Skip to main content
SpringerLink
Log in

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

  • Original Research
  • Published:
Cognition, Technology & Work Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

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.

References

  • Accident Investigation Board Denmark (1999) Summary report, Boeing 767-383, Copenhagen Airport. Author, Copenhagen. Retrieved from http://www.havarikommissionen.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/1999/49-99-KDN-UK.pdf

  • Accident Investigation Board Norway (2004) Incident, early rotation on take-off, Oslo Airport Gardemoen, 04 September 2003, Airbus A321-232 (AIBN, Report number SL 40/2004, 01-Nov-2004). Author, Lillestrom, Norway. Retrieved from http://www.aibn.no/luftfart/rapporter/2004-40-eng

  • Airbus (2004a) Flight operations briefing notes. Standard operating procedures: normal checklists (technical document). Retrieved from http://www.airbus.com/index.php?id=781

  • Airbus (2004b) Flight operations briefing notes. Takeoff and departure operations: understanding takeoff speeds (technical document). Retrieved from http://www.airbus.com/index.php?id=781

  • Airbus (2005) Flight operations briefing notes. Takeoff and departure operations: preventing tail strikes at takeoff (technical document). Retrieved from http://www.airbus.com/index.php?id=781

  • Ashby WR (1959) Requisite variety and its implications for the control of complex systems. Cybernetica 1:83–99. Retrieved from http://pespmc1.vub.ac.be/Books/AshbyReqVar.pdf

  • Australian Transport Safety Bureau (2009) Tail strike, Melbourne Airport (Vic.), 20 March 2009, A6-ERG, Airbus A340-541 (ATSB, Interim Factual Report number AO-2009-012, 18-Dec-2009). Author, Canberra City, Australian Capital Territory. Retrieved from http://www.atsb.gov.au/publications/investigation_reports/2009/aair/ao-2009-012.aspx

  • Aviation Safety Reporting System (2009a) Database online. Report number 670334. Retrieved from http://asrs.arc.nasa.gov/search/database.html

  • Aviation Safety Reporting System (2009b) Database online. Report number 784695. Retrieved from http://asrs.arc.nasa.gov/search/database.html

  • Aviation Safety Reporting System (2009c) Database online. Report number 632164. Retrieved from http://asrs.arc.nasa.gov/search/database.html

  • Aviation Safety Reporting System (2009d) Database online. Report number 790465. Retrieved from http://asrs.arc.nasa.gov/search/database.html

  • Baker D, Dismukes R (2002) A framework for understanding crew performance assessment issues. Int J Aviat Psychol 12(3):205–222

    Article  Google Scholar 

  • BEA (2006) Rapport sur l’incident survenu le 10 décembre 2006, sur l’aérodromoe de Paris Orly, au Boeing 747-400 (BEA, Report number f-ov6210, n.d.). Le Bourget: Boreau d’Enquêtes et d’Analyses pour la Sécurité de l’aviation civile. Retrieved from http://www.bea-fr.org/docspa/2006/f-ov061210/pdf/f-ov061210.pdf

  • BEA (2007) Rapport sur l’incident survenu le 15 novembre 2007, sur l’aérodromoe de Toulouse Blagnac, au Airbus A340-600 (BEA, Report number ISBN: 978-2-11-098259-9, n.d.). Le Bourget: Boreau d’Enquêtes et d’Analyses pour la Sécurité de l’aviation civile. Retrieved from http://www.bea.aero/docspa/2007/f-cj071115/pdf/f-cj071115.pdf

  • BEA (2008) Ministère de l’Ecologie, de l’Energie, du Développement durable et de l’Aménagement du territoire Le Bourget, le 21 avril 2008 Monsieur le Directeur Général de l’Aviation Civile 50, rue Henri Farman 75720 PARIS CEDEX 15 Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile N° 000328/BEA/D PJ. Le Bourget: Boreau d’Enquêtes et d’Analyses pour la Sécurité de l’aviation civile. Retrieved from http://www.bea.aero/recos/reco20080421.pdf

  • Boeing (2000) Erroneous takeoff reference speeds. Boeing Aero Magazine, 11 (QTR_11_00), 1–9. Retrieved from http://www.boeing.com/commercial/aeromagazine/articles/qtr_01_10/index.html

  • Boeing (2007) Tail strikes: prevention. Boeing Aero Magazine, 01 (QTR_01_0), 7–13. Retrieved from http://www.boeing.com/commercial/aeromagazine/articles/qtr_01_10/index.html

  • Christoffersen K, Woods DD (2003) Making sense of change: extracting events from dynamic process data (Institute for Ergonomics/Cognitive Systems Engineering Laboratory Report ERGO-CSEL 01-TR-02). The Ohio State University, Columbus

    Google Scholar 

  • Cook R (1996) Adapting to the new technology in the operating room. Hum Factors 38(4):593–613

    Article  Google Scholar 

  • Dekker SWA (2000) Crew situation awareness in high-tech settings: tactics for research into an ill-defined phenomenon. Transp Hum Factors 2:49–62

