It Keeps Coming Back
You have restructured the same area more than twice, and the problem returned each time. If the structure were the cause, the first change would have fixed it.
What we do
Before something fails
When it keeps failing
Your organisation
Defences ReviewFind the gaps before they line up InvestigationFind the cause and fix itAn AI system
AI Decision Review NewBefore the board approves it AI Decision Review NewAfter a decision goes wrongThe keynote: Fix the System, Not the PilotAll services and fees
Always the first step
The first meeting
90 minutes with the executive who would sponsor the work. No fee.
Organisational investigations // For boards and chief executives
When a problem survives 2 restructures, the cause is usually in the system, not the people. We investigate it the way air accident investigators examine a crash. Your board receives a written finding: what is causing the problem, what it costs and what to change.
Exhibit 01 // The story
Our founder’s own story, and the reason this approach exists.
The board reviewed a green dashboard.
A systems change had stalled. The people doing the work knew why. Nobody could say so.
The chair asked our founder to find out. He listened to the people doing the work.
The chair heard the truth. The board changed the targets.
The system launched.
Ask it of every green report: who told us, and how do they know?
Nobody lied. Each layer softened the bad news a little, and the softening added up. We find out what the people doing the work already know, and put it in writing for the board.
Exhibit 02 // The problem
If one of these describes your organisation, the cause is unlikely to be the people you have been changing.
At a mobile operator, an outage of a few minutes can stop calls and payments for millions of people. At a mine, one power failure can stop production for a whole shift. These are the organisations we work for. These are the people who call us.
Exhibit 03 // Why the cause hides
Our method is adapted from air accident investigation. Investigators there may not ask whose fault it was, because blame does not prevent the next accident. They ask what made the mistake likely.
Every organisation leans on 5 defences. Each one has gaps. A failure gets through only when the gaps line up.
Select a defence to weaken it, or select it again to make it sound.
Exhibit 04 // The plan
A fixed scope and a fixed fee, agreed before we start.
Week 0 // No fee
90 minutes with the executive who would sponsor the work. You leave with a clear answer on whether an investigation is worth doing.
Weeks 1–14
Confidential interviews, from the leadership team to the front line. Your board receives a written finding: what is causing the problem, what it costs and what to change.
Weeks 12–28
Using the FRANK Method™, every change gets one owner and a test anyone can check. We support your team for 12 weeks, then step back.
Exhibit 05 // What is at stake
If nothing changes
After the investigation
How we work // The FRANK Method™
Every engagement has 2 halves, in this order. The investigation looks back, to find what is actually causing the problem. The FRANK intervention looks forward, to make sure the problem does not come back.
Rather listen?
The method, as a conversation, in 10 minutes
Generated from the FranklySpeaking documents. It describes the method, not a client.
The timeline
The same steps in every engagement. Select a step to see what it involves.
Part 1 // The investigation
Part 2 // The FRANK intervention
How we get to the truth
Sponsors often ask: if my people will not tell me, why would they tell you? The method does not depend on it.
We ask people to walk us through real events. A specific story is much harder to spin than an opinion.
Nobody is being judged, so nobody needs to defend themselves.
Nothing reaches you with a name on it. We sit outside your reporting line, and we leave.
We ask everyone the same questions. Where their answers about the same meeting do not match, we know where to look.
A claim becomes a finding only when a second source agrees: another person, a document or a number.
One person can spin a story. 12 people, the minutes and the budget cannot all spin it the same way.
Trace the cause
We follow each problem back to the conditions that made it likely. The failure everyone sees comes last. The conditions were in place long before.
The organisation’s flight recorder // Specimen
Month 0Nothing on the record looks wrong yet.
An accident does not begin when something goes wrong. It begins when the system stops being able to see itself.
Part 2 // The FRANK intervention
Find out what is really happening. Then fix what is causing it.
We put the facts and the evidence in front of the team as one shared picture, so the conversation afterwards stands on solid ground.
