea captain sail his crew and ship directly into the eye of a hurricane? The investigation lasted two years. 

One of two ships owned by TOTE Maritime Inc., the El Faro constantly rotated between Jacksonville, Florida, and San Juan, Puerto Rico, transporting everything from frozen chickens to milk to Mercedes Benzes to the island. The combination roll-on/roll-off and lift-on/lift-off cargo freighter was crewed by U.S. Merchant Marines. Should the El Faro miss a trip, TOTE would lose money, store shelves would be bare, and the Puerto Rican economy would suffer.

The El Faro, a 790-foot, 1970s steamship, set sail at 8:15 p.m. on September 29, 2015, with full knowledge of the National Hurricane Center warning that Tropical Storm Joaquin would likely strengthen to a hurricane within 24 hours.

Albeit with modern navigation and weather technology, the aging ship, with two boilers in need of service, with no life vests or immersion suits, was equipped with open lifeboats that would not be launched once the captain gave the order to abandon ship in the midst of a savage hurricane.

As the Category 4 storm focused on the Bahamas, winds peaking at 140 miles an hour, people and vessels headed for safety. All but one ship. On October 1, 2015, the SS El Faro steamed into the furious storm. Black skies. Thirty to forty foot waves. The Bermuda Triangle. Near San Salvador, the sea freighter found itself in the strongest October storm to hit these waters since 1866. Around 7:30 a.m. on October 1, the ship was taking on water and listing 15 degrees. Although, the last report from the captain indicated that the crew had managed to contain the flooding. Soon after, the freighter ceased all communications. All aboard perished in the worst U.S. maritime disaster in three decades. Investigators from the National Transportation Safety Board (NTSB) were left to wonder why.

When the NTSB launched one of the most thorough investigations in its long history, they spoke with dozens of experts, colleagues, friends, and family of the crew. The U.S. Coast Guard, with help from the Air Force, the Air National Guard, and the Navy, searched in a 70,000 square-mile area off Crooked Island in the Bahamas, spotting debris, a damaged lifeboat, containers, and traces of oil. On October 31, 2015, the USNS Apache searched and found the El Faro, using the CURV 21, a remotely operated deep ocean vehicle.

Thirty days after the El Faro sank, the ship was found 15,000 feet below sea level. The images of the sunken ship showed a breach in the hull and its main navigation tower missing. 

Finally came the crucial discovery when a submersible robot retrieved the ship’s voyage data recorder (VDR), found on Tuesday, April 26, 2016, at 4,600 meters bottom. This black box held everything uttered on the ship’s bridge, up to its final moments.

The big challenge was locating the VDR, only about a foot by eight inches. No commercial recorder had ever been recovered this deep where the pressure is nearly 7,000 pounds per square inch.

The 26-hour recording converted into the longest script—510 pages— ever produced by the NTSB.  The recorder revealed that at the outset, there was absolute certainty among the crew and captain that going was the right thing to do. As the situation evolved and conditions deteriorated, the transcript reveals, the captain dismissed a crew member’s suggestion that they return to shore in the face of the storm. “No, no, no. We’re not gonna turn around,” he said. Captain Michael Davidson then said, “What I would like to do is get away from this. Let this do what it does. It certainly warrants a plan of action.” Davidson went below just after 7:57 p.m. and was not heard again nor present on the bridge until 4:10 a.m. The El Faro and its crew had but three more hours after Davidson reappeared on the bridge, as the recording ends at 7:39 a.m., ten minutes after Captain Davidson ordered the crew to abandon ship.

This NTSB graphic shows El Faro’s track line in green as the ship sailed from Jacksonville to Puerto Rico on October 1, 2015. Color-enhanced satellite imagery from close to the time the ship sank illustrates Hurricane Joaquin in red, with the storm’s eye immediately to the south of the accident site.

The NTSB determined that the probable cause of the sinking of El Faro and the subsequent loss of life was the captain’s insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew. Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions. Also contributing to the sinking was the inadequacy of both TOTE’s oversight and its safety management system.

The NTSB’s investigation into the El Faro sinking identified the following safety issues:

  • Captain’s actions
  • Use of noncurrent weather information
  • Late decision to muster the crew
  • Ineffective bridge resource management
  • Company’s safety management system
  • Inadequate company oversight
  • Need for damage control plan
  • Flooding in cargo holds
  • Loss of propulsion
  • Downflooding through ventilation closures
  • Need for damage control plan
  • Lack of appropriate survival craft

The report also addressed other issues, such as the automatic identification system and the U.S. Coast Guard’s Alternate Compliance Program. On October 1, 2017, the U. S. Coast Guard released findings from its investigation, conducted with the full cooperation of the NTSB. The 199-page report identified causal factors of the loss of 33 crew members and the El Faro, and proposed 31 safety recommendations and four administrative recommendations for future actions to the Commandant of the Coast Guard.

Captain Jason Neubauer, Chairman, El Faro Marine Board of Investigation, U.S. Coast Guard, made the statement, “The most important thing to remember is that 33 people lost their lives in this tragedy. If adopted, we believe the safety recommendations in our report will improve safety of life at sea.”

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