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All case studies

Catastrophic failureAerospace2009

Air France

Air France Flight 447 Crash

Estimated impact: 228 lives; €2.9B in litigation

F14

Decision Quality Index

Critical — 5 biases detected, 2 toxic combinations

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.

Deep hindsight-stripped analysis coming soon. This case is part of our ongoing backfill to reconstruct what the platform would have flagged at decision time. The summary and bias profile below are drawn from primary sources.

Biases present in the decision

Availability Heuristic★ Anchoring BiasGroupthinkAuthority BiasRecency Bias

3D Decision Knowledge Graph

Air France — 5 biases, 2 toxic combinations

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Decision

Critical

High

Medium

Toxic

Bias Intensity Profile

Severity × confidence across 5 detected biases

Toxic combinations

Blind Sprint
Echo Chamber

Reference class base rates

Across all 146 curated case studies in our library:

90%

base failure rate

10%

base success rate

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)

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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