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Startle Effect

Mark Lacagnina delves into the causes of the crash of Air France Flight 447 (AF447) in June 2009 as laid out by the final report of France’s Bureau d’Enquêtes et d’Analyses (BEA). Next month, we will take a closer look at some of the BEA’s recommendations (see, “Sustained Stall”).

To anyone who has followed the investigation and read the interim reports, the final report did not contain any real surprises, but it did, among other things, shine a spotlight on training needs, situational awareness, crew resource management and the “startle effect,” which, coincidentally, appears in two stories in this month’s issue.

The first and most significant story involves AF447, the Rio de Janeiro to Paris nonstop flight that crashed into the Atlantic Ocean, killing all 228 people on board. As Mark details in his story on the BEA’s final report, ice crystals blocked the aircraft’s pitot probes, resulting i…

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