We check whether what the team did matches what it agreed to do. The question is what the system was missing, not who is at fault.
We put a number on it: delay, rework, replacement costs, slow decisions and penalty exposure. A board can act on a finding it can price.
We agree exactly what changes, who owns each change and how anyone outside the room could tell it was done.
12 weeks of putting the changes into practice, tracked against the register, with our support withdrawn on a schedule you can see in advance.
Change only sticks when people agree on 3 things, in this order: what happened, what it costs and what will change.
What you receive
A written position on 3 things: whether this looks like a system problem, what an investigation would examine and what it would cost. If there is nothing worth investigating, the first paragraph says so and you pay nothing. Otherwise the report costs US$2,500, and if you go ahead with the investigation, we deduct it from the fee.
Numbered findings, one to a page. Each carries the pattern, the evidence and the consequence. How many people we heard it from is in the sentence.
Every change scored for severity, likelihood and how easily it would be spotted. Each has one named owner and a completion test anyone could check.
A published schedule for withdrawing our support, with the register re-scored at each step. Your board keeps the register when we leave.
An investigation with no intervention is an expensive document.
Where it comes from
Neither is a management theory. That is deliberate. Management theory comes from the same field that produces the failures we are called in to examine.
Inspiration 1 // Aircraft accident investigation
Investigators may not ask whose fault it was. This is not kindness. Blame does not work. Replace the pilot, and the next pilot sits in the same seat, in front of the same faulty instrument, trained on the same rushed schedule. The accident happens again.
So investigators ask a different question: what did this person believe was true when they acted, and what made it impossible for them to know otherwise? Asked in a boardroom instead of a cockpit, that question is the whole method.
Inspiration 2 // Undercover Boss
In the television series Undercover Boss, a chief executive works inside their own organisation as nobody in particular, and the truth they hear changes at once. People were not lying before. Telling your boss bad news carries real risk, and removing the boss removes the risk.
We do not go undercover on client work. We take the lesson, not the disguise: hierarchy filters the truth before it reaches the top.
The discipline comes from a field that proved blame makes outcomes worse. The starting point comes from what changes when hierarchy is removed. Neither idea is ours. Applying both to one leadership team, in a bounded and independent way, is.
The 6 disciplines
Adopted by the International Civil Aviation Organization in 1951 as Aircraft Accident and Incident Investigation. It is the international standard for investigating a crash.
Used in the investigation, phase 1
Set out by James Reason in 1990. Every defence has gaps. A failure happens when several gaps line up on the same path.
Used in the investigation, phase 4
Set out by Dr Mica Endsley in 1988, in 3 levels: perceiving the data, understanding what it means and predicting what happens next. Most executive failures happen at the second level, not the first.
Used in the investigation, phase 2
Developed by Sidney Dekker. It asks what the system needs to learn, not who deserves blame. That is what keeps a team honest once a finding becomes uncomfortable.
Used in the intervention, Reflect
Developed after well-trained flight crews kept making avoidable, fatal mistakes because a junior officer would not challenge a captain.
Used in the investigation, phase 4
A register kept after the intervention closes. It scores each remaining risk, so a gap that starts to reopen is caught early.
Used in the intervention, Kickstart
When the evidence points to a person
It decides what happens next, and no checklist can make the call for you.
The information never arrived
The system filtered, softened or never delivered the information that would have changed the decision. This is a fault in the system. Fixing how information travels is part of the FRANK intervention.
The information arrived
The information reached the decision-maker clearly, and nothing followed. We do not judge why. We show what arrived, when and what followed, each confirmed by a second source.
Who makes the call. We establish the facts. The board makes the call. A finding says nothing about motive or character, and makes no recommendation about anyone’s job. The person concerned sees it first and can respond, as people involved can with a draft air accident report. The board then receives every finding in full and decides whether it was a choice, and what to do.
We protect sources, not decisions. Everything people tell us stays confidential. Decisions taken with authority are not hidden.
