Comparative analysis of Air France 447 (2009) and Costa Concordia (2012) using FRAM: how organizational culture influences cockpit/bridge decisions

Open Access
Conference Proceedings
Authors: Josue FrancaErik Hollnagel

Abstract: In the night of June 1st, 2009, the Airbus A330 of the Air France Flight AF 447, on the route between Rio de Janeiro (Brazil) and Paris (France), after a series of events, lost altitude and fell into the Atlantic Ocean, leaving no survivors. Few years after this event, in the coast of the Mediterranean Sea, on January 13th, 2012, a cruise vessel named Costa Concordia struck a rock formation on the sea floor, listing and capsizing the vessel, leaving 32 fatalities and dozens of wounded. Two accidents apart in time and space, in different domains - aviation and maritime - but which have more similarities than differences. In this study, a systematic analysis of these two accidents with the FRAM (Functional Resonance Analysis Method) is presented, based on the two official reports issued by the responsible authorities, as well as relevant scientific publications about these events. Applying a Human Factors approach, where work systems are analysed from worker’s perspective, understanding the interactions between organizational, technological, environmental, and individual elements, it was possible to comprehend and identify how the organizational decisions, taken in the executive offices, and company’s culture, resonate till the cockpit/bridge decisions. Particularly in these events, it was perceived that this resonance contributed to the accidents, evidencing the real complexity of the workplaces in the aeronautical and maritime industries, where actions, decisions and relationships reverberate (complexly) throughout the system. In this aspect, it was also noted that the levels of complexity of these two distinct domains, despite being structurally different, require the same adaptive and regenerative responses from work systems and, consequently, from workers, generating the organizational culture of work environments.

Keywords: FRAM, Human Factors, Accident Analysis, Maritime, Aviation

DOI: 10.54941/ahfe1003601

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