37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 733329 |
Time | |
Date | 200704 |
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 | tracon : n90.tracon |
Operator | common carrier : air carrier |
Make Model Name | Global Express |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : maintenance |
Flight Plan | IFR |
Aircraft 2 | |
Flight Phase | climbout : takeoff |
Route In Use | departure sid : teb |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 68 flight time total : 8400 flight time type : 1100 |
ASRS Report | 733329 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : published procedure non adherence : clearance |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
Departing teb runway 24 given teb 5 departure SID. Reviewed and entered in FMS with co-pilot. SID indicated initial level off at 1500 ft until 4.5 DME from teb with final departure altitude of 2000 ft. In VNAV aircraft did not level at 1500 ft and deviation was initially missed and then corrected as aircraft leveled at 2000 ft. Proximate cause of error was failure of VNAV to level in accordance with published SID and misdirected attention of pilots as 1500 ft altitude was exceeded. Contributing factors include fatigue as flight had been scheduled overnight with early departure from europe. Further; immediately prior to departure an unrelated flight control failure had required an abort on the runway and subsequent maintenance troubleshooting resulting in further delay and distraction. Primary corrective action is to more closely monitor actions of automated flight.
Original NASA ASRS Text
Title: A BD700 FLT CREW HAS AN ALT DEV DURING TEB 5 DEP.
Narrative: DEPARTING TEB RWY 24 GIVEN TEB 5 DEP SID. REVIEWED AND ENTERED IN FMS WITH CO-PILOT. SID INDICATED INITIAL LEVEL OFF AT 1500 FT UNTIL 4.5 DME FROM TEB WITH FINAL DEP ALTITUDE OF 2000 FT. IN VNAV ACFT DID NOT LEVEL AT 1500 FT AND DEVIATION WAS INITIALLY MISSED AND THEN CORRECTED AS ACFT LEVELED AT 2000 FT. PROXIMATE CAUSE OF ERROR WAS FAILURE OF VNAV TO LEVEL IN ACCORDANCE WITH PUBLISHED SID AND MISDIRECTED ATTENTION OF PLTS AS 1500 FT ALTITUDE WAS EXCEEDED. CONTRIBUTING FACTORS INCLUDE FATIGUE AS FLT HAD BEEN SCHEDULED OVERNIGHT WITH EARLY DEP FROM EUROPE. FURTHER; IMMEDIATELY PRIOR TO DEP AN UNRELATED FLT CTL FAILURE HAD REQUIRED AN ABORT ON THE RWY AND SUBSEQUENT MAINT TROUBLESHOOTING RESULTING IN FURTHER DELAY AND DISTR. PRIMARY CORRECTIVE ACTION IS TO MORE CLOSELY MONITOR ACTIONS OF AUTOMATED FLT.
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.