37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 651907 |
Time | |
Date | 200503 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl bound lower : 1500 msl bound upper : 1800 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | common carrier : air taxi |
Make Model Name | Turbo Commander 690C |
Operating Under FAR Part | Part 135 |
Flight Plan | IFR |
Aircraft 2 | |
Flight Phase | climbout : initial |
Route In Use | departure sid : teb 5 |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : single pilot |
Qualification | pilot : atp |
Experience | flight time last 90 days : 20 flight time total : 17000 flight time type : 20 |
ASRS Report | 651907 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : far non adherence : published procedure non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Airspace Structure Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Situations | |
Chart | sid : teb 5 |
Narrative:
This was my second trip in the AC690B single pilot at night. It was my third leg of the day. We were on our way home after delivering a patient to the teb airport in nj. I was cleared via the teb 5 departure and was very familiar with the 'hot spots' on that SID; since I was very new to the airplane and to teb. I departed from runway 24 and was planning to climb to 1500 ft; make the turn then climb to 2000 ft. At approximately 1300 ft; just before I was going to level off; a red warning light illuminated on my annunciator panel and distracted me from leveling at 1500 ft. It was a 'door' warning and since I was brand new to the airplane; I was alarmed enough to glance back at the door to look for anything unusual and by the time I looked back at my instruments; I was passing through 1800 ft. I immediately started a descent back to 1500 ft; but the controller noticed the altitude deviation and said since I had already passed the required altitude; just keep climbing to 8000 ft. I then climbed as directed and the remainder of the flight was uneventful. This is a perfect example of human performance. I have over 20 yrs as an airline pilot without a single altitude deviation; but at a new airport in an unfamiliar airplane with a potential emergency warning; I lost my situational awareness enough to deviate from the SID. I had the entire SID committed to memory; but I still became distraction. During the takeoff phase; a master warning is impossible to ignore and a complicated departure; such as the teb 5 adds to the workload. I did not tell the controller about the warning; as he was quite busy and cleared me to 8000 ft since there was no conflict with other traffic.
Original NASA ASRS Text
Title: AN AC690 PLT DISTR BY A MASTER CAUTION LIGHT AFTER TKOF EXCEEDED THE TEB 5 DEP'S 1500 FT RESTR.
Narrative: THIS WAS MY SECOND TRIP IN THE AC690B SINGLE PLT AT NIGHT. IT WAS MY THIRD LEG OF THE DAY. WE WERE ON OUR WAY HOME AFTER DELIVERING A PATIENT TO THE TEB ARPT IN NJ. I WAS CLRED VIA THE TEB 5 DEP AND WAS VERY FAMILIAR WITH THE 'HOT SPOTS' ON THAT SID; SINCE I WAS VERY NEW TO THE AIRPLANE AND TO TEB. I DEPARTED FROM RWY 24 AND WAS PLANNING TO CLB TO 1500 FT; MAKE THE TURN THEN CLB TO 2000 FT. AT APPROX 1300 FT; JUST BEFORE I WAS GOING TO LEVEL OFF; A RED WARNING LIGHT ILLUMINATED ON MY ANNUNCIATOR PANEL AND DISTRACTED ME FROM LEVELING AT 1500 FT. IT WAS A 'DOOR' WARNING AND SINCE I WAS BRAND NEW TO THE AIRPLANE; I WAS ALARMED ENOUGH TO GLANCE BACK AT THE DOOR TO LOOK FOR ANYTHING UNUSUAL AND BY THE TIME I LOOKED BACK AT MY INSTRUMENTS; I WAS PASSING THROUGH 1800 FT. I IMMEDIATELY STARTED A DSCNT BACK TO 1500 FT; BUT THE CTLR NOTICED THE ALT DEV AND SAID SINCE I HAD ALREADY PASSED THE REQUIRED ALT; JUST KEEP CLBING TO 8000 FT. I THEN CLBED AS DIRECTED AND THE REMAINDER OF THE FLT WAS UNEVENTFUL. THIS IS A PERFECT EXAMPLE OF HUMAN PERFORMANCE. I HAVE OVER 20 YRS AS AN AIRLINE PLT WITHOUT A SINGLE ALT DEV; BUT AT A NEW ARPT IN AN UNFAMILIAR AIRPLANE WITH A POTENTIAL EMER WARNING; I LOST MY SITUATIONAL AWARENESS ENOUGH TO DEVIATE FROM THE SID. I HAD THE ENTIRE SID COMMITTED TO MEMORY; BUT I STILL BECAME DISTR. DURING THE TKOF PHASE; A MASTER WARNING IS IMPOSSIBLE TO IGNORE AND A COMPLICATED DEP; SUCH AS THE TEB 5 ADDS TO THE WORKLOAD. I DID NOT TELL THE CTLR ABOUT THE WARNING; AS HE WAS QUITE BUSY AND CLRED ME TO 8000 FT SINCE THERE WAS NO CONFLICT WITH OTHER TFC.
Data retrieved from NASA's ASRS site as of January 2009 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.