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Attributes | |
ACN | 606325 |
Time | |
Date | 200401 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl bound lower : 1500 msl bound upper : 1900 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | general aviation : corporate |
Make Model Name | Citationjet, C525/C526 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : teb |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : n90.tracon |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 4500 flight time type : 850 |
ASRS Report | 606325 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain |
Qualification | pilot : multi engine pilot : atp pilot : instrument |
Experience | flight time last 90 days : 100 flight time total : 4000 flight time type : 1000 |
ASRS Report | 606436 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot conflict : airborne less severe non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar/mode c aircraft equipment : tcas other controllera other flight crewa other flight crewb other other : 3 |
Resolutory Action | controller : issued new clearance flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 12000 vertical : 1000 |
Supplementary | |
Problem Areas | Airport Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : n90.tracon |
Chart | sid : teb 5 |
Publication | Commercial Chart |
Narrative:
After takeoff from teterboro, we were advised by ATC to turn to 290 degrees. At the same time, I noticed altitude was off 400 ft. Trying to correct the altitude, I was slow in the turn (only standard rate). As we were in the turn and descent, the TCAS alert went off. Causes: #1) distraction on the flight deck -- running checklists, turbulence, high volume traffic area (looking for other aircraft), sensitivity to passenger's needs on altitude catch, length of duty day. #2) 5000 ft which was put into altitude hold, human error, misreading departure procedure. Solutions: #1) fly the airplane first -- delay use of checklist until later. #2) double check assigned altitudes. #3) worrying too much about smoothness -- get on altitude and heading. Supplemental information from acn 606436: clearance given was teb 5 (runway heading to 1500 ft turn right 280 degrees). PF flew through altitude to about 1900 ft, crew recognized altitude and began correcting, but failed to initiate turn in timely manner. Entered turn standard rate and was advised 1500 ft 290 degrees by ATC. TCAS alert activated, aircraft rate of turn increased, and ATC asked if we were in turn. We believe a congested area, at night, and fatigue to be contributing factors. Crew became distracted by altitude deviation and led to a heading deviation. A pre takeoff briefing was performed, yet given the congestion of the area, a more thorough or repeating of certain key elements of the departure would have helped keep those elements fresh in our mind. The crew had rested in 'day rooms,' yet needed to be more mindful of outside factors: #1) last leg of day, #2) night, #3) congested area. Extra effort/awareness of being in these outside factors was needed. Callback conversation with reporter acn 606325 revealed the following information: reporter stated they were a part 91 operation on a C525. After takeoff, they received a TCAS TA on an airliner that appeared to be 2 miles away on approach into ewr and were given a turn by ATC to heading 290 degrees. Reporter said they had overshot to 1900 ft and began a slow descent to 1500 feet. He said they were also turning a little slow for passenger comfort. Reporter said for some reason the other pilot had set the altitude to 5000 ft. Reporter said they were rushed, but should have spent more time reviewing the SID and done a better job with the checklist. While en route, the pilot said ATC asked that they call after they land. He said the other pilot talked to ATC and was told they would get back to them. Reporter added that the departure frequency always seems to be congested. He suggested a second frequency be used for faster communications with ATC. The reporter also said the departure chart text would be easier to read if each runway procedure was in a separate paragraph.
Original NASA ASRS Text
Title: C525 CREW OFF RWY 24 AT TEB FLY TEB 5 SID INCORRECTLY AND RECEIVE A TCAS TA ON AN AIRLINER LNDG EWR.
