Root Cause Analysis of Air France Flight 447 Accident (1 June 2009)

2019-07-05
Air accidents are extremely rare events and aviation is the safest mode of transportation. On the other hand, the risk is always present whenever any flights take place (Janic, 2000). Therefore, even identifying the main causes of one accident could be very critical for preventing future crashes that could occur at any point and any time. Therefore, the aim of this study is to investigate the root causes of one of the deadliest accidents in the history of Air France that 228 occupants including the crew and the passengers lost their lives– Accident of Air France Flight 447 in 2009. The root causes investigation started with detecting problem and the information gathered through official reports and media was examined via timeline and information mapping tools. After this step, the possible causes were investigated in terms of environmental, vehicle and human-related factors. The problems were detected as pitot tube blockage, improper actions of pilots in an emergency situation and task sharing problems of the crew. In order to find root causes behind these problems, 2 type of root cause analysis were used — 5 Why Technique and then Fish Bone Technique. The results showed that mainly human factors dominated the problems related to accident causations and there was humanrelated improper actions even behind the mechanical failures. Therefore, at the end of this analysis, it could be said that the needs of the crew should be always evaluated in detail by the organizations. Moreover, training and instructions should be clear and adequate in order to support human-machine interaction, especially during emergency situations. Lastly, hierarchical relationships could have negative effects on the appropriate behaviors of the crew members in emergency situations
XVI European Congress of Psychology, (Jul 2-5, 2019)

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Citation Formats
D. Azık Özkan and T. Özkan, “Root Cause Analysis of Air France Flight 447 Accident (1 June 2009),” presented at the XVI European Congress of Psychology, (Jul 2-5, 2019), Moscov, Russia, 2019, Accessed: 00, 2021. [Online]. Available: https://ecp2019.ru/doc/Book_of_Abstracts_ecp_2019.pdf.