French aviation authorities have released the final report on the June 1, 2009 crash of Air France 447, one of aviation’s most dramatic and troubling disasters. And though earlier reports painted a fairly clear picture of what transpired, there is one surprise in the final documents—the extent to which the authorities blame not mechanical failures but the actions of the flight crew. The Bureau d’Enquete et d’Analyse (BEA) suggests that the accident “shows the limits of the current safety model.” That is, there is an element of fatal risk so deeply baked into modern aviation that it may be unfixable.
A quick recap of the Air France investigation: As PM’s December 2009 cover story reported, suspicion initially centered on the aircraft’s pitot tubes. Data sent by the aircraft in the moments before its disappearance suggested that these airspeed sensors had iced up and stopped working. Most aviation experts assumed that the pitot tubes’ failure and the severe weather (the crew had flown into a severe thunderstorm) were the key factors in this disaster.
But when searchers finally recovered the plane’s flight data recorder and cockpit voice recorders (commonly called black boxes) from the ocean depths in early 2011, those recorders painted a much different picture. Investigators determined that the loss of airspeed was in fact a minor hiccup that would not have endangered the flight if pilots had followed proper procedures. What doomed the flight was a series of almost incomprehensible mistakes on the part of the flight crew. Two were particularly astounding. First, a co-pilot at the controls pulled the plane up into a climb—simply leveling out the aircraft could have saved it. Second, he and the two other pilots on the flight deck failed to realize that, as a result of climbing, the plane had entered an aerodynamic stall and began plummeting toward the ocean.
The BEA’s final report offers revealing insight into the psychological factors behind these failures. Continue reading The Limits of Aviation Safety






