Air 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.
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
Reference class base rates
Across all 143 curated case studies in our library:
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)
We caught these patterns 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.