April 8, 2009 | Dave Janney

NTSB: Multiple Lapses Cited in 2007 American Airlines Engine Fire

Here is the story:


Multiple Lapses…….hmm….does this sound familiar? 

In this case, their oversight failed to identify problems, their troubleshooting resulted in wasted efforts trying to fix a problem, an unapproved tool was used, and finally, the emergency response lacked (duties not delegated, in TapRooT® terms, Crew Teamwork NI). 

Defense in Depth (Multiple Safeguards) failed and led to the accident.

What is the common thread in all these failures?  Human Error.

If you want to learn how to investigate human performance problems, proactively monitor performance and put best practices in place to avoid these types of problems, attend a TapRooT® course.  The schedule and course enrollment link is here:


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