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Safety is of paramount importance to the aviation industry (International Air

Transportation Association, 2012). Airlines negligence in safetymanagementwillleadto
immense loss of lives and assets. Air France experienced its worst day ever since
operation onJune1,2009whenone ofitsscheduledflights AF447,whichwasanAirbus
A330, disappeared from radar en route from Rio deJaneirotoParis (BureaudEnquetes
et dAnalyses, 2012, p. 17). There were 228 people on board including216passengers,
3 flight crews and 9 cabin crews. None of them survived from the tragedy (Bureau
dEnquetes et dAnalyses, 2012, p. 17). The major wreckage of the aircraftandthe flight
recorders were recovered only2yearsaftertheaccident.Thefinalreport oftheaccident,
which was published by Bureau dEnquetes et dAnalyses (BEA), revealed that the two
major causes of the accident were the cockpit crews inappropriate reaction to the not
uncommon blockage problem of the ''Pitot tubes'' (Crocker, 2007, p. 172), the air speed
sensor of the aircraft by ice crystals and pilots inexperience in controlling the aeroplane
under bad weather conditions at high altitudes (Bureau dEnquetes et dAnalyses, 2012,
p. 199). Several measures have been carried outbyAirFranceaftertheaccident.Inthis
The first world's plane crash occurred more than 100 years ago (Rosenberg, 2014) and
since then aviation safety has always been an issue. Thesafetythinkingfactorsevolved
from technical issues to human factors, thento organizationalperformance(Rodrigues&
Cusick, 2012, p. 334). There is no finishing point in the questforaviationsafety. Yantiss
(2011), who is a flight safety pioneer, stated that the industry is continuously searching
for ideas and improvements to prevent future accidents (p. 161). According to
International Civil Aviation Organization (2013), safety management system (SMS) is ''a
systematic approach to managing safety, including the necessary organizational
structures, accountabilities, policies and procedures'' (p. xii). Airlines and the aviation
industry as a whole incorporate ''safety policy'', ''safety risk management'', ''safety
assurance'' and ''safety promotion'' into the safety management systems (Rodrigues &
Cusick, 2012, p. 335). Prior to the AF 447 tragedy, Air France had realized the
drawbacks of Pitot tubes in use and decided to replace them with another model
(Thomson, 2015, p. 66). Unfortunately, it was twoweekstoolateforAF447tohavenew
Pitot tubes changed when the A330 fleets' Pitot tubes replacement was completed on
June 11, 2009 (Bureau dEnquetes etdAnalyses,2012,p.215).AirFranceidentifiedthe

risk by implementing safety risk management butfailedto havepromptactionswhichled

BEAs conclusion that there were two main causes of the accident is in line with James
Reasons (2008) Swiss Cheese Model (p. 97). Themodelillustratesthaterrorsdonot
necessarily occur in isolation (Moriarty, 2015, p. 84). Air France revealed that both
mechanic problems and human factors contributed to the accident. Federal Aviation
Administration (FAA, 2009) stated that advancing technology improves flight safety but
human error is difficult to eliminate (p. 52).FAA(2009)alsopointedoutthatthemajority
of plane crashes are related to human factors (p. 52). In order to prevent a repeated
case from happening, not only did Air France replaced the problematic Pitot tubes by
another model with different manufacturer in technical perspective, the Airline also
implemented several measures on crew management and flight simulator trainings
(Bureau dEnquetes et dAnalyses, 2012, p. 215216). An Air Frances internal safety
report revealed that there is a close relationship between accidents and pilots
situational awareness, decisionmaking and crew resource management. In
addition, there is room for improvement for pilots when maneuvering theplanes(Bureau
dEnquetes et dAnalyses, 2012, p. 215). These coincide with the causal factors of the
accident that pilots did not realize the stalling of the plane when pilot in control pulled
backwards the sidestick tolift theheadoftheaircraft.Thisinappropriateactioncontinued
and eventually brought the plane to submerge into the Atlantic Ocean (Strassmann,
Additional trainings are given to pilots when Air France discovered that the less
experienced pilots on AF 447 neverreceivedflightsimulation trainingforstallrecoveryat
high altitudes and were incapable of responding tothissituation(Thomson,2015,p.67).
By introducing an additionalunreliableairspeedsessionintheflightsimulator trainings,
Air France prepares its pilots for nonautopilot flying without indicated airspeed at high
altitudes (Bureau dEnquetes et dAnalyses, 2012, p. 215). Weather radar and ice
crystals issues are also highlighted in flight crews briefings (Bureau dEnquetes et
dAnalyses, 2012, p. 215). The absence of Captain in the cockpit and the least
experienced pilot flying the plane when AF 447 began to stall revealed the poor crew
resource management (Wall & Flottau, 2011). Palmer (2013) pointed out that the
youngest cockpit crew made an unwise decision to fly the plane into the thunderstorm
while pilots of nearby aircraft avoided it. The Captain disagreed with his action implicitly

