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.