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, the French accident investigation authority concluded that the incident resulted from a series of events that began when the autopilot disconnected as a result of the aircraft’s Pitot tubes freezing upon entry to an adverse weather system. The findings placed scrutiny on the aircrew’s response, pinpointing their lack of awareness of what was going on and of what procedure was required to respond. This reflects a common tendency for accident investigations to cite poor situation awareness on behalf of individuals as a key causal factor. This presentation argues that this is inappropriate, instead offering a systems level view that can be used to demonstrate how systems and not individuals lose situation awareness. This is demonstrated via a systems analysis of situation awareness during the Air France crash. The analysis demonstrates that it was the sociotechnical system comprising aircrew, cockpit and aeroplane systems that lost situation awareness, rather than the aircrew alone. In closing, the importance of taking a systems view when examining concepts such as situation awareness during accident events is articulated.
2015 University Research Conference: Integrate, Innovate, Inspire, Sunshine Coast, Australia 13-16 July 2015