Category: Topic of the Week

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

May 23rd, 2018 by

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

Join TapRooT®’s Facebook Live tomorrow!

May 22nd, 2018 by

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

Why Use the TapRooT® Root Cause Analysis Method for Quality?

May 21st, 2018 by

If you missed the Quality Problem-Solving session on Facebook Live with TapRooT® professionals Benna Dortch and Chris Vallee, here is another opportunity to get in on the discussion.

Why use the TapRooT® Root Cause Analysis Method for Quality from TapRooT® Root Cause Analysis on Vimeo.

Chris has brought our clients a keener understanding of “quality” with his expertise. Here is a sample:

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine, etc.) or recalls that may be impacting us today (air bags). These recalls all have a major theme—a company made something and somebody got hurt or worse. This is a theme of “them versus those” perception.

Stop and ask, When is the last time quality and safety were discussed as one topic in your current company’s operations?

You received a defective tool or product …
You issued a defective tool or product …
A customer complained …
A customer was hurt …

Each of the occurrences above often triggers an owner for each type of problem:

The supplier …
The vendor …
The contractor …
The manufacturer …
The end user …

We can stop and ask, Who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development, or corrective action implementation?

This is where we create our own internal silos for problem-solving; each problem often has its own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments’ training and experiences.

Does anyone else see a problem or an opportunity here?

Circle your calendar for Facebook Live this Wednesday and connect with us:

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

When? Wednesday, May 23

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

NOTE: Remember to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

See you today for TapRooT® Facebook Live at noon Eastern

May 16th, 2018 by

Tune into TapRooT®’s Facebook Live today as we talk with TapRooT® Senior Associate Chris Vallee about Quality Problem Solving. 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 16

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

NOTE: Remember to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training

May 11th, 2018 by

Last week on TapRooT® TV, Michelle Wishoun and Benna Dortch discussed how to efficiently navigate our TapRooT® and the positive impact it can have on your professional career. We pack a lot into our blog!

Among our blog features are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

We always 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? Every Wednesday

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

Catch up on the conversation with Michelle and Benna  via Vimeo:

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training from TapRooT® Root Cause Analysis on Vimeo.

If you want to chime in the conversation, or have a question or comment, feel free to shout out here and we’ll get right back to you. Thank you for watching TapRoot® TV!

Auditing: A better way to approach investigations on problems and losses

May 10th, 2018 by

This Wednesday, for our Facebook Live discussion, TapRooT® professionals Benna Dortch and Dave Janney tackled why companies are not proactive in addressing and solving recurring problems and the key differences between incident investigation root cause analysis and the root cause analysis of audit findings. Within this conversation, we touched on inadequate or ineffective audits and why it is those fall short of yielding improvements.

Dave’s book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, is part of the TapRooT® for Audits set that fleshes out the topic of audits into seven steps. Feel free to order the set and call on us for further discussion or a training course.

Watch the discussion via Vimeo

Why are Auditing and Proactive Improvement so important? from TapRooT® Root Cause Analysis on Vimeo.

Tune in for our Wednesday Facebook Live next week. We look forward to being with you on Wednesdays! Here’s how to connect with us for next week’s Facebook Live:

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

When?  Wednesday, May 16

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

 

See you today on Facebook Live!

May 9th, 2018 by

Ben Franklin said it best, “An ounce of prevention is worth a pound of cure.” How can being proactive turn your organization around? A root cause audit can address many problems and losses that persistently plague companies. Join today’s Facebook Live discussion between TapRooT® professionals Benna Dortch and Dave Janney as they evaluate audits and proactive improvements and how they figure in your organizational planning.

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? Today, Wednesday, May 9

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

Join TapRooT®’s Facebook Live tomorrow

May 8th, 2018 by

We cannot overstate Ben Franklin’s sage advice in his safety axiom, “An ounce of prevention is worth a pound of cure.” Many problems and losses that persistently plague companies can be best addressed by proactively performing a root cause audit. Join the discussion between TapRooT® professionals Benna Dortch and Dave Janney as they evaluate audits and proactive improvements and how they figure in your organizational planning.

