Control of operations in extreme conditions: Lessons from Air France 447

Air France flight 447 was lost over the Atlantic in 2009. Although aviation cases rarely appear in the Operations Management literature, we argue that the AF447 vividly illustrates the conditions under which the operators of complex systems experience a collapse of sense-making, preventing them from diagnosing problems quickly and correctly. Using concepts of sense-making and high-reliability organisation, we argue that certain system designs take operators and decision-makers “out of the loop” of daily operations. This results in a degradation of system knowledge that only becomes apparent under extreme conditions, just when it is most crucial.