but it was not realized by the copilot and the action remained uncorrected (Palmer,
2013). In order to reinforce copilots responsibilities and optimize the decisionmaking
process, a new decisionmaking method is introduced to ensure copilots to voice out
their next action before the final decision is made by the Captain (Bureau dEnquetes et
Air France is also spendingextraefforttokeeptrackofitsaircraft.Itwas2hourslater for
Air France to be notified of the lost contact of AF 447 by another Air Frances airliner
(Cramoisi, 2010). The first search team for the aircraft departed more than 9 hoursafter
the crash (United States Government Accountability Office, 2015, p. 14). The delayed
search and rescue created the obstacle for a swift recovery of AF 447. The lengthy
search for AF 447s wreckageprompted AirFrancetoimplementamoreprecisetracking
system for its aircraft from year 2010 with the standard higher than the average of the
industry (Air France KLM, n.d
). Recommended by BEA, Air France equipped all its
aircraft with underwater locator beacon flight recorders with 90 days of autonomy to
replace the one with 30 days of signal emission used by AF 447 (Bureau dEnquetes et
dAnalyses, 2012, p. 203). This would maximize the chance for the recovery of flight
recorders in the event of searches which are longer than 30 days. Furthermore, Air
France reduced the interval for the automated reporting of the aircrafts position from10
minutes to 1 minute when there is a divergence of planned flight path (Air France KLM,
). This can detect the abnormality of the flight track which may lead to an imminent
This review of literature has focused on Air Frances remedies for the AF 447 accident.
The loss of AF 447 gives a tragic lesson to Air France and the Airline is committed to
optimizing its safety management systems to the utmost to prevent future accidents. Air
France takesaccountoftheimportanceoforganizational performancetotheconstruction
of an effective SMS. It is essential for anairlinetocreateaculturethatflight safetyisthe
number one priority which is respected by every employeeinthecompanyandrelated
entities (Air France KLM, n.d
). This will raise[ ] safety awareness and result[ ] in a
reduction of accidents and injuries (Stolzer & Gogliam, 2015, p. 219). With the
application of SMS, Air Frances flight safety procedures are reinforced on a dailybasis.
Nevertheless, the French Airline is always striving for improvements of safety
management so that it can detect potential risks in a proactivemanner(AirFranceKLM,
). Air Frances effort to improve its safety management system is recognized. It is

hoped that future tragedies will be deterred by the increase inaviationsafetyawareness



Air France KLM. (n.d.).

Flight safety, our number one priority
. Retrieve December 12,

Cramoisi, G. (2010).
Air crash investigations: lost over the Atlantic, the mysterious


Federal Aviation Administration, U.S. Department of Transportation, Flight Standards

Service. (2009).
Risk management handbook.
Retrieved from
International Air Transportation Association. (2012).
Safety: the blame game.

International Civil Aviation Organization. (2013).



Reason, J. (2008). Perception of unsafe acts.

The human contribution: unsafe acts,

Rodrigues, C. C. & Cusick, S.K.(2012).

(5thed.). NewYork,

Stolzer, A. J. & Goglia, J. J. (2015).

Safety management systems in aviation.

Strassmann, M. (2013, June 1). Air France flight 447's lessons four years later


Thomson, J. R. (2015).
High integrity systems and safety management in hazardous

United States Government Accountability Office (2015).

Aviation safety proposals to
enhance aircraft tracking and flight data recovery may aid accident investigation,
Wall, R. & Flottau, J. (2011). Updated: AF447 pilots never formally identified stall.







Yantiss, B. (2011). SMS implementation. In A. Stolzer, C. Halford, & J. Goglia (Eds.),
Implementing safety management systems in aviation (pp. 161268). Farnham,