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|
Attributes | |
ACN | 411530 |
Time | |
Date | 199808 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ege |
State Reference | CO |
Altitude | msl bound lower : 9000 msl bound upper : 9000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdv |
Operator | general aviation : corporate |
Make Model Name | Beechjet 400 |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 4200 flight time type : 1700 |
ASRS Report | 411530 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On departure from ege, we were cleared via the published IFR departure procedure for runway 25. After lift-off we maintained a 215 degree heading as per the procedure. Upon making the second turn, which was supposed to be to the right, I inadvertently turned left. My sic recognized my error the same time that ATC controllers did. We were advised to make an immediate right turn to avoid aspen approach airspace. We complied immediately. The wrong turn and following confusion caused a momentary breakdown in crew coordination, navigation, etc. Facts: the departure procedure was set up and briefed twice prior to passenger arrival. Departure was briefed again immediately prior to departure. Sic was advised to read each step as we flew the procedure. Contributing factors: lack of plain view diagram to insure crew had proper visualization of the procedure to be flown. Procedure was typed with very small print, about the size of a classified ad. Captain's inability to properly visualize procedure to be flown. Task saturation of crew during a critical phase of flight. Abnormal stress associated with planning/flying an aircraft in high/hot/heavy conditions in mountainous terrain. Distractions caused by passenger (children) in the cabin of the aircraft. 2 pilots flying together for the first time. Afterwards I learned that pilots and controllers alike have complained that this procedure is easy to mess up. I believe a published SID with a plain view diagram would help alleviate some potential for pilot error in flying this procedure. Aspen's sids could be used as a model for establishing a SID for eagle.
Original NASA ASRS Text
Title: CAPT OF A BEECH JET 400, (BE40), INADVERTENTLY TURNED THE OPPOSITE DIRECTION DURING A SID DEP IN HIGH MOUNTAINOUS AREA ARPT. ARTCC RADAR CTLR NOTICED THE ERROR AND INTERVENED TO DIRECT THE RPTR BACK THE CORRECT DIRECTION.
Narrative: ON DEP FROM EGE, WE WERE CLRED VIA THE PUBLISHED IFR DEP PROC FOR RWY 25. AFTER LIFT-OFF WE MAINTAINED A 215 DEG HDG AS PER THE PROC. UPON MAKING THE SECOND TURN, WHICH WAS SUPPOSED TO BE TO THE R, I INADVERTENTLY TURNED L. MY SIC RECOGNIZED MY ERROR THE SAME TIME THAT ATC CTLRS DID. WE WERE ADVISED TO MAKE AN IMMEDIATE R TURN TO AVOID ASPEN APCH AIRSPACE. WE COMPLIED IMMEDIATELY. THE WRONG TURN AND FOLLOWING CONFUSION CAUSED A MOMENTARY BREAKDOWN IN CREW COORD, NAV, ETC. FACTS: THE DEP PROC WAS SET UP AND BRIEFED TWICE PRIOR TO PAX ARR. DEP WAS BRIEFED AGAIN IMMEDIATELY PRIOR TO DEP. SIC WAS ADVISED TO READ EACH STEP AS WE FLEW THE PROC. CONTRIBUTING FACTORS: LACK OF PLAIN VIEW DIAGRAM TO INSURE CREW HAD PROPER VISUALIZATION OF THE PROC TO BE FLOWN. PROC WAS TYPED WITH VERY SMALL PRINT, ABOUT THE SIZE OF A CLASSIFIED AD. CAPT'S INABILITY TO PROPERLY VISUALIZE PROC TO BE FLOWN. TASK SATURATION OF CREW DURING A CRITICAL PHASE OF FLT. ABNORMAL STRESS ASSOCIATED WITH PLANNING/FLYING AN ACFT IN HIGH/HOT/HVY CONDITIONS IN MOUNTAINOUS TERRAIN. DISTRACTIONS CAUSED BY PAX (CHILDREN) IN THE CABIN OF THE ACFT. 2 PLTS FLYING TOGETHER FOR THE FIRST TIME. AFTERWARDS I LEARNED THAT PLTS AND CTLRS ALIKE HAVE COMPLAINED THAT THIS PROC IS EASY TO MESS UP. I BELIEVE A PUBLISHED SID WITH A PLAIN VIEW DIAGRAM WOULD HELP ALLEVIATE SOME POTENTIAL FOR PLT ERROR IN FLYING THIS PROC. ASPEN'S SIDS COULD BE USED AS A MODEL FOR ESTABLISHING A SID FOR EAGLE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.