12–16 weeks to a finding, a fixed fee agreed before it starts, and 12 weeks of support while the fix takes hold.
Cases // 6 investigations, disguised
Names, countries, dates and exact figures are altered. The mechanism, the sequence and the order of magnitude are not. Open any file for the full story.
The case files
In every one, a capable leadership team was producing a result it had not chosen. In none of them was anybody hiding anything. They are ordered by what the problem was costing.
Quarterly targets missed 3 times despite heavy network investment. Functions blaming each other. A restructure under consideration that would have removed 2 executives.
Board packs and minutes against the organisation chart people actually use. One-to-one sessions across the executive team and the layer below it.
3 members of the executive team were working to 3 different versions of the strategy. Disagreement between them appeared nowhere in the record.
Duplicated investment and resource conflict, modelled at US$38m a month. That number moved the conversation from alignment as a value to alignment as a line in the accounts.
The turning point14 decisions across 22 months, traced and dated. Each one made complete sense if you believed the version of the strategy that person believed.
The question for your board: Would 5 of your executives describe the strategy the same way?
A new core banking system, approved 3 years running and late every year. The executive committee had settled on the view that it was a supplier problem.
What the committee approved, set against what the budget actually released, year by year. Sessions with the committee and with the finance team that set the budget.
The committee approved the programme in full. The budget was set months later by a different team, on a different timetable, treating it as one request among many. Neither side knew the other was working from a different number.
Delay and rework on the new system, modelled at US$12m–18m a month, before counting what the missing capability was worth.
The turning pointneither team owned the contradiction. Both were doing their job correctly. The money went into the gap between them.
The question for your board: What did we approve last year, and how much of it was actually funded?
4 years of internal audits passed with perfect marks. The chief risk officer could not point to anything wrong and did not believe the record.
5 years of audit findings against what people described in session. Where a concern had been raised, and what happened to the person who raised it.
A concern raised publicly 5 years earlier had been answered publicly and badly. The lesson the organisation drew was that raising a concern costs you something.
17 issues downgraded before they reached the executive layer, 3 of them still live, with combined exposure modelled at US$90m.
The turning pointthe audits were accurate. They recorded what had been reported, and what had been reported was shaped by one incident 5 years earlier.
The question for your board: When did someone last raise a concern early here, and what happened to them?
3 restructures of one reporting line in 4 years. Structure had been the answer often enough that somebody on the board began to doubt it.
A dated timeline of all 3 restructures, followed back 4 levels past the symptom, separating the immediate triggers from the conditions that came before all of them.
Decision rights were redrawn every time. What people were actually allowed to approve stayed exactly where it was. Each new structure inherited the old bottleneck intact.
Deferred capital decisions and a stalled production ramp, modelled at R1.2bn across 2 years. The restructures themselves were the smaller number.
The turning pointone approval limit had not moved since before the first restructure, and every stalled decision had passed through it.
The question for your board: Which approval limit has not moved since your last restructure?
Senior departures were read one at a time, each with its own story. Exit interviews cited fit and pace, and nothing specific.
The exit record treated as evidence, not as reporting. Escalation routes traced upward from the operating level, and how long each step took to respond.
A formal escalation route existed, with no deadline for a response. So issues moved informally instead, carried by people whose own bonus depended on the function they were escalating past.
Replacement, lost delivery and deferred network decisions, modelled at R310m across 18 months. Most of it sat in the delay, not in the recruitment.
The turning pointthe same 3 names appeared in 9 separate accounts of why a decision had stalled, and none of them was in the minutes.
The question for your board: When an escalation is raised here, how long until someone answers?
Senior departures accelerating ahead of a refinancing. Exit interviews citing cultural friction, with the specifics missing from every one.
The chief executive’s calendar against the pattern of what reached them. Sessions with the layer below, and the way problems were phrased when they arrived.
Problems raised at the top were met with an answer, not a question. Disagreement was met with questioning that ran until the other person gave up. The layer below learned to bring only the version that ended the conversation fastest.