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 9

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

Last week, Michelle Wishoun and Benna Dortch discussed how to efficiently navigate our TapRooT® blog and the significantly positive impact it can have on your professional career. Connect to this important discussion via our Vimeo.

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training from TapRooT® Root Cause Analysis on Vimeo.

Tips, Tricks, & Tools: Discover how TapRooT®’s blog can help you

May 2nd, 2018 by

Tune into TapRooT®’s Facebook Live today. Join TapRooT® professionals Benna Dortch and Michelle Wishoun as they discuss the TapRooT® blog and how its contents can make a significant difference in your professional life. Among blog features to be discussed are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

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 2

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

If you missed last week’s Facebook Live session with TapRooT®’s Benna Dortch and Barb Carr as they discussed the benefits of hands-on learning, catch up on the discussion via the Vimeo below. Feel free to comment or ask questions on our Facebook page.

TapRooT® TV – Benefits of Hands On Learning from TapRooT® Root Cause Analysis on Vimeo.

NOTE: Remember to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Join us for Facebook Live tomorrow: What TapRooT®’s blog can do for you

May 1st, 2018 by

Join TapRooT® professionals Benna Dortch and Michelle Wishoun as they discuss the TapRooT® blog and how its contents can make a significant difference in your professional performance and development.

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 2

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

Among blog features to be discussed are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

Lunch & Learn: Meet TapRooT® at noon EST on Facebook Live!

April 18th, 2018 by

Tune into TapRooT®’s Facebook Live today. You’ll join TapRooT® professionals as we explore a contemporary, workplace-relevant topic. 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, April 18

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

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

NOTE: Remember to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

You’re invited to Facebook Live for Wednesday lunch

April 16th, 2018 by

We invite you to tune into TapRooT®’s Facebook Live every Wednesday. You’ll be joining TapRooT® professionals as we bring you a contemporary, workplace-relevant topic. Put a reminder on your calendar, in your phone, or stick a post-it on your forehead to watch TapRooT®’s Facebook Live this week for another terrific discussion and for news you can use. We look forward to being with you on Wednesdays!

Here’s how to connect with us for Wednesday’s Facebook Live:

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

When? Wednesday, April 18, 2018

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

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

NOTE: Be sure to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

The Scientific Method In Relation To Root Cause Analysis

April 13th, 2018 by

Did you miss last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation? Here’s an opportunity to catch up on the discussion, as Mark and Barb distill the disciplines and factors that historically have been involved in solving complex problems. Also, peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

Tune into TapRooT®’s Facebook Live every Wednesday. You’ll be joining TapRooT® professionals as we bring you a workplace-relevant topic. Put a reminder on your calendar or in your phone to watch TapRooT®’s Facebook Live this week for another terrific discussion and for news you can use. We look forward to being with you on Wednesdays!

Here’s the info you need to connect with us for our next Facebook Live:

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

When? Wednesday, April 18, 2018

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

NOTE: Save the date for 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Tune in today: Is the scientific method best for root cause analysis?

April 11th, 2018 by

Scribble yourself a note to clear your calendar at lunchtime today. You don’t want to miss TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discuss methodologies for root cause analysis in incident investigation. You may hear some namedropping, such as “Albert Einstein” and “Isaac Newton,” as Mark and Barb distill the disciplines and factors that historically have been involved in solving complex problems. Take time to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

Here’s the info you need to connect with us today:

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

When? Today! April 11, 2018

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

In last week’s Facebook Live session, we delved into the timely topic of autonomous vehicles. Join the conversation below with Ken Reed and Benna Dortch as they discuss safety and other factors surrounding these vehicles. After listening to Ken and Benna, post your comments here. As always, we look forward to chatting with you!

Be sure to tune into TapRooT®’s Facebook Live every week. You’ll be joining TapRooT® professionals as we bring you a workplace-relevant topic. Put a reminder on your calendar or in your phone to watch TapRooT®’s Facebook Live next week for another terrific discussion and for news you can use.

