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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 639225 |
Time | |
Date | 200412 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl bound lower : 1300 msl bound upper : 1600 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | general aviation : corporate |
Make Model Name | Gulfstream V |
Operating Under FAR Part | Part 91 |
Navigation In Use | other other vortac |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : dalton |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp pilot : cfi |
ASRS Report | 639225 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : company policies non adherence : published procedure non adherence : clearance other anomaly |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance controller : issued advisory flight crew : became reoriented |
Supplementary | |
Problem Areas | Flight Crew Human Performance Airspace Structure |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
For our departure out of teb we were given the dalton departure, runway 19. This procedure has you climb on runway heading until 800 ft, then turn right heading 280 degrees, maintaining VFR at or below 1300 ft, expect IFR activation after crossing the 230 degree radial from teb VOR. We set the airplane up for a normal departure with 1510 ft set in the flight reference MDA window. I used rated takeoff because of the wind and airport conditions. We briefed the takeoff and the departure procedure before we started engines. The one thing I thought of on the takeoff roll was to leave my flaps down until we were stabilized on the 280 degree heading. I did not communicate this. I just figured in my mind the call would be just delayed a few seconds and the call out would be the same as our fokker, flight level change, then flaps up. The takeoff was normal with positive rate gear up, at about 600 ft. I thought I called for flight level change, and then to set manual speed of 190 knots. I then started concentrating on making the turn to 280 degrees. As soon as we turned to 280 degrees, we were getting an overspd warning for the flap setting. I could not figure out why the warning was going off, so I just pulled the power levers to flight idle. The speed started to come back to 190 KTS and I adjusted the power manually, but my altitude went 1500-1600 ft. We were then asked our altitude by the controller and we told him that we were correcting at this time. As soon as the airplane went through 1510 ft, we started getting a 'don't sink' warning from the GPWS. Since the airplane was still in the climb mode, I stopped the descent because I was not sure where the airplane was in relation to the terrain, at this point. After a few seconds, I noticed that we were not in flight level change, but in the climb mode still. At about this time, the controller gave us a climb clearance to 10000 ft. We set automatic speed and it went to 250 KTS for the airspeed and then we selected flight level change and engaged the autothrottles. The speed went back to 200 KTS and the throttles started back to flight idle at this time. I turned the autothrottles off and set 250 KTS again in manual and re-engaged the autothrottles and they started working again in the proper way. Looking back, several factors helped cause this incident. First, was the fact it had been a month since I had last flown the airplane from the left seat. Second, I should have briefed an altitude that I wanted flight level change to be engaged by. Third, I should not have changed a procedure on the runway without briefing it. We have been having autothrottles problem with this airplane. I am not sure how much that contributed to the incident. This procedure is not the best for teb departures in high performance jets. I feel it is counter intuitive to be lowering your nose in the takeoff portion of your flight. This works against all the automation that we have become accustomed to. If one thing goes wrong, the margin for safety is greatly reduced. If we continue to go into this airport, my recommendation for this procedure would be for a normal takeoff, but at 400 ft to call for flight level change, and manual speed of 160 KTS, and leave the flaps at 20 degrees. Also, I would select 1300 ft in the MDA window. The autoplt should also be engaged as soon as possible so both pilots are able to monitor the airplane.
Original NASA ASRS Text
Title: ATL OVERSHOT ON DALTON SID BY A DEP GLF5 FLT CREW 3 MILES SW OF TEB.