Talent loss and decisions taken on curated data, modelled at €14m a year. Direct replacement cost was a small part of it.
The turning pointthe behaviour was not hidden. It had been described internally as decisiveness. The cost was not the behaviour. It was what the organisation stopped telling itself as a result.
The question for your board: When someone brings you bad news, do you answer or ask?
How these are published
Clients agree to this work on the understanding that what we find stays between us. So the cases are disguised, deliberately and consistently.
| Altered on purpose | Exactly as found |
|---|---|
| The client name, in every case | The sector, so you can judge whether it is your world |
| The country and the region | The mechanism, which is the part that transfers |
| Dates, and the year of the work | The sequence of what we looked at and what we found |
| The size of the organisation and the exact figures | The order of magnitude, so the number still means something |
| Any detail that would identify a person | The fact that nobody involved was hiding anything |
Where a client clears a figure in writing, we publish it with their name attached. Until then, the shape is real and the identifiers are not.
In all 6, the leadership team was capable. The information it was working from was not.
If one of these reads like your organisation, the first meeting costs nothing and ends with a clear answer.
Services and fees
We do 2 things. We check your defences before something fails, and we investigate when a problem keeps coming back. We do the same for decisions made by AI systems. It is one method each time, applied at a different moment, which is why each has its own name.
Before something fails
When it keeps failing
Your organisation
Defences ReviewFrom US$15,000 InvestigationFrom US$35,000An AI system
AI Decision ReviewBefore approval. From US$7,500 AI Decision ReviewAfter a failure. From US$12,000Always the first step // No fee
90 minutes with the executive who would sponsor the work. If we find nothing worth investigating, we say so and you pay nothing. If we find something, we write a preliminary report for US$2,500. If you then go ahead with the investigation, we deduct the US$2,500 from its fee, so the report costs you nothing.
Before something fails
A check of the 5 defences your organisation relies on, before a failure shows you where they are weak. Useful before a merger, a new strategy or a system going live.
From US$15,000
When a problem keeps failing
For a problem that has survived more than one fix. 12–16 weeks to find the cause and agree the changes, then 12 weeks of support while the fix takes hold.
From US$35,000
For AI systems // New in 2027
The same 2 services, for decisions made or shaped by AI: a board session before approval, or a review after a failure.
From US$7,500
Board session from US$7,500 // Review after a failure from US$12,000
For a room
The method in under an hour, for conferences, executive teams and boards. Delivered by our founder, Frank Tsuro.
Fees depend on the room and what it is for.
Fees are a guide and are fixed before any work starts. We quote in rand for South African clients.
Fee guide
3 questions give you an indicative fee and the right first step. Your answers go into the booking, so you do not repeat yourself.
The fee guide needs JavaScript. You can still book the first meeting.
Is this us
Worth investigating
We would decline
We have worked in telecommunications, energy, mining, logistics, infrastructure, construction, banking and state-owned enterprises.
AI Decision Review // New in 2027
The discipline we use for any failure, applied to decisions made or shaped by AI. Before your board approves a system, or after one goes wrong.
5 of 163. A 2025 University of Cambridge study looked at 163 reports of AI incidents tagged as responses. Only 5 were official responses from the company involved. Even those lacked the detail needed to learn from them.
Richards, Benn and Zilka, From Incidents to Insights, University of Cambridge, 2025. Read the paper
When to use it
We settle one question before the board approves: what the system will decide, from which records, and who answers when it is wrong. The board leaves with a written standard for what it needs to see first.
We find out what the business believed at the time, how the decision was actually made and where the defences had gaps. The blame does not land on the nearest person by default. You receive a written finding and the changes, each with an owner.
A regular check of how AI-assisted decisions are approved, watched and corrected, reported straight to the board.
Governance context
King V asks boards to oversee decisions that AI systems influence or make. The review gives the board the evidence to show it did.
