Category: Topic of the Week

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.


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.


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 Because the system uses outdated hardware that has no automatic redundant backup.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:




National Transportation Safety Board

Washington, DC 20594






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:

NTSB Media Contact:     Keith Holloway

(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.


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