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|
Attributes | |
ACN | 776138 |
Time | |
Date | 200802 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl bound lower : 2000 msl bound upper : 4000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Turbulence |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | general aviation : corporate |
Make Model Name | Gulfstream IV |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : initial |
Route In Use | departure sid : teb |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 120 flight time total : 10000 flight time type : 1500 |
ASRS Report | 776138 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp pilot : cfi |
Experience | flight time last 90 days : 140 flight time total : 24400 flight time type : 1060 |
ASRS Report | 776137 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : far non adherence : clearance non adherence : company policies |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Departing teb airport on the teb 5 SID; our aircraft climbed without permission from the departure controller. According to the SID; our aircraft should have been at 2000 ft MSL at the time of the altitude deviation. The captain; who was hand flying the aircraft; mistakenly heard a climb clearance for another company aircraft with a very similar call sign which had departed the same runway and was flying the same SID. The captain reached over and changed the altitude selector in the cockpit to 9000 ft MSL and began an aggressive climb from 2000 ft MSL. This all transpired at the time the airport tower controller had passed us over to the departure controller. Additionally; there was moderate turbulence on the departure which was IMC and the controller requested that our transponder be 'recycled' and that we squawk 'identify.' these actions required me as co-pilot to be 'heads down' in the cockpit for a longer than usual period as the turbulence made these actions more difficult than usual. The departure controller questioned what altitude we were climbing to and informed us that we had not been cleared to climb. There were no apparent traffic conflicts and the controller instructed us to continue our climb to 8000 ft MSL with a right turn 20 degrees to a heading of 300. The remainder of the flight was uneventful and there was no indication from the controller of any traffic conflict or further actions to be taken by him or us. There are several contributing factors to this altitude deviation. Here are some of the significant issues in chronological order: 1) aircraft with nearly identical call signs departed from the same runway immediately after each other; and flying the same SID. This can obviously lead to miscommunication between controllers and pilots in the respective aircraft and requires special attention regarding communication procedures. Possible solution: allow a departure of a non-company aircraft between the two company aircraft with similar call signs to lessen the chance for confusion. 2) sids with significant altitude; heading; and distance constraints require close adherence to all standard operating procedures. This coupled with high density traffic at many of the airports where we operate requires pilots to be vigilant for all segments of the airport and departure regimes. Our company dictates that the co-pilot makes all changes to the altitude alerter in the cockpit. This is especially important when the PF is hand flying the aircraft. This ensures both pilots are aware and agree on any altitude changes and have an opportunity to resolve any questions regarding altitude assignment and/or changes in altitude. The captain did not follow these procedures and I was too busy with my head down to notice until I felt the continued climb from 2000 ft MSL and saw that 9000 ft had been set into the altitude alerter. Automation can greatly reduce the workload on both the PF and the PNF if it is used correctly. Our company encourages its use. Its use here might have prevented the aggressive climb and allowed more time to verify the altitude. 3) improper radio discipline and cockpit communication was a major factor to this deviation. Upon my switching frequencies from tower to departure controllers; the captain heard the tail end of a clearance for a climb for our company aircraft. While the controller instructed me to check our transponder; the captain commenced a climb and did not tell departure that he was climbing. He did not tell me he was climbing. When I realized we were climbing and saw that the altitude alerter had been changed I asked him what altitude we had been cleared to. He said 9000 ft. I asked if he was sure. I checked with departure and passing approximately 3000 ft MSL told them that we were climbing to 9000 ft. At that time departure informed us that we had not been cleared to climb. I told the captain to level off and immediately after that the controller continued our climb to 8000 ft. In busy sits especially in the terminal area; always follow proper radio protocol. Have positive communication established with each controller and make sure all crew members are in agreement with what those instructions are.
Original NASA ASRS Text
Title: GIV FLT CREW RPTS ALT DEV DEPARTING TEB AFTER CAPT COMPLIES WITH CLRNC INTENDED FOR ANOTHER ACFT WITH SIMILAR SOUNDING CALL SIGN.
