Decision IntelAir France
Air France Flight 447 Crash
Estimated impact: 228 lives; €2.9B in litigation
Air France Flight 447 crashed into the Atlantic en route from Rio to Paris, killing 228 people. Pitot tube icing caused unreliable airspeed readings, and the pilots responded with a sustained nose-up input that stalled the aircraft. Despite stall warnings, the crew never diagnosed the stall.
Decision context
Whether pilots adequately diagnosed the automation disconnect and stall condition, and whether Air France's training adequately prepared crews for manual high-altitude flying after automation failure.
What the company’s own filing already carried
Not our reading of a memo. Air France's own 20-F, filed 2007-07-09 (18 months before the 2009 decision), was read by the audit engine's deterministic structural layer: the same detectors that run on every audit, with no language model involved. Everything below is drawn from the company's own disclosure, before any knowledge of what followed, and never from the decision itself.
Survivable as structured: if the flagged risk fires, the deal has the exits, cushions, or staging to absorb the hit and continue.
The structural layer flagged no unabsorbed condition in this filing.
- This reads the company's own 20-F (filed 18 months before the decision), not the decision memo itself, so it can only understate what a full audit of the memo would surface.
- It reads the structure of the situation, not the trigger: whether a shock to the flagged conditions would be absorbed, never that a shock arrives.
- A reading of a dated filing, not a prediction: every condition can be checked against the company's own 20-F.
Decision anatomy
Red = risk factor present · Green = protective factor present
Biases present in the decision
★ Primary driver · Severity estimated from bias type and decision outcome
Toxic combinations
The curated library this case sits in
Across all 155 curated case studies in our library, by documented outcome:
The library is curated toward documented failures, so this split describes the library, not the base rate of deals. The case above is one row in it.
Lessons learned
- Anchoring to automation-era flying skills meant pilots could not revert to basic instrument scan when automation disconnected
- Availability heuristic: pilots were trained for engine failures, not high-altitude stalls — the untrained scenario was the fatal one
- CRM breakdown: the captain was resting and the two co-pilots failed to communicate their conflicting control inputs
Source: BEA Final Report on AF447 (2012); William Langewiesche, "The Human Factor," Vanity Fair (2014) (NTSB Report)
These patterns were flaggable in Air France's own record — before the outcome.
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Workflows that fire on decisions like Air France’s
The same Recognition-Rigor Framework that documents this case audits memos in the same shape — before the outcome forces the lesson.