Narrative: AFTER TKOF FROM TETERBORO, WE WERE ADVISED BY ATC TO TURN TO 290 DEGS. AT THE SAME TIME, I NOTICED ALT WAS OFF 400 FT. TRYING TO CORRECT THE ALT, I WAS SLOW IN THE TURN (ONLY STANDARD RATE). AS WE WERE IN THE TURN AND DSCNT, THE TCAS ALERT WENT OFF. CAUSES: #1) DISTRACTION ON THE FLT DECK -- RUNNING CHECKLISTS, TURB, HIGH VOLUME TFC AREA (LOOKING FOR OTHER ACFT), SENSITIVITY TO PAX'S NEEDS ON ALT CATCH, LENGTH OF DUTY DAY. #2) 5000 FT WHICH WAS PUT INTO ALT HOLD, HUMAN ERROR, MISREADING DEP PROC. SOLUTIONS: #1) FLY THE AIRPLANE FIRST -- DELAY USE OF CHECKLIST UNTIL LATER. #2) DOUBLE CHECK ASSIGNED ALTS. #3) WORRYING TOO MUCH ABOUT SMOOTHNESS -- GET ON ALT AND HDG. SUPPLEMENTAL INFO FROM ACN 606436: CLRNC GIVEN WAS TEB 5 (RWY HDG TO 1500 FT TURN R 280 DEGS). PF FLEW THROUGH ALT TO ABOUT 1900 FT, CREW RECOGNIZED ALT AND BEGAN CORRECTING, BUT FAILED TO INITIATE TURN IN TIMELY MANNER. ENTERED TURN STANDARD RATE AND WAS ADVISED 1500 FT 290 DEGS BY ATC. TCAS ALERT ACTIVATED, ACFT RATE OF TURN INCREASED, AND ATC ASKED IF WE WERE IN TURN. WE BELIEVE A CONGESTED AREA, AT NIGHT, AND FATIGUE TO BE CONTRIBUTING FACTORS. CREW BECAME DISTRACTED BY ALT DEV AND LED TO A HDG DEV. A PRE TKOF BRIEFING WAS PERFORMED, YET GIVEN THE CONGESTION OF THE AREA, A MORE THOROUGH OR REPEATING OF CERTAIN KEY ELEMENTS OF THE DEP WOULD HAVE HELPED KEEP THOSE ELEMENTS FRESH IN OUR MIND. THE CREW HAD RESTED IN 'DAY ROOMS,' YET NEEDED TO BE MORE MINDFUL OF OUTSIDE FACTORS: #1) LAST LEG OF DAY, #2) NIGHT, #3) CONGESTED AREA. EXTRA EFFORT/AWARENESS OF BEING IN THESE OUTSIDE FACTORS WAS NEEDED. CALLBACK CONVERSATION WITH RPTR ACN 606325 REVEALED THE FOLLOWING INFO: RPTR STATED THEY WERE A PART 91 OP ON A C525. AFTER TKOF, THEY RECEIVED A TCAS TA ON AN AIRLINER THAT APPEARED TO BE 2 MILES AWAY ON APCH INTO EWR AND WERE GIVEN A TURN BY ATC TO HDG 290 DEGS. RPTR SAID THEY HAD OVERSHOT TO 1900 FT AND BEGAN A SLOW DSCNT TO 1500 FEET. HE SAID THEY WERE ALSO TURNING A LITTLE SLOW FOR PAX COMFORT. RPTR SAID FOR SOME REASON THE OTHER PLT HAD SET THE ALT TO 5000 FT. RPTR SAID THEY WERE RUSHED, BUT SHOULD HAVE SPENT MORE TIME REVIEWING THE SID AND DONE A BETTER JOB WITH THE CHKLIST. WHILE ENRTE, THE PLT SAID ATC ASKED THAT THEY CALL AFTER THEY LAND. HE SAID THE OTHER PLT TALKED TO ATC AND WAS TOLD THEY WOULD GET BACK TO THEM. RPTR ADDED THAT THE DEPARTURE FREQ ALWAYS SEEMS TO BE CONGESTED. HE SUGGESTED A SECOND FREQ BE USED FOR FASTER COMS WITH ATC. THE RPTR ALSO SAID THE DEP CHART TEXT WOULD BE EASIER TO READ IF EACH RWY PROC WAS IN A SEPARATE PARAGRAPH.
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.