The keynote · Delivered by Frank Tsuro
Fix the system, not the pilot.
What aviation learned by refusing to accept human error as an explanation. A keynote from FranklySpeaking, delivered by our founder.
The audience stops looking for who to blame
They start looking for what made the mistake likely. That one change makes the next incident less probable.
The room leaves with
The trigger and the conditions
The difference between the immediate trigger and the conditions already in place, and what each costs to fix.
The room leaves with
Never one big cause
Why a serious failure usually rests on several small factors, not one big one.
The room leaves with
When blame stops coming first
What changes in an organisation the day blame stops being the first question.
The talk in 3 movements
Pilot error
For most of the 20th century, aircraft accident reports ended with pilot error. The next crew sat in the same seat, in front of the same instruments.
The decision that changed aviation
The industry decided that human error would start an investigation, not end it. If a capable crew did something that killed them, the question became what made that action reasonable at the time.
Inside your organisation
The same discipline, applied to business failure: separate the trigger from the conditions, show what each costs to fix and what a leadership team must do to hold the change in place.
A capable person doing something dangerous is a fact about the conditions, not about the person.
4 ways to bring it to your organisation
For operating businesses where failure is visible and expensive: energy, telecoms, mining, ports, logistics, construction, financial services and regulators.
45–60 minutes
Keynote
For leadership conferences, executive teams and boards. The talk ends with a question your people can ask on Monday.
Half day
Keynote and workshop
Applied to one of your own incidents, closed and safe to discuss. Every participant receives an editable workbook.
90 minutes
Board or risk committee session
For directors who receive incident reviews. It ends with a written standard for the reviews the board will accept.
45–60 minutes
Panel or moderated conversation
As panellist or chair. 6 questions that open a real conversation, not a speech.
How booking works
Fees depend on the room and what it is for. They are agreed before anything is booked. Dates are held for 10 working days while you get approval.
Before
A 15-minute call on who is in the room and what they need to leave with. Then 2 or 3 background conversations with your people, 20 minutes each, in confidence.
On the day
Slides 48 hours ahead, as PDF and PowerPoint. Frank works from the stage, not from a lectern.
After
A one-page delegate follow-up with the 3 questions from the talk, yours to circulate.
The keynote comes from our investigation work.
It gives a room the core of the method in under an hour.