King V asks
Clear accountability for the decisions, actions and outcomes of AI systems (Principle 10).
The review gives
A dated record of who decided what, on what information.
King V asks
AI used with ethics, accountability, transparency, explainability, fairness and privacy, among other values.
The review gives
A test of the decision against the values that matter for it.
King V asks
The board explains any practice it has not adopted, and concludes on its governance outcomes.
The review gives
Evidence for that explanation and that conclusion.
King V was published by the Institute of Directors in South Africa in 2025. This is a summary for context, not legal advice.
Tell us about the AI system you are about to approve, or the decision that went wrong. The first meeting has no fee. In 2027 we are taking on a small number of boards.
The keynote // Delivered by Frank Tsuro
What aviation learned by refusing to accept human error as an explanation. A keynote from FranklySpeaking, delivered by our founder, Frank Tsuro.
The promise
They start looking for what made the mistake likely. That one change makes the next incident less probable.
The talk
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 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.
Frank Tsuro applies the same discipline to business failure. He separates the trigger from the conditions, shows 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.
Formats
45–60 minutes
For leadership conferences, executive teams and boards. The talk ends with a question your people can ask on Monday.
Half day
Applied to one of your own incidents, closed and safe to discuss. Every participant receives an editable workbook.
90 minutes
For directors who receive incident reviews. It ends with a written standard for the reviews the board will accept.
45–60 minutes
As panellist or chair. 6 questions that open a real conversation, not a speech.
For operating businesses where failure is visible and expensive: energy, telecoms, mining, ports, logistics, construction, financial services and regulators.
Dates are held for 10 working days while you get approval.
Fee
Fees depend on the room and what it is for. They are agreed before anything is booked.
It gives a room the core of the method in under an hour.
The 4-minute check // Nothing stored // No sign-up
10 statements about your organisation. Say how true each one is. You will see your 5 defences, how strong each one is and whether the gaps line up.
Your result
Answer all 10 statements above. Every organisation has gaps. What matters is whether they line up.
How to read the drawing: each slab is one defence, and each oval is a gap in it. The bigger the gap, the weaker the defence. The arrow is a problem looking for a way through. It gets through only where gaps line up. A gap that sits away from the arrow does not line up with the others, so that defence still blocks.
This is one person’s view on one day. It is an indication, not a finding. A finding needs evidence from your whole leadership team, which is what the first meeting starts.
The first meeting // No fee
Questions rather than a presentation. It ends with a clear answer on whether an investigation is warranted. If it is not, that is what we tell you.
How it runs
Bring whoever has the authority to act on what we find. Without that person, we can describe the problem but we cannot tell you whether it can be fixed.
Before
Nothing to prepare. Board papers and minutes come later, under the engagement.
During
A consistent set of questions about what your team sees, what it understands and what it expects next.
After
A clear answer: is this a system problem? If it is, we offer a preliminary report on what an investigation would examine and what it would cost.
The calendar opens in a new tab and takes about a minute. You can add a note about what you are facing.
How it can end
Outcome
We say an investigation is not warranted and show what we looked at to reach that view. We will not follow up.
Outcome
The difficulty is real, and it is a different discipline. We tell you which, and what a good version of that hire looks like.
Outcome
A preliminary report sets out what we would examine, which defences are in scope, how long it takes and what it costs. It costs US$2,500. If you go ahead with the investigation, we deduct it from the fee, so the report costs you nothing. You decide after reading it.
We need a sponsor with the authority to act on whatever the investigation finds.
The 4-minute check scores the same 5 defences from 10 questions. It is an indication, not a finding, and it is free.
Questions // Plain answers
Short answers, in the order people usually ask them. If yours is not here, ask it.
What we do
We find out why a problem keeps coming back, and help you fix the cause so it stays fixed.
Our clients are organisations where a small failure costs millions. At a mobile operator, an outage of a few minutes can stop calls and payments for millions of people. At a mine, one power failure can stop production for a whole shift.
