December 15, 2009 | Mark Paradies

More on the Colgan Air Crash Near Buffalo

Here’s a story from CNN:

I can’t help but think that the company comments sound a lot like the comments from BP’s management after the Texas City refinery explosion.

Of course, management is right … Crew errors did lead to the crash. Planes seldom fall from the sky without crew errors. (Although there are notable exceptions.)

The real questions is WHY (what are the root causes) of the crew errors and bad behaviors.

Often, management doesn’t want to talk about these problems because fixing them requires changes in things that management controls:

– Training

– Procedures

– Human Engineering

– Work Direction

– Management Systems

– Communications

– Quality Control

Now for comparing the Colgan Air Crash and the BP Texas City explosion … When you start looking into the details, there are lots of similarities:

– Crew fatigue

– Not following procedures and shortcutting checklists

– Operators/pilots making basic mistakes

– Inexperienced crews responding to the unexpected

Let’s wait for the NTSB report before we jump to conclusions, but I’d recommend that management dig deeper when they look at blame as the cause of an accident.

Root Cause Analysis
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