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|
Attributes | |
ACN | 794206 |
Time | |
Date | 200807 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | general aviation : corporate |
Make Model Name | P180 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude climbout : initial |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 12 flight time total : 4000 flight time type : 12 |
ASRS Report | 794206 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
While departing on the teb 5 departure; we failed to maintain 1500 ft on the departure instead climbing to 2000 ft. It was a perfect example of a human factors incident. I haven't flown much in the past year; am in a new aircraft and have only been to teb once before. I was flying with a pilot who is very familiar with teb but new to this aircraft's avionics. Our passenger came out to the aircraft a little earlier than expected which caused us to rush a bit to catch up on all of our preflight preparations. In particular; I mis-read and mis-briefed the departure -- I understood it to be a climb to 1500 ft then a climbing right turn to 280 degrees and 2000 ft -- I missed the fact that there was a level-off at 1500 ft until 4.5 DME. As I briefed the departure my pm asked me if I wanted 1500 ft or 2000 ft in the altitude preselect. Because of my confusion about the level off; I asked for 2000 ft. He also showed me that he had programmed the FMS for the departure; we failed to notice that the selection on the pfd was 'localizer' from the ILS that we had just done. We discussed the possibility of having the FMS fly the departure. After takeoff we selected 'navigation' on the fcp but the flight director indicated a turn in the wrong direction. I continued to hand fly while the pm tried to figure out why the flight director showed the incorrect turn. Upon reaching 1500 ft I began the turn to 280 degrees and continued the climb to 2000 ft without performing the level-off. He noticed that I was continuing the climb and stated 'altitude.' I mis-understood his callout to mean that he was concerned about my level-off at 2000 ft. He again said 'altitude' and I said I was leveling off. He then pushed on the control wheel momentarily -- I still didn't understand. At that point ATC called and asked for our altitude. It was then that I realized that I should have leveled off at 1500 ft. ATC told us to maintain the 2000 ft and turn to a heading. There were several contributing factors starting with our unfamiliarity of the avionics; my unfamiliarity with the airspace; and rushing through the briefing without complete verification of understanding.
Original NASA ASRS Text
Title: P180 CAPT FAILS TO COMPREHEND TEB 5 SID AND CLBS TO 2000 FT PRIOR TO TEB 4.5 DEM.
Narrative: WHILE DEPARTING ON THE TEB 5 DEP; WE FAILED TO MAINTAIN 1500 FT ON THE DEP INSTEAD CLBING TO 2000 FT. IT WAS A PERFECT EXAMPLE OF A HUMAN FACTORS INCIDENT. I HAVEN'T FLOWN MUCH IN THE PAST YEAR; AM IN A NEW ACFT AND HAVE ONLY BEEN TO TEB ONCE BEFORE. I WAS FLYING WITH A PLT WHO IS VERY FAMILIAR WITH TEB BUT NEW TO THIS ACFT'S AVIONICS. OUR PAX CAME OUT TO THE ACFT A LITTLE EARLIER THAN EXPECTED WHICH CAUSED US TO RUSH A BIT TO CATCH UP ON ALL OF OUR PREFLT PREPARATIONS. IN PARTICULAR; I MIS-READ AND MIS-BRIEFED THE DEP -- I UNDERSTOOD IT TO BE A CLB TO 1500 FT THEN A CLBING R TURN TO 280 DEGS AND 2000 FT -- I MISSED THE FACT THAT THERE WAS A LEVEL-OFF AT 1500 FT UNTIL 4.5 DME. AS I BRIEFED THE DEP MY PM ASKED ME IF I WANTED 1500 FT OR 2000 FT IN THE ALTITUDE PRESELECT. BECAUSE OF MY CONFUSION ABOUT THE LEVEL OFF; I ASKED FOR 2000 FT. HE ALSO SHOWED ME THAT HE HAD PROGRAMMED THE FMS FOR THE DEP; WE FAILED TO NOTICE THAT THE SELECTION ON THE PFD WAS 'LOC' FROM THE ILS THAT WE HAD JUST DONE. WE DISCUSSED THE POSSIBILITY OF HAVING THE FMS FLY THE DEP. AFTER TAKEOFF WE SELECTED 'NAV' ON THE FCP BUT THE FLT DIRECTOR INDICATED A TURN IN THE WRONG DIRECTION. I CONTINUED TO HAND FLY WHILE THE PM TRIED TO FIGURE OUT WHY THE FLT DIRECTOR SHOWED THE INCORRECT TURN. UPON REACHING 1500 FT I BEGAN THE TURN TO 280 DEGS AND CONTINUED THE CLB TO 2000 FT WITHOUT PERFORMING THE LEVEL-OFF. HE NOTICED THAT I WAS CONTINUING THE CLB AND STATED 'ALTITUDE.' I MIS-UNDERSTOOD HIS CALLOUT TO MEAN THAT HE WAS CONCERNED ABOUT MY LEVEL-OFF AT 2000 FT. HE AGAIN SAID 'ALTITUDE' AND I SAID I WAS LEVELING OFF. HE THEN PUSHED ON THE CTL WHEEL MOMENTARILY -- I STILL DIDN'T UNDERSTAND. AT THAT POINT ATC CALLED AND ASKED FOR OUR ALTITUDE. IT WAS THEN THAT I REALIZED THAT I SHOULD HAVE LEVELED OFF AT 1500 FT. ATC TOLD US TO MAINTAIN THE 2000 FT AND TURN TO A HDG. THERE WERE SEVERAL CONTRIBUTING FACTORS STARTING WITH OUR UNFAMILIARITY OF THE AVIONICS; MY UNFAMILIARITY WITH THE AIRSPACE; AND RUSHING THROUGH THE BRIEFING WITHOUT COMPLETE VERIFICATION OF UNDERSTANDING.
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.