37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 932706 |
Time | |
Date | 201102 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | N90.TRACON |
State Reference | NY |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Make Model Name | Challenger CL604 |
Operating Under FAR Part | Part 91 |
Flight Phase | Initial Climb |
Route In Use | SID RUUDY2 |
Flight Plan | IFR |
Component | |
Aircraft Component | MCP |
Person 1 | |
Function | Pilot Flying Captain |
Qualification | Flight Crew Multiengine Flight Crew Instrument Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 60 Flight Crew Total 2735 Flight Crew Type 282 |
Person 2 | |
Function | Pilot Not Flying First Officer |
Qualification | Flight Crew Air Transport Pilot (ATP) Flight Crew Multiengine |
Experience | Flight Crew Last 90 Days 50 Flight Crew Total 14500 Flight Crew Type 600 |
Events | |
Anomaly | Deviation - Altitude Crossing Restriction Not Met Deviation - Procedural Published Material / Policy |
Narrative:
On the day in question; teterboro (teb) clearance assigned the RUUDY2 departure for our IFR clearance. I was the flying pilot. Prior to taxi from the GA ramp; I briefed the pilot not flying on the takeoff and read the departure aloud in its entirety. All notes and text on the SID were addressed. For some reason that I cannot explain; after reading the SID aloud to my copilot; I set 2;000 ft into the altitude pre-selector (even though I just read that the first level off was at 1;500 ft at wentz); handed the SID over to the co-captain and asked if he had any questions regarding the brief and/or SID. I also compared what was programmed in the FMS to what clearance had read and there were no discrepancies. My co-captain said he had no questions so I called for the appropriate checklists. I called for the takeoff checklist as we made our way onto the runway and lined up on the center line. My co-captain called checklist complete; I responded and confirmed that we were cleared for takeoff. I advanced the power levers and began the roll. After lift-off the appropriate call outs as per our fom were made and the appropriate checklists were called for and completed. I flew the flight director on my pfd; reflecting the SID that was programmed into the FMS. I did not elect to engage the auto pilot; rather I chose to hand-fly the aircraft. As we were climbing; I flew heading 240 to intercept the 260 degree course to wentz. However; I did not level off at 1;500 ft to cross wentz as the SID described; because the altitude preselector was programmed to 2;000 ft; the flight director was guiding me to 2;000 ft; where I then leveled off. We had not yet reached wentz. Moments after leveling off at 2;000 ft; new york departure called and queried us as to what altitude we were at. We advised that we were at 2;000 ft. The controller responded; 'you should be at 1;500 ft as per the departure; I have arrivals to sequence for ewr; next time please review the departure more carefully.' my co-captain immediately set 1;500 ft in the preselector and I descended the aircraft down to capture and maintain 1;500 ft. I called for the auto pilot to be turned on and my co-captain did so. Shortly thereafter; the same controller issued to us a new altitude to 6;000 ft. A frequency change and no further instructions regarding the altitude deviation were given.we continued the flight without further incident. There was no TA or RA associated with the altitude deviation; nor was there any disruption in sequence of arriving traffic into ewr. While in cruise my co-captain and I discussed what had happened; why and read the departure procedure several times. That evening; while on the ground; we concluded that it was an eye-brain-hand malfunction on my part because part of me was thinking about the 1;500 ft initial altitude limit; and another part of me was thinking about the 2;000 ft altitude limit; and I inadvertently input the wrong altitude limit in the altitude preselector. To compound the matter; neither of us caught the error during our challenge and command of the procedure; so there was an ear-eye-brain-mouth malfunction on my co-captain's part because he did not catch my error either. We recognize this as a flaw in our CRM; and have resolved that in the future; during our briefing of each other; we will both independently visually verify the procedure altitude limits according to the chart and settings input by the flying pilot into the altitude preselector. We have initiated our own corrective training since.
Original NASA ASRS Text
Title: After carefully briefing the RUUDY2 departure from TEB a CL604 flight crew climbs directly to 2;000 FT; exceeding the 1;500 FT crossing restriction at WENTZ.
Narrative: On the day in question; Teterboro (TEB) Clearance assigned the RUUDY2 Departure for our IFR clearance. I was the flying pilot. Prior to taxi from the GA ramp; I briefed the pilot not flying on the takeoff and read the departure aloud in its entirety. All notes and text on the SID were addressed. For some reason that I cannot explain; after reading the SID aloud to my copilot; I set 2;000 FT into the altitude pre-selector (even though I just read that the first level off was at 1;500 FT at WENTZ); handed the SID over to the Co-Captain and asked if he had any questions regarding the brief and/or SID. I also compared what was programmed in the FMS to what Clearance had read and there were no discrepancies. My Co-Captain said he had no questions so I called for the appropriate checklists. I called for the takeoff checklist as we made our way onto the runway and lined up on the center line. My Co-Captain called checklist complete; I responded and confirmed that we were cleared for takeoff. I advanced the power levers and began the roll. After lift-off the appropriate call outs as per our FOM were made and the appropriate checklists were called for and completed. I flew the flight director on my PFD; reflecting the SID that was programmed into the FMS. I did not elect to engage the auto pilot; rather I chose to hand-fly the aircraft. As we were climbing; I flew heading 240 to intercept the 260 degree course to WENTZ. However; I did not level off at 1;500 FT to cross WENTZ as the SID described; because the altitude preselector was programmed to 2;000 FT; the flight director was guiding me to 2;000 FT; where I then leveled off. We had not yet reached WENTZ. Moments after leveling off at 2;000 FT; New York Departure called and queried us as to what altitude we were at. We advised that we were at 2;000 FT. The Controller responded; 'You should be at 1;500 FT as per the departure; I have arrivals to sequence for EWR; next time please review the departure more carefully.' My Co-Captain immediately set 1;500 FT in the preselector and I descended the aircraft down to capture and maintain 1;500 FT. I called for the auto pilot to be turned on and my Co-Captain did so. Shortly thereafter; the same Controller issued to us a new altitude to 6;000 FT. A frequency change and no further instructions regarding the altitude deviation were given.We continued the flight without further incident. There was no TA or RA associated with the altitude deviation; nor was there any disruption in sequence of arriving traffic into EWR. While in cruise my Co-Captain and I discussed what had happened; why and read the departure procedure several times. That evening; while on the ground; we concluded that it was an eye-brain-hand malfunction on my part because part of me was thinking about the 1;500 FT initial altitude limit; and another part of me was thinking about the 2;000 FT altitude limit; and I inadvertently input the wrong altitude limit in the altitude preselector. To compound the matter; neither of us caught the error during our challenge and command of the procedure; so there was an ear-eye-brain-mouth malfunction on my Co-Captain's part because he did not catch my error either. We recognize this as a flaw in our CRM; and have resolved that in the future; during our briefing of each other; we will both independently visually verify the procedure altitude limits according to the chart and settings input by the flying pilot into the altitude preselector. We have initiated our own corrective training since.
Data retrieved from NASA's ASRS site as of April 2012 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.