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Attributes | |
ACN | 814480 |
Time | |
Date | 200812 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl single value : 2000 |
Environment | |
Flight Conditions | VMC Marginal |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | general aviation : personal |
Make Model Name | Cessna Citation Undifferentiated or Other Model |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure sid : teb |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : single pilot |
Qualification | pilot : multi engine pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 50 flight time total : 14000 flight time type : 2100 |
ASRS Report | 814480 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot altitude deviation : crossing restriction not met incursion : taxiway non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : provided flight assist controller : issued new clearance controller : issued advisory flight crew : overcame equipment problem |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Airport Chart Or Publication Environmental Factor Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I had arrived at teb the previous evening and was to depart around XA00 local time. I was operating the citation jet as a single pilot for the private owner. As I had not been to teb in many years; I called for and received my clearance prior to the arrival of my passenger and carefully reviewed the assigned SID. In fact; as an exercise and safeguard; I wrote out the departure procedure on my flight log; which would be available to me in addition to the chart. The runway 24 procedure required an initial climb to 1500 ft MSL on the runway heading; then a turn to 280 degrees and climb to and maintain 2000 ft after crossing 4.5 DME from teb. At this same time; I copied the ATIS and also set the standby altimeter to the current setting. The pressure had risen significantly during the night. I did not set the pilot's and co-pilot's altimeters at this time as they are integral to the EFIS/pfds and require the ship's power and avionics master be on. The FBO ramp was extremely congested and my plane was parked close to the FBO entrance; which was in the blast zone of my exhaust. After boarding my passenger and starting engines; I moved away from the entrance as soon as possible. There was no room on the ramp to loiter; so I requested taxi clearance to runway 24 before completing my 'before taxi' checks. This was my big mistake; but that didn't become apparent until later. I was instructed to cross the approach end of runway 19 and proceed to runway 24. As I approached the end of runway 19; it appeared that the taxiway was closed on the other side. There were a large number of orange traffic cones blocking various areas and men and equipment were working in the area. This confused me and I initiated a premature turn at taxiway left; which was just short of the approach end of runway 19. I immediately realized my mistake; though still confused about the traffic cones; and turned back toward the approach end of runway 19. At the same time; teb ground issued a reprimand to me. I responded that I had caught my error; but that the cones were confusing from ground level in that area. (Just after passing taxiway left; it became apparent; due to the changing angle of view; that there actually was a narrow lane open between the cones that permitted normal taxi.) unfortunately; this confusion on the taxi route happened at the same time that I was performing the instrument cross check on the pre-taxi check. When I resumed the checklist; I didn't realize that I had managed to skip the altimeter cross check. I had never reset the pilot's and co-pilot's altimeters; but I didn't catch this error until airborne. Upon takeoff; I concentrated on both the noise abatement procedure (having been met by an airport official upon arrival the evening before; who was very insistent upon the consequences of failing to meet the noise standard) and the vertical/lateral SID requirements. I was surprised when teb tower; before handing me off; asked me if I frequented teb and advised that there was an 'additional altitude restriction' (that I had missed) to 'keep you clear of ewr traffic overhead.' this alarmed me; because I thought I had completely misread the SID. I realized only later that I had flown too high (above 1500 ft) due to a missset altimeter. Frankly; the call by tower rattled me a little and as I switched to ny departure; I couldn't understand how I missed a step on the SID. It wasn't until ATC questioned me a couple of minutes later about whether I was level at 6000 ft that I realized my altimeter error. Meanwhile; my autoplt had disengaged and wouldn't reengage (left/right attitude miscompare due to an ahrs precession issue -- I took it to maintenance the next day). Then I was given a vector to intercept the col '350 degree radial inbound and resume the SID.' I wasn't expecting the vector and radial and when I programmed the FMS I incorrectly entered the reciprocal of 350 as 190 instead of 170. I soon realized that the commanded turn to intercept was wrong; but as I tried to sort it out; departure issued me a vector. (I had just switched from VOR mode to FMS mode on the pfd. I could have switched back to VOR and dialed in the radial; but since the FMS already had the rest of the SID after col programmed; it seemed logical to use it. Unfortunately; by this time; alone and with no autoplt; I was starting to get loaded up. I wasn't having any trouble hand-flying heading and altitude; but I was having difficulty quickly troubleshooting and re-programming the EFIS/FMS in ny's busy airspace.) this whole comedy of errors could have been avoided had I found a place to 'park it' and complete the 'before taxi' checklist before taxiing! As a single pilot; I rely greatly on my checklist and 'flow;' as I have no sic for a backstop. Unfortunately; due to the unusual circumstances of the crowded ramp; I set myself up for failure by rushing and inappropriate multi-tasking. As a result the perfectly foreseeable distraction during taxi caused a critical mistake to go uncorrected. The autoplt problem and possibly the erroneous radial to col would have occurred anyway; but there would have been no stress inducing altitude busts (and accompanying remarks from ATC); so presumably those issues would have been handled more efficiently. As it happened; my careful attention to the requirements of the SID came to naught; because of this basic error. I vow to redouble my efforts at checklist discipline in order to avoid ever having another such incident.