Narrative: FOR OUR DEP OUT OF TEB WE WERE GIVEN THE DALTON DEP, RWY 19. THIS PROC HAS YOU CLB ON RWY HDG UNTIL 800 FT, THEN TURN R HDG 280 DEGS, MAINTAINING VFR AT OR BELOW 1300 FT, EXPECT IFR ACTIVATION AFTER CROSSING THE 230 DEG RADIAL FROM TEB VOR. WE SET THE AIRPLANE UP FOR A NORMAL DEP WITH 1510 FT SET IN THE FLT REFERENCE MDA WINDOW. I USED RATED TKOF BECAUSE OF THE WIND AND ARPT CONDITIONS. WE BRIEFED THE TKOF AND THE DEP PROC BEFORE WE STARTED ENGINES. THE ONE THING I THOUGHT OF ON THE TKOF ROLL WAS TO LEAVE MY FLAPS DOWN UNTIL WE WERE STABILIZED ON THE 280 DEG HDG. I DID NOT COMMUNICATE THIS. I JUST FIGURED IN MY MIND THE CALL WOULD BE JUST DELAYED A FEW SECONDS AND THE CALL OUT WOULD BE THE SAME AS OUR FOKKER, FLT LEVEL CHANGE, THEN FLAPS UP. THE TKOF WAS NORMAL WITH POSITIVE RATE GEAR UP, AT ABOUT 600 FT. I THOUGHT I CALLED FOR FLT LEVEL CHANGE, AND THEN TO SET MANUAL SPD OF 190 KNOTS. I THEN STARTED CONCENTRATING ON MAKING THE TURN TO 280 DEGS. AS SOON AS WE TURNED TO 280 DEGS, WE WERE GETTING AN OVERSPD WARNING FOR THE FLAP SETTING. I COULD NOT FIGURE OUT WHY THE WARNING WAS GOING OFF, SO I JUST PULLED THE PWR LEVERS TO FLT IDLE. THE SPD STARTED TO COME BACK TO 190 KTS AND I ADJUSTED THE PWR MANUALLY, BUT MY ALT WENT 1500-1600 FT. WE WERE THEN ASKED OUR ALTITUDE BY THE CTLR AND WE TOLD HIM THAT WE WERE CORRECTING AT THIS TIME. AS SOON AS THE AIRPLANE WENT THROUGH 1510 FT, WE STARTED GETTING A 'DON'T SINK' WARNING FROM THE GPWS. SINCE THE AIRPLANE WAS STILL IN THE CLB MODE, I STOPPED THE DSCNT BECAUSE I WAS NOT SURE WHERE THE AIRPLANE WAS IN RELATION TO THE TERRAIN, AT THIS POINT. AFTER A FEW SECONDS, I NOTICED THAT WE WERE NOT IN FLT LEVEL CHANGE, BUT IN THE CLB MODE STILL. AT ABOUT THIS TIME, THE CTLR GAVE US A CLB CLRNC TO 10000 FT. WE SET AUTO SPD AND IT WENT TO 250 KTS FOR THE AIRSPD AND THEN WE SELECTED FLT LEVEL CHANGE AND ENGAGED THE AUTOTHROTTLES. THE SPD WENT BACK TO 200 KTS AND THE THROTTLES STARTED BACK TO FLT IDLE AT THIS TIME. I TURNED THE AUTOTHROTTLES OFF AND SET 250 KTS AGAIN IN MANUAL AND RE-ENGAGED THE AUTOTHROTTLES AND THEY STARTED WORKING AGAIN IN THE PROPER WAY. LOOKING BACK, SEVERAL FACTORS HELPED CAUSE THIS INCIDENT. FIRST, WAS THE FACT IT HAD BEEN A MONTH SINCE I HAD LAST FLOWN THE AIRPLANE FROM THE LEFT SEAT. SECOND, I SHOULD HAVE BRIEFED AN ALT THAT I WANTED FLT LEVEL CHANGE TO BE ENGAGED BY. THIRD, I SHOULD NOT HAVE CHANGED A PROC ON THE RWY WITHOUT BRIEFING IT. WE HAVE BEEN HAVING AUTOTHROTTLES PROB WITH THIS AIRPLANE. I AM NOT SURE HOW MUCH THAT CONTRIBUTED TO THE INCIDENT. THIS PROC IS NOT THE BEST FOR TEB DEPS IN HIGH PERFORMANCE JETS. I FEEL IT IS COUNTER INTUITIVE TO BE LOWERING YOUR NOSE IN THE TKOF PORTION OF YOUR FLT. THIS WORKS AGAINST ALL THE AUTOMATION THAT WE HAVE BECOME ACCUSTOMED TO. IF ONE THING GOES WRONG, THE MARGIN FOR SAFETY IS GREATLY REDUCED. IF WE CONTINUE TO GO INTO THIS ARPT, MY RECOMMENDATION FOR THIS PROC WOULD BE FOR A NORMAL TKOF, BUT AT 400 FT TO CALL FOR FLT LEVEL CHANGE, AND MANUAL SPD OF 160 KTS, AND LEAVE THE FLAPS AT 20 DEGS. ALSO, I WOULD SELECT 1300 FT IN THE MDA WINDOW. THE AUTOPLT SHOULD ALSO BE ENGAGED AS SOON AS POSSIBLE SO BOTH PLTS ARE ABLE TO MONITOR THE AIRPLANE.
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.