37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 705409 |
Time | |
Date | 200607 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl bound lower : 1500 msl bound upper : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : teb.tower |
Operator | general aviation : personal |
Make Model Name | Bonanza 36 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure sid : teb 5 |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : private |
Experience | flight time last 90 days : 75 flight time total : 900 flight time type : 900 |
ASRS Report | 705409 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure |
Resolutory Action | none taken : anomaly accepted none taken : insufficient time |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I made an error executing the teb 5 departure procedure resulting in the 500 ft altitude incursion. The procedure read: 'takeoff runway 24: climb runway heading until reaching 1500 ft; then right turn heading 280 degrees. Maintain 1500 ft until passing teb 4.5 DME; then climb and maintain 2000 ft...' in my case I misread the SID; and started a climb to 2000 ft after rolling out on the 280 degree heading. The controller called out this error to me. I estimate that I started the climb at 3.0 DME; which resulted in me being 500 ft too high for that segment of flight. The cause of this error was me misreading the SID. Contribution factors were: a) teb is a very busy airport that results in high cockpit workload for a single pilot; B) it was at the end of a business day where pilot fatigue may have contributed; C) the SID is complicated given it requires DME or the tracking of a neighboring NDB radial; which is an out-of-the-normal operation for pilots that increasingly use GPS as their primary navigation method; and D) in the vast majority of cases the tower or departure controllers preempt a SID clearance; thus I may have been complacent because I was expecting the controller to dispense with the procedure and give me a vector or altitude assignment. In the future I will read SID's more carefully; particularly at teb. I would suggest the use of a GPS fix; rather than DME; as a workload reduction tool for single pilot operations. I think it would be much easier if the SID read 'maintain 1500 ft to xxyyy fix; then a climbing right turn to 2000 ft on a heading of 280 degrees.' this would read more like a missed approach procedure; which is more familiar to a pilot.
Original NASA ASRS Text
Title: A BE36 PLT FLYING THE TEB 5 DEP OUT OF TEB MISREAD THE SID AND DEVIATED FROM THE 1500 FT RESTR; CLBING TO 2000 FT.
Narrative: I MADE AN ERROR EXECUTING THE TEB 5 DEP PROC RESULTING IN THE 500 FT ALT INCURSION. THE PROC READ: 'TAKEOFF RWY 24: CLB RWY HEADING UNTIL REACHING 1500 FT; THEN R TURN HEADING 280 DEGS. MAINTAIN 1500 FT UNTIL PASSING TEB 4.5 DME; THEN CLB AND MAINTAIN 2000 FT...' IN MY CASE I MISREAD THE SID; AND STARTED A CLB TO 2000 FT AFTER ROLLING OUT ON THE 280 DEG HEADING. THE CTLR CALLED OUT THIS ERROR TO ME. I ESTIMATE THAT I STARTED THE CLB AT 3.0 DME; WHICH RESULTED IN ME BEING 500 FT TOO HIGH FOR THAT SEGMENT OF FLT. THE CAUSE OF THIS ERROR WAS ME MISREADING THE SID. CONTRIBUTION FACTORS WERE: A) TEB IS A VERY BUSY ARPT THAT RESULTS IN HIGH COCKPIT WORKLOAD FOR A SINGLE PLT; B) IT WAS AT THE END OF A BUSINESS DAY WHERE PLT FATIGUE MAY HAVE CONTRIBUTED; C) THE SID IS COMPLICATED GIVEN IT REQUIRES DME OR THE TRACKING OF A NEIGHBORING NDB RADIAL; WHICH IS AN OUT-OF-THE-NORMAL OP FOR PLTS THAT INCREASINGLY USE GPS AS THEIR PRIMARY NAV METHOD; AND D) IN THE VAST MAJORITY OF CASES THE TWR OR DEP CTLRS PREEMPT A SID CLRNC; THUS I MAY HAVE BEEN COMPLACENT BECAUSE I WAS EXPECTING THE CTLR TO DISPENSE WITH THE PROC AND GIVE ME A VECTOR OR ALT ASSIGNMENT. IN THE FUTURE I WILL READ SID'S MORE CAREFULLY; PARTICULARLY AT TEB. I WOULD SUGGEST THE USE OF A GPS FIX; RATHER THAN DME; AS A WORKLOAD REDUCTION TOOL FOR SINGLE PLT OPS. I THINK IT WOULD BE MUCH EASIER IF THE SID READ 'MAINTAIN 1500 FT TO XXYYY FIX; THEN A CLIMBING R TURN TO 2000 FT ON A HEADING OF 280 DEGS.' THIS WOULD READ MORE LIKE A MISSED APCH PROC; WHICH IS MORE FAMILIAR TO A PLT.
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.