Aviation Accident Case Studies

Aviation accidents rarely stem from a single cause. They result from interactions between human performance, system design, and organisational conditions within complex systems.

At their core, accidents occur not because individuals are negligent or aircraft are poorly built, but because the system as a whole fails at a specific moment under specific conditions. The Aviation Risk Lab examines these events from a systems perspective, focusing on how outcomes are produced and how they can be prevented.

Using frameworks like the Swiss cheese model, STAMP, and ICAO safety principles, each case study analyses event sequences, system design, human factors, and system interactions. The aim is not to assign blame, but to understand and improve the system.

Aviation safety is built on lessons from past accidents—each investigation, regulation, and redesign contributes to safer systems. This library captures that process, using failure to reduce future risk and make aviation safer.

🔎 Explore Case Studies

Qantas Flight 32 Accident Analysis: How Aircraft Systems Contain Cascading Failures

Qantas Flight 32 is aviation’s most important positive case study after US Airways 1549. On 4 November 2010, an Airbus...

Helios Airways Flight 522 — The Switch Left in the Wrong Position

Helios Airways Flight 522 flew a ghost flight across the Aegean Sea for approximately two hours with an incapacitated crew,...

United Air Lines Flight 173 — The Hierarchy of Silence

United Air Lines Flight 173 ran out of fuel on a night approach to Portland International Airport while the captain...

China Airlines Flight 120 — The Fuel Leak Nobody Saw Until It Was Too Late

China Airlines Flight 120 caught fire on the apron at Naha Airport immediately after landing, when fuel that had been...

Concorde AF Flight 4590 — Runway Debris, Fuel, Fire and the Limits of Certification

Concorde Flight 4590 is the accident that ended commercial supersonic passenger flight. On 25 July 2000, a titanium wear strip...

de Havilland Comet Crashes (1954) — Pressurisation and the Crack That Remade Aviation

The de Havilland Comet was the world’s first commercial jet airliner. It was also the aircraft that killed 56 people...

ValuJet Flight 592 — The Oxygen Generators in the Hold

ValuJet 592 crashed into the Florida Everglades six minutes after takeoff because chemical oxygen generators that should never have been...

Ethiopian Airlines Flight 302 — MCAS Again, Five Months Later

Five months after Lion Air 610 killed 189 people, Ethiopian Airlines 302 crashed for the same reason. The Boeing 737...

Colgan Air Flight 3407: Fatigue, Training, and System Pressure

Colgan Air Flight 3407 stalled on approach to Buffalo-Niagara International Airport and crashed into a house, killing 50 people. The...

Qantas Flight 32: When Systems Prevented Catastrophe

Qantas Flight 32 is often described as a “successful emergency landing.” But that description undersells what actually happened. This was...

British Airways Flight 38 Accident Analysis: Engine Icing and the Limits of Automation

British Airways Flight 38 is often described as a landing accident caused by a sudden loss of engine thrust on...

UPS Airlines Flight 1354 — Cargo, Smoke and the Descent That Wasn’t Stopped

UPS Flight 1354 struck terrain 1.6 miles short of Birmingham-Shuttlesworth International Airport’s Runway 18 during a night instrument approach while...

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Lion Air Flight 610 — MCAS and the Architecture of a Single Point of Failure

Lion Air Flight 610 is the accident that exposed a fundamental systems engineering failure in one of the world’s most...

Malaysian Airlines Flight MH17 — Airspace, Conflict and the Unasked Question

Malaysia Airlines Flight MH17 was shot down by a Buk surface-to-air missile over eastern Ukraine on 17 July 2014, killing...

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Mid-Air Collision Over Washington DC: When Shared Airspace Becomes a System of Assumptions

On 29 January 2025, American Eagle Flight 5342 — a CRJ-700 regional jet on approach to Washington Reagan National Airport’s...

American Airlines Flight 191 — The Engine That Took the Slat With It

American Airlines Flight 191 is the deadliest aviation accident on US soil. During the takeoff roll at Chicago O’Hare, the...

Asiana Airlines Flight 214 — The Automation They Didn’t Understand

Asiana Airlines Flight 214 struck the seawall below San Francisco International Airport’s Runway 28L threshold at 116 knots — 37...

TAM Airlines Flight 3054 — The Thrust Reverser, the Wet Runway and No Margin

TAM Airlines Flight 3054 landed at São Paulo Congonhas Airport on a wet runway with one thrust reverser locked out...

United Air Lines Flight 232 — Hydraulics, Teamwork and the Impossible Landing

United Air Lines Flight 232 is the case study that defined what Crew Resource Management looks like when it saves...

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Tenerife Airport Disaster — When a System Has No More Margins Left

The Tenerife disaster is not the story of one mistake. It is the story of a system that had been...

Korean Air Cargo Flight 6316 When ground handling and system assumptions collapsed in sequence

Korean Air Cargo Flight 6316 crashed during a rejected takeoff at Shanghai Hongqiao Airport, killing all three crew members and...