Original NASA ASRS Text
Title: SINGLE PLT OF CESSNA CITATION EXPERIENCES NUMEROUS ATC AND SID COMPLIANCE ANOMALIES ON DEP FROM TEB.
Narrative: I HAD ARRIVED AT TEB THE PREVIOUS EVENING AND WAS TO DEPART AROUND XA00 LOCAL TIME. I WAS OPERATING THE CITATION JET AS A SINGLE PLT FOR THE PRIVATE OWNER. AS I HAD NOT BEEN TO TEB IN MANY YEARS; I CALLED FOR AND RECEIVED MY CLRNC PRIOR TO THE ARR OF MY PAX AND CAREFULLY REVIEWED THE ASSIGNED SID. IN FACT; AS AN EXERCISE AND SAFEGUARD; I WROTE OUT THE DEP PROC ON MY FLT LOG; WHICH WOULD BE AVAILABLE TO ME IN ADDITION TO THE CHART. THE RWY 24 PROC REQUIRED AN INITIAL CLB TO 1500 FT MSL ON THE RWY HDG; THEN A TURN TO 280 DEGS AND CLB TO AND MAINTAIN 2000 FT AFTER CROSSING 4.5 DME FROM TEB. AT THIS SAME TIME; I COPIED THE ATIS AND ALSO SET THE STANDBY ALTIMETER TO THE CURRENT SETTING. THE PRESSURE HAD RISEN SIGNIFICANTLY DURING THE NIGHT. I DID NOT SET THE PLT'S AND CO-PLT'S ALTIMETERS AT THIS TIME AS THEY ARE INTEGRAL TO THE EFIS/PFDS AND REQUIRE THE SHIP'S POWER AND AVIONICS MASTER BE ON. THE FBO RAMP WAS EXTREMELY CONGESTED AND MY PLANE WAS PARKED CLOSE TO THE FBO ENTRANCE; WHICH WAS IN THE BLAST ZONE OF MY EXHAUST. AFTER BOARDING MY PAX AND STARTING ENGINES; I MOVED AWAY FROM THE ENTRANCE AS SOON AS POSSIBLE. THERE WAS NO ROOM ON THE RAMP TO LOITER; SO I REQUESTED TAXI CLRNC TO RWY 24 BEFORE COMPLETING MY 'BEFORE TAXI' CHECKS. THIS WAS MY BIG MISTAKE; BUT THAT DIDN'T BECOME APPARENT UNTIL LATER. I WAS INSTRUCTED TO CROSS THE APCH END OF RWY 19 AND PROCEED TO RWY 24. AS I APCHED THE END OF RWY 19; IT APPEARED THAT THE TXWY WAS CLOSED ON THE OTHER SIDE. THERE WERE A LARGE NUMBER OF ORANGE TFC CONES BLOCKING VARIOUS AREAS AND MEN AND EQUIPMENT WERE WORKING IN THE AREA. THIS CONFUSED ME AND I INITIATED A PREMATURE TURN AT TXWY L; WHICH WAS JUST SHORT OF THE APCH END OF RWY 19. I IMMEDIATELY REALIZED MY MISTAKE; THOUGH STILL CONFUSED ABOUT THE TFC CONES; AND TURNED BACK TOWARD THE APCH END OF RWY 19. AT THE SAME TIME; TEB GND ISSUED A REPRIMAND TO ME. I RESPONDED THAT I HAD CAUGHT MY ERROR; BUT THAT THE CONES WERE CONFUSING FROM GND LEVEL IN THAT AREA. (JUST AFTER PASSING TXWY L; IT BECAME APPARENT; DUE TO THE CHANGING ANGLE OF VIEW; THAT THERE ACTUALLY WAS A NARROW LANE OPEN BETWEEN THE CONES THAT PERMITTED NORMAL TAXI.) UNFORTUNATELY; THIS CONFUSION ON THE TAXI RTE HAPPENED AT THE SAME TIME THAT I WAS PERFORMING THE INSTRUMENT CROSS CHECK ON THE PRE-TAXI CHECK. WHEN I RESUMED THE CHECKLIST; I DIDN'T REALIZE THAT I HAD MANAGED TO SKIP THE ALTIMETER CROSS CHECK. I HAD NEVER RESET THE PLT'S AND CO-PLT'S ALTIMETERS; BUT I DIDN'T CATCH THIS ERROR UNTIL AIRBORNE. UPON TKOF; I CONCENTRATED ON BOTH THE NOISE ABATEMENT PROC (HAVING BEEN MET BY AN ARPT OFFICIAL UPON ARR THE EVENING