NOTE: Save the date for 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Wednesdays & TapRooT® Topics: How safe is safe enough? Are you ready for autonomous vehicles?

April 9th, 2018 by

When we delve into the timely topic of autonomous vehicles, we encounter myriad discussion points. Join the conversation with Ken Reed and Benna Dortch as they discuss the safety factors involved with autonomous vehicles. After listening to Ken and Benna, post your comments here. We look forward to chatting with you!

Be sure to tune into TapRooT®’s Facebook Live every week. You’ll be joining TapRooT® professionals as they bring you a workplace-relevant topic with takeaways.

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

When? Every Wednesday (The next one is April 11, 2018.)

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

If you missed the recent FB Live session, featuring Benna Dortch and Barb Carr discussing Effective Listening Skills Inventory for Investigative Interviews, be sure to tune into this one to incorporate great takeaways. Put a reminder on your calendar or in your phone to watch TapRooT®’s Facebook Live next week for another terrific discussion and for news you can use.

NOTE: Save the date for 2019 Global TapRooT® Summit: March 11-15, in Houston, TX (La Torretta Lake Resort)!

Have Wednesday lunch with us! Watch Facebook Live at noon (EST)!

April 4th, 2018 by

Be sure to catch TapRooT®’s Facebook Live session today. You’ll be joining TapRooT®’s VP Ken Reed and Implementation Strategist Benna Dortch as they bring you a workplace-relevant topic with takeaways.

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

When? Today, Wednesday, April 4

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

If you missed last week’s FB Live session, featuring Benna Dortch and Barb Carr discussing Effective Listening Skills Inventory for Investigative Interviews, be sure to tune into this one to incorporate great takeaways. Put a reminder on your calendar or in your phone to watch TapRooT®’s Facebook Live next week for another terrific discussion and for news you can use.

NOTE: Save the date for 2019 Global TapRooT® Summit: March 11-15, in Houston, TX (La Torretta Lake Resort)!

Effective Listening Skills Inventory for Investigative Interviews

March 29th, 2018 by

Do you ever interrupt someone because you fear “losing” what you want to say? Do you become momentarily engrossed in your thoughts, then return to reality to find someone awaiting your answer to a question you didn’t hear? Most of us are at fault for interrupting or being distracted from time to time. Particularly, though, in an interview environment where focus is key, distractions or interruptions can be detrimental to the interview.

Watch, listen, learn from this week’s conversation between Barb Carr and Benna Dortch:

Effective Listening Skills Inventory For Investigation Interviews from TapRooT® Root Cause Analysis on Vimeo.

Now, learn how to inventory your listening skills. Internalizing suggestions can recalibrate your thought and communication processes. Your work and your communication style will reflect the changes you’ve made.

Feel free to comment or ask questions on Facebook. We will respond!

Bring your lunch next Wednesday and join TapRooT®’s Facebook Live session. You’ll pick up valuable, workplace-relevant takeaways from an in-depth discussion between TapRooT® professionals. We’ll be delighted to have your company.

Here’s the scoop for tuning in next week:

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

When? Wednesday, April 4, 2018

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

Thank you for joining us!

Active Listening Inventory

March 28th, 2018 by

Are you a good listener? No one is born that way. Listening is a learned skill and practice makes perfect. Read through the following inventory statements and check for areas where you can improve your skills.

1. I listen without interrupting or finishing another’s sentences.
2. I am comfortable with long pauses in conversation.
3. I don’t “tune-out.”
4. I avoid distractions when listening.
5. I respond appropriately when someone is talking to let them know I am listening.
6. I am patient.
7. When someone is speaking, I am listening and not thinking of my next question or comment.
8. I am aware of my non-verbal messages as well as those displayed by others.

Join Us for Facebook Live Wednesday, February 21 at Noon EST

February 19th, 2018 by

So… you took a TapRooT® course.  Is there anything you can do now to continue performance improvement? Join Dave Janney and Benna Dortch as they discuss training options that can boost your career on Facebook Live.