Our FRANK Method™ is inspired by aircraft accident investigation and by a lesson from Undercover Boss: the truth people tell changes when rank leaves the room. Your board receives a written finding: what is causing the problem, what it costs and what to change.
Boards and the executives who answer to them: board chairs and directors, audit and risk committee chairs, chief executives and chief operating officers, chief risk officers and heads of internal audit.
Many of our clients have already had all 3. Each did its job, and the problem came back.
We start where they stop: we prove the cause first, then help your team fix it until the fix holds.
FRANK names the 5 stages that fix the problem: frame the reality, reflect on alignment, articulate the impact, name the adjustments and kickstart realignment.
We always investigate first, because a fix without a proven cause is a guess. But what a board pays for is a change that holds, so the method is named after the part that looks forward.
Ask 5 people on your leadership team, separately, what the strategy is right now. If you would get 5 different answers, there is something here.
Then look at the cost: missed targets, people who have left, and board time spent on questions nobody could answer. If you can put a number on it, the first meeting is worth having.
Because they report into the structure that is hiding the problem. You cannot ask someone to audit the hierarchy that sets their own bonus. This is not a criticism of those roles. It is why the work has to be independent.
How it works in practice
We do not need anyone to be completely honest. The method is built so the truth shows up anyway.
We do not go undercover. People know an independent review is happening. One person can spin a story. 12 people, the minutes and the budget cannot all spin it the same way.
Nothing becomes a finding until a second, independent source confirms it: another person, a document or a number. Confidentiality is built into the method, not promised.
We protect sources, not decisions. Everything people tell us stays confidential. Decisions taken with authority are not hidden.
The board receives every finding in full and decides what to do. We establish the facts. The board makes the call.
The same rules apply. The finding states the facts, and the sponsor sees it first and can respond, like anyone else. We will not soften a finding to protect whoever pays the invoice.
Say so, and show us what you think we got wrong. Usually it is one of 2 things: context we did not have, which we will check, or a fact that is uncomfortable but true.
Time and cost
An investigation takes 12–16 weeks to reach a finding and agree the changes, then 12 weeks of support while the fix takes hold. A Defences Review is shorter and is scoped to your organisation.
Every fee is fixed before work starts, so you know the cost and the end date. As a guide, a Defences Review starts from US$15,000 and an investigation from US$35,000. The first meeting is free.
The fee guide gives an indicative fee for your situation in 3 questions.
You are buying a finding, not a number of days.
A written finding in weeks 10–14. Then a list of the agreed changes, each with an owner and a test, and a plan for the 12 weeks while we step back. Your board keeps the list when we leave.
90 minutes with the executive who would sponsor the work. Questions, not a presentation. If we find nothing worth investigating, we say so and you pay nothing. If an investigation is warranted, a preliminary report sets out the scope and the fee. It costs US$2,500, and if you go ahead with the investigation, we deduct it from the fee.
AI and King V
It checks the decisions your AI systems make, or help people make, using the same method as our other reviews.
There are no guarantees, but the board can show it asked the right questions. It is the same method we use before a failure (a Defences Review) and after one (an investigation), applied to AI. See the AI Decision Review.
Where it helps a board. King V asks boards to govern technology and AI with clear accountability, and to conclude on their governance outcomes. Our reviews give that conclusion evidence. We do not sell King V compliance work, and this is not legal advice.
About us
FranklySpeaking was founded and is led by Frank Tsuro. Investigations are delivered by our team of associates and partners, to one method.
We have teams in Johannesburg and Harare, and associates elsewhere. We work internationally, in person and online.
No. Frank advises a leader, personally, on a decision. FranklySpeaking works on the organisation when a problem keeps coming back. If the question is a decision in front of you, start with Frank’s advisory work.
Yes. Our founder gives the keynote Fix the System, Not the Pilot, for conferences, executive teams and boards. Fees depend on the room and what it is for. See the keynote.
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