Mystery over the Atlantic: the tragic fate of Air France Flight 447

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Theoretical basis This case has two primary purposes. First, it allows students to examine how cognitive bias can affect decision making in stressful situations. Students explore why individuals make flawed choices. They learn about how managers shape the context and the process through which teams make decisions. For instance, automation can create a climate in which people then struggle to cope with the unexpected when it happens. Students examine why individuals make these systematic errors in judgment. The case demonstrates that leaders need to be aware of the traps that individuals and teams encounter when they make decisions in crisis situations, and it enables students to discuss the strategies that leaders can employ to avoid these traps. Second, the case provides an opportunity to examine a catastrophic failure in detail. Students discover that it can be nearly impossible to identify a single factor that caused the failure. Instead, they learn how to apply multiple theoretical perspectives to examine a serious organizational breakdown. They become familiar with important concepts from behavioral decision theory, such as complex systems theory and how it interacts with cognitive bias. Research methodology The technical report released by the French Aviation Authority along with the primary flight cockpit voice recorder data were used as the basis for this case. Other available public data such as news reports were used to round out the case study. Case overview/synopsis On June 9, 2009, on a routine flight from Rio de Janeiro to Paris, Air France 447 (AF 447), carrying 220 people crashed in the mid-Atlantic Ocean. Drawing from various first-hand accounts (cockpit voice recorder) and secondary evidence of the tragedy, the case provides a detailed account of the key events that took place leading up to the accident. The case describes how the pilots on AF447 were confronted with a scenario they had not faced before, and through the confusion made a series of errors. Through many of the quotes in the text, readers gain an understanding of the impressions and perceptions of the pilots, including how they felt about many of the critical decisions and incidents during the last minutes of the flight. The case concludes by highlighting the main findings of the BEA report. Complexity academic level This case study is appropriate for undergraduate students studying organizational behavior. It is also appropriate for MBA-level leadership and behavior classes.