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How a cockpit calculates its speeds and why errors while doing this are so hard to detect

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Abstract

Recent incidents have shown that the production of take-off speeds is an activity vulnerable to miscalculations with a potential for disastrous outcomes. The aim of this paper is to analyze the calculation of the take-off speeds in a modern airline cockpit as a distributed cognitive activity in order to identify possible vulnerabilities in this process. We took the cockpit as the joint cognitive system under analysis and conducted an ethnographic study based on documental analysis, flight observations, interviews, and the analysis of 22 events involving failures related to the calculation of take-off speeds. The main argument is that the cognitive systems engineering perspective, with less focus on the human contribution than it is common in investigations, levels people and artifacts in the system as equal contributors to its eventual performance. Our analysis identified four assertions regarding vulnerabilities in the process of take-off speeds calculation: (1) representations at the level of the cockpit are always partial and incomplete; (2) some interactions require interpretation rather than institution; (3) interactions of agents do not follow a canonical process of coordination; (4) the control of the prevention of failures is accurate but inadequate. These vulnerabilities are a matter of interactions among cognitive systems in the cockpit, rather than vulnerabilities of individual agents, such as humans or artifacts.

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Notes

  1. Gross Weight (GW), sometimes also referred as Take-off Weight (TOW) or Actual Take-off Weight (ATOW)—is the entire weight of the airplane, including fuel, passengers, and luggage. The airplane’s take-off gross weight is the gross weight at the beginning of take-off and is used as the basis for the calculation of take-off speeds.

  2. V1—Take-off decision speed—is the speed during take-off for which it is the last possible moment, in the event of an engine failure or rejected take-off, to safely stop the airplane on the remaining runway.

  3. Vr—Rotation speed—is the speed during take-off at which the pilot starts to rotate to the lift-off attitude in order to start flying.

  4. V2—Take-off safety speed—is the initial climb out speed used after lift-off to achieve a certain height in a certain distance, in order to ensure adequate control and climb performance in case of an engine failure.

  5. EFB—Electronic Flight Bags are devices that display a variety of aviation data or perform basic calculations (e.g. performance data, fuel calculations, etc.). In the past, some of these functions were traditionally accomplished using paper references or were based on data provided to the flight crew by a flight dispatcher. The scope of the EFB system functionality may also include various other hosted databases and applications. Physical EFB displays may use various technologies, formats, and forms of communication. These devices are sometimes referred to as auxiliary performance computers (APC) or laptop auxiliary performance computers (LAPC).

  6. ACARS—Aircraft Communications Addressing and Reporting System is a digital data link system for transmission of messages between the aircraft and ground stations.

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Authors and Affiliations

  1. School of Aeronautical Science, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

    Eder Henriqson

  2. Leonardo da Vinci Laboratory for Complexity and Systems Thinking, Lund University, Lund, Sweden

    Roel van Winsen & Sidney W. A. Dekker

  3. Industrial Engineering and Transport Department, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

    Tarcisio Abreu Saurin

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  1. Eder Henriqson
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  2. Roel van Winsen
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  3. Tarcisio Abreu Saurin
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  4. Sidney W. A. Dekker
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Correspondence to Eder Henriqson.

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Henriqson, E., van Winsen, R., Saurin, T.A. et al. How a cockpit calculates its speeds and why errors while doing this are so hard to detect. Cogn Tech Work 13, 217–231 (2011). https://doi.org/10.1007/s10111-010-0161-4

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