37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 685061 |
Time | |
Date | 200601 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl single value : 1500 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | common carrier : air taxi |
Make Model Name | Learjet 31 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : initial climbout : takeoff |
Route In Use | departure sid : teb |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : commercial pilot : cfi pilot : atp pilot : instrument |
Experience | flight time last 90 days : 100 flight time total : 3676 flight time type : 100 |
ASRS Report | 685061 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After loading the passenger and starting the engines; I (PF) began to taxi while the captain (PNF) was running the taxi checklist. The captain was reading the departure procedure and setting the appropriate navigation aids and then briefed me on the departure (teb 5) while I taxied to runway 24. I then read back to him the departure procedure as I understood it (departure runway 24 climb to 1500 ft then turn right to a heading of 280 degrees and climb to 2000 ft). He told me that was correct and set the altitude selector to 1500 ft. We completed the checklists and then departed runway 24. On departure; I climbed runway heading to 1500 ft then initiated a turn to heading 280 degrees; asked the captain to reset the altitude selector to 2000 ft as I continued the climb to 2000 ft. The captain at this point took the handoff from the control tower to contact departure. The captain told me to level off at 1500 ft because we had not passed the teb 4.5 DME yet. I did not understand what he was telling me to do because that was not how I understood the procedure or briefed him previously. He was looking at the departure procedure in front of him so I initiated a descent to return back to 1500 ft. Once we passed the 4.5 DME I initiated a climb to 2000 ft and completed the departure procedure. I believe there were a few things that led up to not flying the departure procedure properly. Fatigue was a factor because I had been up for over 15 hours; although I still was under the maximum duty time for the day of 14 hours. So with fatigue came complacency in that the captain did not correct my briefing of the departure procedure; assuming I understood the procedure. Also there was a rush to get the passenger to their destination so we could return home before exceeding our maximum duty day. So by rushing to get off the ground as soon as possible we did not set up and brief the departure procedure before initiating the taxi. To correct the problem; first; we should be methodical in all checklists and procedures knowing that we were fatigued and mistakes can occur. Second; we should back each other up while flying the airplane and make sure the flying pilot is flying the proper heading; altitude and procedure as appropriate. Third; to not become complacent and assume the other pilot understands the given instructions. Fourth; not be pressured into getting back on time causing us to be hurried and skip appropriate procedures and giving all attention to the appropriate task.
Original NASA ASRS Text
Title: LJ31 FLT CREW FAILS TO LEVEL AT 1500 FT PER TEB 5 SID.
Narrative: AFTER LOADING THE PAX AND STARTING THE ENGINES; I (PF) BEGAN TO TAXI WHILE THE CAPT (PNF) WAS RUNNING THE TAXI CHKLIST. THE CAPT WAS READING THE DEP PROC AND SETTING THE APPROPRIATE NAV AIDS AND THEN BRIEFED ME ON THE DEP (TEB 5) WHILE I TAXIED TO RWY 24. I THEN READ BACK TO HIM THE DEP PROC AS I UNDERSTOOD IT (DEP RWY 24 CLB TO 1500 FT THEN TURN R TO A HEADING OF 280 DEGS AND CLB TO 2000 FT). HE TOLD ME THAT WAS CORRECT AND SET THE ALT SELECTOR TO 1500 FT. WE COMPLETED THE CHKLISTS AND THEN DEPARTED RWY 24. ON DEP; I CLBED RWY HEADING TO 1500 FT THEN INITIATED A TURN TO HEADING 280 DEGS; ASKED THE CAPT TO RESET THE ALTITUDE SELECTOR TO 2000 FT AS I CONTINUED THE CLB TO 2000 FT. THE CAPT AT THIS POINT TOOK THE HANDOFF FROM THE CTL TWR TO CONTACT DEP. THE CAPT TOLD ME TO LEVEL OFF AT 1500 FT BECAUSE WE HAD NOT PASSED THE TEB 4.5 DME YET. I DID NOT UNDERSTAND WHAT HE WAS TELLING ME TO DO BECAUSE THAT WAS NOT HOW I UNDERSTOOD THE PROC OR BRIEFED HIM PREVIOUSLY. HE WAS LOOKING AT THE DEP PROC IN FRONT OF HIM SO I INITIATED A DESCENT TO RETURN BACK TO 1500 FT. ONCE WE PASSED THE 4.5 DME I INITIATED A CLB TO 2000 FT AND COMPLETED THE DEP PROC. I BELIEVE THERE WERE A FEW THINGS THAT LED UP TO NOT FLYING THE DEP PROC PROPERLY. FATIGUE WAS A FACTOR BECAUSE I HAD BEEN UP FOR OVER 15 HRS; ALTHOUGH I STILL WAS UNDER THE MAXIMUM DUTY TIME FOR THE DAY OF 14 HRS. SO WITH FATIGUE CAME COMPLACENCY IN THAT THE CAPT DID NOT CORRECT MY BRIEFING OF THE DEP PROC; ASSUMING I UNDERSTOOD THE PROC. ALSO THERE WAS A RUSH TO GET THE PAX TO THEIR DEST SO WE COULD RETURN HOME BEFORE EXCEEDING OUR MAX DUTY DAY. SO BY RUSHING TO GET OFF THE GND AS SOON AS POSSIBLE WE DID NOT SET UP AND BRIEF THE DEP PROC BEFORE INITIATING THE TAXI. TO CORRECT THE PROB; FIRST; WE SHOULD BE METHODICAL IN ALL CHKLISTS AND PROCS KNOWING THAT WE WERE FATIGUED AND MISTAKES CAN OCCUR. SECOND; WE SHOULD BACK EACH OTHER UP WHILE FLYING THE AIRPLANE AND MAKE SURE THE FLYING PLT IS FLYING THE PROPER HEADING; ALT AND PROC AS APPROPRIATE. THIRD; TO NOT BECOME COMPLACENT AND ASSUME THE OTHER PLT UNDERSTANDS THE GIVEN INSTRUCTIONS. FOURTH; NOT BE PRESSURED INTO GETTING BACK ON TIME CAUSING US TO BE HURRIED AND SKIP APPROPRIATE PROCS AND GIVING ALL ATTENTION TO THE APPROPRIATE TASK.
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.