    Article  Google Scholar 

  • Endsley MR, Garland DJ (eds) (2000) Situation awareness analysis and measurement. Lawrence Erlbaum Associates, Mahawah

    Google Scholar 

  • Fennell K, Sherry L, Roberts RJ Jr, Feary M (2006) Difficult access: the impact of recall steps on flight management system errors. Int J Aviat Psychol 16(2):175–196

    Article  Google Scholar 

  • Flick U (1998) Na introduction to qualitative research. Sage, London

    Google Scholar 

  • Flin R, Martin L (2001) Behavioral markers for crew resource management: a review of current practice. Int J Aviat Psychol 11(1):95–118

    Article  Google Scholar 

  • Goldsmith T, Johnson P (2002) Assessing and improving evaluation of aircrew performance. Int J Aviat Psychol 12(3):223–240

    Article  Google Scholar 

  • Helmreich R, Merritt A, Wilhelm J (1999) The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol 9(1):19–32

    Article  Google Scholar 

  • Henriqson E, Saurin TA (2009) Impact factors on teamwork performance in glass cockpit aircraft from the cognitive systems engineering perspective. In: Proceedings of the 17th triennial congress of the international ergonomics association, Aerospace human factors, 9–14 August 2009. International Ergonomics Association, Beijing

  • Hollnagel E (1998) Context, cognition, and control. In: Waern Y (ed) Co-operative in process management: cognition and information technology. Taylor & Francis, London, pp 27–51

    Google Scholar 

  • Hollnagel E (1999) Modeling the controller of a process. Trans Inst Measur Control 21(4/5):163–170

    Article  Google Scholar 

  • Hollnagel E (2002) Time and time again. Theor Issues Ergon Sci 3(2):143–158

    Article  Google Scholar 

  • Hollnagel E (2003) Prolegomenon to cognitive task design. In: Hollnagel E (ed) Handbook of cognitive task design. Lawrence Erlbaum Associates, Mahawah, pp 3–16

    Chapter  Google Scholar 

  • Hollnagel E, Woods DD (1983) Cognitive systems engineering: new wine in new bottles. Int J Man—Mach Stud 18:583–600

    Article  Google Scholar 

  • Hollnagel E, Woods DD (2005) Joint cognitive systems: foundations of cognitive systems engineering. Taylor & Francis, Boca Raton

    Book  Google Scholar 

  • Hutchins E (1995a) How a cockpit remembers its speeds. Cognit Sci 19:265–288

    Article  Google Scholar 

  • Hutchins E (1995b) Cognition in the wild. MIT Press, Cambridge

    Google Scholar 

  • Hutchins E, Holder BE, Perez RA (2002) Culture and flight deck operations (Prepared for the Boeing Company, Sponsored Research Agreement 22-5003). University of California, San Diego. Retrieved from http://hci.ucsd.edu/lab/hci_papers/EH2002-2.pdf

  • Klein G, Woods DD, Bradshaw J, Hoffman RR, Feltovich PJ (2004) Ten challenges for making automation a “Team Player” in joint human–agent activity. IEEE Intell Sys 19(6):91–95

    Article  Google Scholar 

  • Klein G, Feltovich PJ, Bradshaw JM, Woods DD (2005) Common ground and coordination in joint activity. In: Rouse W, Boff K (eds) Organizational simulation. Wiley, New York

    Google Scholar 

  • LAA (2008) Use of erroneous parameters at takeoff (Study ordered from the Laboratoire d’Anthropologie Appliquée (LAA) by the Boreau d’Enquêtes et d’Analyses (BEA) and the Direction Générale de l’Aviation Civile (DGAC), in which Air France and Corsairfly participated, Document number AA 556/2008, English, May-2008). Le Bourget: Boreau d’Enquêtes et d’Analyses pour la Sécurité de l’aviation civile. Retrieved from http://www.bea.aero/etudes/utilisation.de.parametres.errones.au.decollage/utilisation.de.parametres.errones.au.decollage.pdf

  • Loukopoulos LD, Dismukes RK, Barshi I (2009) The multitasking myth: handling complexity in real-world operations. Ashgate, Aldershot

    Google Scholar 

  • National Transportation Safety Board (1999) Accident occurred on November 11, 1998 in Portland, OR, Delta Airlines Flight 51, MD-11 (Report no. SEA99LA014, n.d.). Author, Washington, DC

  • National Transportation Safety Board (2001) Accident occurred on December 28, 2001 in Anchorage, AK, Evergreen International Airlines, Boeing 747-128 (Factual Report no. ANC02LA008, n.d.). Author, Washington, DC

  • National Transportation Safety Board (2005) Safety Recommendation, in reply refers to A-05-03 through – 07, 08 March 2005. Author, Washington, DC. Retrieved from http://www.ntsb.gov/Recs/letters/2005/A05_03_07.pdf

