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|
Attributes | |
ACN | 610228 |
Time | |
Date | 200403 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : teb.vor |
State Reference | NJ |
Altitude | msl bound lower : 1500 msl bound upper : 1740 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon tower : teb.tower |
Operator | general aviation : corporate |
Make Model Name | Citation X |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : teb5 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 15000 flight time type : 1500 |
ASRS Report | 610228 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : published procedure non adherence : company policies non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude flight crew : returned to original clearance |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departing teb on teb 5 SID. SID requires aircraft to maintain 1500 ft MSL until passing teb DME 4.5 mi fix then allows a climb to 2000 ft. Overhead arrival path to ewr airport requires aircraft departing teb to remain at the published altitudes (1500 ft and then 2000 ft) until cleared to a higher altitude by ATC. The altitude alerter was set to 2000 ft instead of 1500 ft. The flight director command and altitude alerter warning were programmed for 2000 ft instead of 1500 ft. As we approached 1500 ft, instead of leveling off first, we began our turn to 280 degrees per the SID. We maintained less than 200 KTS being below class B airspace. The attention paid to the heading change of 40 degrees and the speed control allowed us to climb to 1740 ft MSL. The aircraft was being hand flown. ATC and the first officer both advised of the 1500 ft requirement. We immediately returned to 1500 ft until passing the appropriate climb point which was the teb 4.5 DME fix. The climb from 1500 ft to 1740 ft occurred between the 3.9 and 4.4 mile distance from the teb VOR. We had carefully briefed the departure and the first officer suggested the alerter be set to 1500 ft instead of 2000 ft. Having flown the departure many times, I felt 2000 ft was satisfactory. (How wrong I was.) our SOP's were proper, the execution of them was less so. We had not been rushed, nor was weather a factor. In retrospect, I failed to follow a long held belief that the altitude alerter is a stop sign and should be used in just that way. Being familiar with the aircraft, the airport and the departure let me fall into a poor situation awareness mode. Through the efforts of my first officer and ATC, we were able to minimize the altitude excursion. Clearly the lesson learned is that familiarity and a problem free environment are no guarantee that mistakes will not still happen. The alerter is a stop sign and an early warning device. I was truly humbled by the experience.
Original NASA ASRS Text
Title: A C750 CAPT ADMITTED THAT HE IMPROPERLY PROGRAMMED HIS AUTOMATION, AGAINST THE ADVICE OF HIS FO, CAUSING AN ALT HDG DEV WHEN FLYING THE TEB SID.
Narrative: DEPARTING TEB ON TEB 5 SID. SID REQUIRES ACFT TO MAINTAIN 1500 FT MSL UNTIL PASSING TEB DME 4.5 MI FIX THEN ALLOWS A CLB TO 2000 FT. OVERHEAD ARR PATH TO EWR ARPT REQUIRES ACFT DEPARTING TEB TO REMAIN AT THE PUBLISHED ALTS (1500 FT AND THEN 2000 FT) UNTIL CLRED TO A HIGHER ALT BY ATC. THE ALT ALERTER WAS SET TO 2000 FT INSTEAD OF 1500 FT. THE FLT DIRECTOR COMMAND AND ALT ALERTER WARNING WERE PROGRAMMED FOR 2000 FT INSTEAD OF 1500 FT. AS WE APCHED 1500 FT, INSTEAD OF LEVELING OFF FIRST, WE BEGAN OUR TURN TO 280 DEGS PER THE SID. WE MAINTAINED LESS THAN 200 KTS BEING BELOW CLASS B AIRSPACE. THE ATTN PAID TO THE HDG CHANGE OF 40 DEGS AND THE SPEED CTL ALLOWED US TO CLB TO 1740 FT MSL. THE ACFT WAS BEING HAND FLOWN. ATC AND THE FO BOTH ADVISED OF THE 1500 FT REQUIREMENT. WE IMMEDIATELY RETURNED TO 1500 FT UNTIL PASSING THE APPROPRIATE CLB POINT WHICH WAS THE TEB 4.5 DME FIX. THE CLB FROM 1500 FT TO 1740 FT OCCURRED BETWEEN THE 3.9 AND 4.4 MILE DISTANCE FROM THE TEB VOR. WE HAD CAREFULLY BRIEFED THE DEP AND THE FO SUGGESTED THE ALERTER BE SET TO 1500 FT INSTEAD OF 2000 FT. HAVING FLOWN THE DEP MANY TIMES, I FELT 2000 FT WAS SATISFACTORY. (HOW WRONG I WAS.) OUR SOP'S WERE PROPER, THE EXECUTION OF THEM WAS LESS SO. WE HAD NOT BEEN RUSHED, NOR WAS WEATHER A FACTOR. IN RETROSPECT, I FAILED TO FOLLOW A LONG HELD BELIEF THAT THE ALT ALERTER IS A STOP SIGN AND SHOULD BE USED IN JUST THAT WAY. BEING FAMILIAR WITH THE ACFT, THE ARPT AND THE DEP LET ME FALL INTO A POOR SIT AWARENESS MODE. THROUGH THE EFFORTS OF MY FO AND ATC, WE WERE ABLE TO MINIMIZE THE ALT EXCURSION. CLEARLY THE LESSON LEARNED IS THAT FAMILIARITY AND A PROB FREE ENVIRONMENT ARE NO GUARANTEE THAT MISTAKES WILL NOT STILL HAPPEN. THE ALERTER IS A STOP SIGN AND AN EARLY WARNING DEVICE. I WAS TRULY HUMBLED BY THE EXPERIENCE.
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.