Turkish Airlines Flight 981 — A Door That Was Never Safe

Turkish Airlines Flight 981 is the story of a design flaw that was known, documented, reported, partially corrected, and then...

TWA Flight 800 — The Fuel Tank That Sparked in the Dark

TWA Flight 800 exploded at 13,700 feet over the Atlantic Ocean twelve minutes after departing JFK, killing all 230 people...

Pinnacle Airlines Flight 3701 — Pushing an Aircraft Past Its Limits for Fun

Pinnacle Airlines Flight 3701 crashed on a repositioning flight after the crew flew the empty CRJ-200 to FL410 — 4,000...

Lauda Air Flight 004 — The Thrust Reverser That Deployed at 44,000 Feet

Lauda Air Flight 004 is the accident that proved an event long considered essentially impossible was, in fact, possible: the...

Air Midwest Flight 5481 — When Weight and Balance Lies

Air Midwest Flight 5481 stalled immediately after takeoff from Charlotte because the elevator control cables had been incorrectly rigged during...

Eastern Air Lines Flight 401 — The Altitude No One Owned

Eastern Air Lines Flight 401 is the case study that gave the aviation safety world the concept of channelised attention...

Germanwings Flight 9525 — The System That Couldn’t See What Was in Front of It

Germanwings 9525 was deliberately flown into the French Alps by First Officer Andreas Lubitz, who had concealed a severe depressive...

China Airlines Flight 006 When automation silently removed the aircraft from stable reality

China Airlines Flight 006 is one of the most dramatic automation-induced upsets in aviation history. Cruising at 41,000 feet over...

Pakistan International Airlines Flight 8303 — Gear Up, Phones Out and No Safety Culture

PIA Flight 8303 made a gear-up touchdown at Karachi’s Jinnah International Airport, scraping both engine nacelles on the runway, then...

El Al Flight 1862 — When the Engine Takes the Wing With It

El Al Cargo Flight 1862 lost the Number 3 and Number 4 engines simultaneously when the inboard midspar fuse pin...

Air Florida Flight 90 — Ice, Complacency and the Decision Not to Wait

Air Florida Flight 90 is the case study that defines the de-icing failure scenario. On a bitterly cold January afternoon...

British Airways Flight 5390 — The Windscreen and the Captain Who Nearly Left

The captain of British Airways Flight 5390 was sucked partially out of the aircraft through the forward windscreen at 23,000...

Crossair Flight 3597 — CFIT in the Night

Crossair Flight 3597 struck a wooded hill 7 kilometres south of Zurich Airport while conducting a night visual approach to...

TransAsia Airways Flight 235 — The Engine Nobody Wanted to Shut Down

TransAsia Airways Flight 235 crashed into the Keelung River in Taipei after the crew shut down the functioning left engine...

Lufthansa Flight 2904 When braking distance was a system assumption, not a guaranteed reality

Lufthansa Flight 2904 overran the end of Warsaw’s Runway 33 in a severe crosswind and rain storm, struck a bank...

Aloha Airlines Flight 243 — The Fuselage That Flew Apart at 24,000 Feet

Aloha Airlines Flight 243 is the case study that created the discipline of ageing aircraft structural management. On 28 April...

Air Ontario Flight 1363 — Ice, Engine Economics and the Go Decision

Air Ontario 1363 is the de-icing accident that went deepest into the organisational system. An aircraft departed Dryden Airport with...

Malaysia Airlines Flight MH370 — The Aircraft Nobody Could Find

Malaysia Airlines Flight MH370 departed Kuala Lumpur for Beijing on the night of 8 March 2014 and disappeared. At 01:21...

Adam Air Flight 574 — Distracted by the IRS While the Aircraft Flew Into the Sea

Adam Air Flight 574 entered a spiralling dive and broke apart at high speed over the Makassar Strait after the...

American Airlines Flight 96 — The Door That Nearly Did It First

American Airlines Flight 96 is the accident that should have prevented THY 981. On 12 June 1972, two years before...

USAir Flight 405 — The Contaminated Wing at LaGuardia

USAir 405 crashed into Flushing Bay at the end of LaGuardia’s Runway 13 in freezing rain, killing 27 people. The...

XL Airways Germany Flight 888T — When the Test Flight Flew Into the Sea

XL Airways Germany 888T was conducting an airworthiness verification flight — a delivery check for a lease changeover — when...

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Uber Autonomous Crash: Seeing vs Understanding

This case study sits at the boundary of aviation and autonomous systems — included here because the failure modes it...

Überlingen Mid-Air Collision (2002) When two systems trusted the same idea of separation

The Überlingen mid-air collision is the case study where two safety systems — the air traffic controller and the Traffic...

Chalk’s Ocean Airways Flight 101 — The Wing That Should Have Been Retired

Chalk’s Ocean Airways Flight 101 lost its right wing during departure from Watson Island, Miami, killing all 20 people on...