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

When? Wednesday, February 21, 2018

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

Join Us for Facebook Live, Wednesday, February 14 at Noon EST

February 13th, 2018 by

Why do we work so hard on root cause analysis? Because we want effective corrective actions! Join Ken Reed and Benna Dortch as they discuss innovative correction actions on Facebook Live.

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

When? Wednesday, February 14, 2018

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

Another 5-Why Example … Good or Bad?

February 4th, 2010 by

Here’s a 5-Why example from a recent posting on Business Week “Modern Analyst” saying how wonderful 5-Why’s is.

Issue: Employees did not receive their pay stubs on pay day.

· Why? Because the printing system failed the day before pay day.

· Why? Because the system could not recover from a hardware fault.

· Why? Because the system uses outdated hardware that has no automatic redundant backup.

· Why? Because the system hasn’t been replaced as it hasn’t been identified as a high enough priority to allocate budget to its replacement in the current economic climate.

· Why? Because the organization does not have an enterprise planning methodology that weighs the risks of current operational systems failing versus the criticality of these systems and the impact of such a failure.

Well, what do you think? Good or bad example?

What do you think of their “root cause”?

I’ll wait for others to post to share my ideas…

NTSB Finds That Pilot Srewed Up … BUT WHY?

February 3rd, 2010 by

Here’s the press release from the NTSB:

****************************************************

NTSB PRESS RELEASE

*********************************************

National Transportation Safety Board

Washington, DC 20594

FOR IMMEDIATE RELEASE: February 2, 2010

SB-10-02

*********************************************

CAPTAIN’S INAPPROPRIATE ACTIONS LED TO
CRASH OF FLIGHT 3407 IN CLARENCE CENTER,
NEW YORK, NTSB SAYS

********************************************

The National Transportation Safety Board determined that the captain of Colgan Air flight 3407 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.


In a report adopted today in a public Board meeting in

Washington, additional flight crew failures were noted as causal to the accident.


On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport.


The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post-crash fire. The flight was a 14 Code of Federal Regulations (CFR)Part 121 scheduled passenger flight from Newark, New Jersey. Night visual meteorological conditions prevailed at the time of the accident.


The report states that, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column.


However, the captain inappropriately pulled aft on the control column and placed the airplane into an accelerated aerodynamic stall.


Contributing to the cause of the accident were the

Crew members’ failure to recognize the position of the low-speed cue on their flight displays, which indicated that the stick shaker was about to activate, and their failure to adhere to sterile cockpit procedures.


Other contributing factors were the captain’s failure to effectively manage the flight and Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.


As a result of this accident investigation, the Safety Board issued recommendations to the Federal Aviation Administration (FAA) regarding strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training, and airspeed selection procedures. Additional recommendations address FAA’s oversight and use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, use of personal portable electronic devices on the flight deck, and weather information provided to pilots.


At today’s meeting, the Board announced that two issues that had been encountered in the Colgan Air investigation would be studied at greater length in proceedings later this year.


The Board will hold a public forum this Spring exploring pilot and air traffic control high standards.


This accident was one in a series of incidents investigated by the Board in recent years – including a mid-air collision over the Hudson River that raised questions of air traffic control vigilance, and the Northwest Airlines incident last year where the airliner overflew its destination airport in Minneapolis because the pilots were distracted by non-flying activities – that have involved air transportation professionals deviating from expected levels of performance.


In addition, this Fall the Board will hold a public forum on code sharing, the practice of airlines marketing their services to the public while using other companies to actually perform the transportation. For example, this accident occurred on a Continental Connection flight, although the transportation was provided by Colgan Air.


A summary of the findings of the Board’s report are available on the NTSB’s website at:


http://www.ntsb.gov/Publictn/2010/AAR1001.htm


NTSB Media Contact:     Keith Holloway

hollow@ntsb.gov

(202) 314-6100

*************************************************************************

Now – What do you think….

Does that sound like root causes?

I’d like to know why a trained pilot would pull back on a stick when the stick shaker activates.

And I don’t think the fact that they were talking in thew cockpit has anay thing to do with it.

Ideas????

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