BEFORE; WHO WAS VERY INSISTENT UPON THE CONSEQUENCES OF FAILING TO MEET THE NOISE STANDARD) AND THE VERTICAL/LATERAL SID REQUIREMENTS. I WAS SURPRISED WHEN TEB TOWER; BEFORE HANDING ME OFF; ASKED ME IF I FREQUENTED TEB AND ADVISED THAT THERE WAS AN 'ADDITIONAL ALTITUDE RESTRICTION' (THAT I HAD MISSED) TO 'KEEP YOU CLEAR OF EWR TRAFFIC OVERHEAD.' THIS ALARMED ME; BECAUSE I THOUGHT I HAD COMPLETELY MISREAD THE SID. I REALIZED ONLY LATER THAT I HAD FLOWN TOO HIGH (ABOVE 1500 FT) DUE TO A MISSSET ALTIMETER. FRANKLY; THE CALL BY TOWER RATTLED ME A LITTLE AND AS I SWITCHED TO NY DEP; I COULDN'T UNDERSTAND HOW I MISSED A STEP ON THE SID. IT WASN'T UNTIL ATC QUESTIONED ME A COUPLE OF MINUTES LATER ABOUT WHETHER I WAS LEVEL AT 6000 FT THAT I REALIZED MY ALTIMETER ERROR. MEANWHILE; MY AUTOPLT HAD DISENGAGED AND WOULDN'T REENGAGE (L/R ATTITUDE MISCOMPARE DUE TO AN AHRS PRECESSION ISSUE -- I TOOK IT TO MAINT THE NEXT DAY). THEN I WAS GIVEN A VECTOR TO INTERCEPT THE COL '350 DEG RADIAL INBOUND AND RESUME THE SID.' I WASN'T EXPECTING THE VECTOR AND RADIAL AND WHEN I PROGRAMMED THE FMS I INCORRECTLY ENTERED THE RECIPROCAL OF 350 AS 190 INSTEAD OF 170. I SOON REALIZED THAT THE COMMANDED TURN TO INTERCEPT WAS WRONG; BUT AS I TRIED TO SORT IT OUT; DEP ISSUED ME A VECTOR. (I HAD JUST SWITCHED FROM VOR MODE TO FMS MODE ON THE PFD. I COULD HAVE SWITCHED BACK TO VOR AND DIALED IN THE RADIAL; BUT SINCE THE FMS ALREADY HAD THE REST OF THE SID AFTER COL PROGRAMMED; IT SEEMED LOGICAL TO USE IT. UNFORTUNATELY; BY THIS TIME; ALONE AND WITH NO AUTOPLT; I WAS STARTING TO GET LOADED UP. I WASN'T HAVING ANY TROUBLE HAND-FLYING HDG AND ALTITUDE; BUT I WAS HAVING DIFFICULTY QUICKLY TROUBLESHOOTING AND RE-PROGRAMMING THE EFIS/FMS IN NY'S BUSY AIRSPACE.) THIS WHOLE COMEDY OF ERRORS COULD HAVE BEEN AVOIDED HAD I FOUND A PLACE TO 'PARK IT' AND COMPLETE THE 'BEFORE TAXI' CHECKLIST BEFORE TAXIING! AS A SINGLE PLT; I RELY GREATLY ON MY CHECKLIST AND 'FLOW;' AS I HAVE NO SIC FOR A BACKSTOP. UNFORTUNATELY; DUE TO THE UNUSUAL CIRCUMSTANCES OF THE CROWDED RAMP; I SET MYSELF UP FOR FAILURE BY RUSHING AND INAPPROPRIATE MULTI-TASKING. AS A RESULT THE PERFECTLY FORESEEABLE DISTRACTION DURING TAXI CAUSED A CRITICAL MISTAKE TO GO UNCORRECTED. THE AUTOPLT PROBLEM AND POSSIBLY THE ERRONEOUS RADIAL TO COL WOULD HAVE OCCURRED ANYWAY; BUT THERE WOULD HAVE BEEN NO STRESS INDUCING ALTITUDE BUSTS (AND ACCOMPANYING REMARKS FROM ATC); SO PRESUMABLY THOSE ISSUES WOULD HAVE BEEN HANDLED MORE EFFICIENTLY. AS IT HAPPENED; MY CAREFUL ATTENTION TO THE REQUIREMENTS OF THE SID CAME TO NAUGHT; BECAUSE OF THIS BASIC ERROR. I VOW TO REDOUBLE MY EFFORTS AT CHECKLIST DISCIPLINE IN ORDER TO AVOID EVER HAVING ANOTHER SUCH INCIDENT.
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.