  • Neisser U (1976) Cognition and reality. WH Freeman, San Francisco

    Google Scholar 

  • Nemeth C, Cook R, O’Connor M, Klock PA (2004) Using cognitive artifacts to understand distributed cognition. IEEE Trans Syst Man Cybern 34(6):726–735

    Article  Google Scholar 

  • Salas E, Wilson KA, Burke CS, Wightman DC (2006) Does crew resource management training work? An update, an extension and some critical needs. Hum Factors 48(2):392–412

    Article  Google Scholar 

  • Sarter NB, Woods DD (1992) Pilot Interaction with cockpit automation: operational experiences with the flight management system. Int J Aviat Psychol 2(4):303–321

    Article  Google Scholar 

  • Sarter NB, Woods DD (1994) Pilot interaction with cockpit automation II: an experimental study of pilots’ model and awareness of the flight management and guidance system. Int J Aviat Psychol 4(1):1–28

    Article  Google Scholar 

  • South Africa Civil Aviation Authority (2003) Incident at the take-off with a Boeing 747-300, on 11 March 2003 (Report number REF 0263). Author, Johannesburg. Retrieved from http://www.caa.co.za

  • Thomas M (2004) Predictors of threat and error management: identification of core non-technical skills and implications for training systems design. Int J Aviat Psychol 14(2):207–231

    Article  Google Scholar 

  • Transport Accident Investigation Commission (2003) Boeing 747-412, flight SQ 286, tail strike during take-off, Auckland International Airport (Aviation Occurrence Report no. 03-003). Author, New Zealand. Retrieved from http://www.taic.org.nz/ReportsandSafetyRecs/AviationSafetyRecommendations/tabid/80/Page/0/Mode/Aviation/Recipient/Singapore%20International%20Airlines/ImplementationStatus/Open/Keywords/03-003/IssuedDateOffset/0/language/en-US/Default.aspx

  • Transportation Safety Board of Canada (2003) Reduced power at take-off and collision with terrain. Boeing 747-244SF 9-GMKJ, Halifax International Airport, Nova Scotia, 14 October 2004 (Aviation Investigation Report no. A04H0004). Author, Gatineu. Retrieved from http://www.tsb.gc.ca/eng/rapports-reports/aviation/2004/a04h0004/a04h0004.asp

  • Transportation Safety Board of Canada (2006a) Tail strike on take-off and aircraft pitch up on final approach, Air Canada, Airbus 330-343 C-GHLM, Frankfurt/Main Airport, 14 June 2002 (Aviation Investigation Report no. A02F0069). Author, Gatineu. Retrieved from http://www.tsb.gc.ca/eng/rapports-reports/aviation/2002/a02f0069/a02f0069.asp

  • Transportation Safety Board of Canada (2006b) Take-off performance calculation error, Air Canada, Embraer 190-100 C-FHIU, Edmonton, Alberta, 12 July 2006 (Aviation Investigation Report no. A06A0096). Author, Gatineu. Retrieved from http://www.tsb.gc.ca/eng/rapports-reports/aviation/2006/a06a0096/a06a0096.pdf

  • Wickens C, Hollands JG (2000) Engineering psychology and human performance. Prentice-Hall, Englewood Cliffs

    Google Scholar 

  • Woljter R (2009) Functional modeling of constraint management in aviation safety and command and control (Dissertation no. 1247). Department of Computer and Information Science, Linköpings University, Linköpings. Retrieved from http://liu.diva-portal.org/smash/get/diva2:210824/FULLTEXT01

  • Woods DD (1993) Process-tracing methods for the study of cognition outside of the experimental psychology laboratory. In: Klein GA, Orasanu J, Calderwood R, Zsambok CE (eds) Decision making in action: models and methods. Ablex, Mahwah

    Google Scholar 

  • Woods DD (2003) Discovering how distributed cognitive systems works. In: Hollnagel E (ed) Handbook of cognitive task design. Lawrence Erlbaum Associates, Hillsdale, pp 37–54

    Chapter  Google Scholar 

  • Woods DD, Hollnagel E (2006) Joint cognitive systems: patterns in cognitive systems engineering. Taylor & Francis, Boca Raton

    Book  Google Scholar 

  • Woods DD, Tinapple D, Roesler A, Feil M (2002) Studying cognitive work in context: facilitating insight at the intersection of people, technology and work. Cogn. Syst. Eng. Lab. Inst. Ergon., Ohio State University, Columbus. Retrieved from http://csel.eng.ohio-state.edu/woodscta

  • Woods DD, Dekker SWA, Cook RJ, Johannesen L, Sarter NB (2009) Behind human error. Ashgate, Aldershot (in press)

Download references

Author information

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

Authors
  1. Eder Henriqson
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roel van Winsen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tarcisio Abreu Saurin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sidney W. A. Dekker
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eder Henriqson.

Rights and permissions

Reprints and permissions

About this article

Cite this article

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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10111-010-0161-4

Keywords

Search

Navigation