Investigating Accidents in Highly Automated Systems: Systemic Problems Identified Through Analysis of Air France 447

Shem Malmquist, Nancy Leveson

September 2019, International Society of Air Safety Investigators

Captain Shem Malmquist and Dr. Nancy Leveson performed an analysis of the Air France 447 accident using Causal Analysis using System Theory (CAST). This conference paper was presented before the International Society of Air Safety Investigators (ISASI) in September, 2019. This conference is attended by professional aircraft accident investigators from all over the world.

A full copy of the paper is available for download here.