Narrative: DEPARTING TEB ARPT ON THE TEB 5 SID; OUR ACFT CLBED WITHOUT PERMISSION FROM THE DEP CTLR. ACCORDING TO THE SID; OUR ACFT SHOULD HAVE BEEN AT 2000 FT MSL AT THE TIME OF THE ALT DEV. THE CAPT; WHO WAS HAND FLYING THE ACFT; MISTAKENLY HEARD A CLB CLRNC FOR ANOTHER COMPANY ACFT WITH A VERY SIMILAR CALL SIGN WHICH HAD DEPARTED THE SAME RWY AND WAS FLYING THE SAME SID. THE CAPT REACHED OVER AND CHANGED THE ALT SELECTOR IN THE COCKPIT TO 9000 FT MSL AND BEGAN AN AGGRESSIVE CLB FROM 2000 FT MSL. THIS ALL TRANSPIRED AT THE TIME THE ARPT TOWER CTLR HAD PASSED US OVER TO THE DEP CTLR. ADDITIONALLY; THERE WAS MODERATE TURBULENCE ON THE DEP WHICH WAS IMC AND THE CTLR REQUESTED THAT OUR XPONDER BE 'RECYCLED' AND THAT WE SQUAWK 'IDENT.' THESE ACTIONS REQUIRED ME AS CO-PLT TO BE 'HEADS DOWN' IN THE COCKPIT FOR A LONGER THAN USUAL PERIOD AS THE TURBULENCE MADE THESE ACTIONS MORE DIFFICULT THAN USUAL. THE DEP CTLR QUESTIONED WHAT ALT WE WERE CLBING TO AND INFORMED US THAT WE HAD NOT BEEN CLRED TO CLB. THERE WERE NO APPARENT TFC CONFLICTS AND THE CTLR INSTRUCTED US TO CONTINUE OUR CLB TO 8000 FT MSL WITH A R TURN 20 DEGS TO A HDG OF 300. THE REMAINDER OF THE FLT WAS UNEVENTFUL AND THERE WAS NO INDICATION FROM THE CTLR OF ANY TFC CONFLICT OR FURTHER ACTIONS TO BE TAKEN BY HIM OR US. THERE ARE SEVERAL CONTRIBUTING FACTORS TO THIS ALT DEV. HERE ARE SOME OF THE SIGNIFICANT ISSUES IN CHRONOLOGICAL ORDER: 1) ACFT WITH NEARLY IDENTICAL CALL SIGNS DEPARTED FROM THE SAME RWY IMMEDIATELY AFTER EACH OTHER; AND FLYING THE SAME SID. THIS CAN OBVIOUSLY LEAD TO MISCOMMUNICATION BETWEEN CTLRS AND PLTS IN THE RESPECTIVE ACFT AND REQUIRES SPECIAL ATTENTION REGARDING COM PROCS. POSSIBLE SOLUTION: ALLOW A DEP OF A NON-COMPANY ACFT BETWEEN THE TWO COMPANY ACFT WITH SIMILAR CALL SIGNS TO LESSEN THE CHANCE FOR CONFUSION. 2) SIDS WITH SIGNIFICANT ALT; HDG; AND DISTANCE CONSTRAINTS REQUIRE CLOSE ADHERENCE TO ALL STANDARD OPERATING PROCS. THIS COUPLED WITH HIGH DENSITY TFC AT MANY OF THE ARPTS WHERE WE OPERATE REQUIRES PLTS TO BE VIGILANT FOR ALL SEGMENTS OF THE ARPT AND DEP REGIMES. OUR COMPANY DICTATES THAT THE CO-PLT MAKES ALL CHANGES TO THE ALT ALERTER IN THE COCKPIT. THIS IS ESPECIALLY IMPORTANT WHEN THE PF IS HAND FLYING THE ACFT. THIS ENSURES BOTH PLTS ARE AWARE AND AGREE ON ANY ALT CHANGES AND HAVE AN OPPORTUNITY TO RESOLVE ANY QUESTIONS REGARDING ALT ASSIGNMENT AND/OR CHANGES IN ALT. THE CAPT DID NOT FOLLOW THESE PROCS AND I WAS TOO BUSY WITH MY HEAD DOWN TO NOTICE UNTIL I FELT THE CONTINUED CLB FROM 2000 FT MSL AND SAW THAT 9000 FT HAD BEEN SET INTO THE ALT ALERTER. AUTOMATION CAN GREATLY REDUCE THE WORKLOAD ON BOTH THE PF AND THE PNF IF IT IS USED CORRECTLY. OUR COMPANY ENCOURAGES ITS USE. ITS USE HERE MIGHT HAVE PREVENTED THE AGGRESSIVE CLB AND ALLOWED MORE TIME TO VERIFY THE ALT. 3) IMPROPER RADIO DISCIPLINE AND COCKPIT COM WAS A MAJOR FACTOR TO THIS DEV. UPON MY SWITCHING FREQUENCIES FROM TWR TO DEP CTLRS; THE CAPT HEARD THE TAIL END OF A CLRNC FOR A CLB FOR OUR COMPANY ACFT. WHILE THE CTLR INSTRUCTED ME TO CHK OUR XPONDER; THE CAPT COMMENCED A CLB AND DID NOT TELL DEP THAT HE WAS CLBING. HE DID NOT TELL ME HE WAS CLBING. WHEN I REALIZED WE WERE CLBING AND SAW THAT THE ALT ALERTER HAD BEEN CHANGED I ASKED HIM WHAT ALT WE HAD BEEN CLRED TO. HE SAID 9000 FT. I ASKED IF HE WAS SURE. I CHKED WITH DEP AND PASSING APPROX 3000 FT MSL TOLD THEM THAT WE WERE CLBING TO 9000 FT. AT THAT TIME DEP INFORMED US THAT WE HAD NOT BEEN CLRED TO CLB. I TOLD THE CAPT TO LEVEL OFF AND IMMEDIATELY AFTER THAT THE CTLR CONTINUED OUR CLB TO 8000 FT. IN BUSY SITS ESPECIALLY IN THE TERMINAL AREA; ALWAYS FOLLOW PROPER RADIO PROTOCOL. HAVE POSITIVE COM ESTABLISHED WITH EACH CTLR AND MAKE SURE ALL CREW MEMBERS ARE IN AGREEMENT WITH WHAT THOSE INSTRUCTIONS ARE.
Data retrieved from NASA's ASRS site as of May 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.