Pilot error versus sociotechnical systems failure: a distributed situation awareness analysis of Air France 447

ABSTRACT

The Air France 447 crash occurred in 2009 when an Airbus A330 stalled and fell into the Atlantic Ocean, killing all on board. Following a major investigation, it was concluded that the incident resulted from a series of events that began when the autopilot disconnected after the aircraft's Pitot tubes froze in an adverse weather system. The findings place scrutiny on the aircrew's subsequent lack of awareness of what was going on and of what procedure was required, and their failure to control the aircraft. This article argues that this is inappropriate, instead offering a systems level view that can be used to demonstrate how systems, not individuals, lose situation awareness. This is demonstrated via a distributed situation awareness-based description of the events preceding the crash. The findings demonstrate that it was the sociotechnical system comprising aircrew, cockpit and aeroplane systems that lost situation awareness, rather than the aircrew alone.

KEYWORDS:

• Air France 447
• distributed situation awareness
• aviation
• accident analysis

Acknowledgments

The authors would like to acknowledge the two anonymous reviewers for their insightful and helpful comments on the initial manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This research was funded by Professor Salmon's current Australian Research Council Future Fellowship [FT140100681].

Notes on contributors

Paul M. Salmon

Paul M. Salmon holds the chair in human factors and is the creator and director of the Centre for Human Factors and Sociotechnical Systems at the University of the Sunshine Coast. He currently holds an Australian Research Council Future Fellowship applying systems thinking theory and methods in safety critical systems.

Guy H. Walker

Guy H. Walker is an associate professor in human factors within Heriot Watt's School of the Built Environment. His research reflects a trend towards increasing cross-disciplinary activities and a recognition that solutions to transportation problems have at their core a complex cultural and technological system that can no longer be approached by one academic specialism alone.

Neville A. Stanton

Neville A. Stanton holds the chair in human factors engineering in the Faculty of Engineering and the Environment at the University of Southampton and has published over 200 international peer-reviewed journal papers and 30 books on human factors and ergonomics. Neville's research interests include naturalistic decision-making (co-chair at NDM2009, international conference held in London), distributed situation awareness and distributed cognition, human error and human reliability analysis, socio-technical systems design and cognitive work analysis, task analysis and human factors methods.