Air Inter Flight 148 When the interface made two different actions look the same

Air Inter Flight 148 struck Mont Sainte-Odile at 2,620 feet while on a night approach to Strasbourg Airport, killing 87...

American Airlines Flight 1420 — Thunderstorms, Speed and the Decision to Land

American Airlines Flight 1420 overran Runway 04R at Little Rock National Airport in a severe thunderstorm and struck approach lighting...

TWA Flight 514 — CFIT and the Clearance Misunderstood

TWA Flight 514 struck Mount Weather at 1,670 feet during descent toward Washington Dulles International Airport on an overcast December...

Korean Air Flight 801 — CFIT, Authority Gradient and the Approach That Wasn’t Questioned

Korean Air Flight 801 struck Nimitz Hill at 660 feet, 3.6 nautical miles short of Guam International Airport’s Runway 06L,...

China Airlines Flight 611 — The Repair That Held for Twenty-Two Years

China Airlines Flight 611 broke apart in cruise flight over the Taiwan Strait on 25 May 2002. The aircraft’s aft...

Air France Flight 296 — The Air Show, the Computer and the Trees

Air France Flight 296 is one of aviation’s most technically and legally contested accidents. On 26 June 1988, a brand-new...

Alaska Airlines Flight 261 — The Jackscrew That Was Never Lubricated

Alaska Airlines 261 plunged into the Pacific Ocean when the jackscrew assembly controlling its trimmable horizontal stabiliser stripped its final...

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The Columbia Accident: When Uncertainty Becomes the Decision

The Space Shuttle Columbia disintegrated during re-entry on 1 February 2003, killing all seven crew members. The proximate cause was...

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Swissair Flight 111 — The In-Flight Fire That Couldn’t Be Stopped

Swissair 111 perished because an in-flight fire started in the entertainment system wiring above the cockpit ceiling and spread through...

Avianca Flight 052 — Fuel, Holding and the Language Barrier That Costs Lives

Avianca Flight 052 ran out of fuel and crashed short of JFK Airport on the evening of 25 January 1990,...

Southwest Airlines Flight 1380 — The Fan Blade That Escaped

Southwest Airlines Flight 1380 experienced an uncontained engine failure when a CFM56-7B fan blade separated due to a metal fatigue...

Qantas Flight 72 When the system reacted correctly to something that wasn’t real

Qantas Flight 72 experienced two uncommanded pitch-down events at cruise altitude when a faulty Air Data Inertial Reference Unit (ADIRU)...

Turkish Airlines Flight 1951 — The Altimeter That Fooled the Throttle

Turkish Airlines 1951 stalled short of Amsterdam’s Runway 18R because one of the aircraft’s two radio altimeters was generating a...

Pan Am Flight 103 — Lockerbie and the System That Received a Warning

Pan Am Flight 103 was destroyed by a bomb concealed in a Samsonite suitcase in the forward cargo hold, killing...

Air India Flight 182 — The Baggage That Nobody Screened

Air India Flight 182 was destroyed by an explosive device concealed in checked baggage, killing all 329 people on board....

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Air Transat 236: The Flight That Shouldn’t Have Turned Around

Air Transat Flight 236 ran out of fuel over the Atlantic Ocean approximately 120 miles from the Azores, descended from...

US Airways Flight 1549 — The River Landing That Required Thirty-Five Years of Safety Progress

US Airways Flight 1549 is aviation’s most important positive case study — the case that demonstrates what the safety system...

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Air France Flight 447 — When the Automation Stopped and the Crew Couldn’t Take Over

Air France 447 is the defining 21st-century case study in automation dependency and the degradation of manual flying proficiency. When...

Air Canada Flight 143 — The Gimli Glider and the Unit Conversion Nobody Checked

The Gimli Glider is aviation’s most famous arithmetic error. On 23 July 1983, a brand-new Boeing 767 — Air Canada’s...

PSA Flight 182 — The Mid-Air No Radar Could Prevent

Pacific Southwest Airlines Flight 182 collided with a Cessna 172 in the congested airspace over San Diego at 9,350 feet,...

American Airlines Flight 587 — Composite Rudder and the Limits of Training

American Airlines Flight 587 lost its entire vertical stabiliser two minutes after departure from JFK Airport, killing all 265 people...

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Japan Airlines Flight 123: Structural Fatigue and Systemic Maintenance Drift

Japan Airlines Flight 123 is the deadliest single-aircraft accident in aviation history. Five hundred and twenty people died on 12...

Understanding These Case Studies

These analyses focus on system-level interactions rather than single causes.

Browse All Case Studies by Category: Case Studies

Human Factors Case Studies: Human Factors

Systems Engineering Case Studies: Systems Engineering

Automation Case Studies: Automation And Technology

Maintenance Case Studies: Maintenance And Airworthiness