A LEAR-35 FLC FAILS TO DETECT THE FACT THAT THE CAPT HAD AN INCORRECT ALTIMETER SETTING IN HIS INST. THEY WERE 700 FT AGL ON THE SID WHEN THEIR ALT SHOULD HAVE BEEN 1500 FT.
Synopsis
A LEAR-35 FLC FAILS TO DETECT THE FACT THAT THE CAPT HAD AN INCORRECT ALTIMETER SETTING IN HIS INST. THEY WERE 700 FT AGL ON THE SID WHEN THEIR ALT SHOULD HAVE BEEN 1500 FT.
Narrative
WHILE ON THE RAMP AT THE FBO IN TETERBORO; I RECEIVED THE IFR CLRNC FROM TETERBORO TO FARGO; ND. WE WERE GIVEN THE TETERBORO FOUR DEP WITH RWY 19. I SET THE NAV RADIOS AND INSTS FOR THE DEP. I RECEIVED THE LATEST ATIS AND COMPLETED COCKPIT CHKS. WE WERE IN A BIT OF A RUSH SINCE OUR PAX HAD MOVED OUR DEP TIME UP BY 3 HRS. WE HAD JUST ARRIVED TO THE PLANE FROM THE HOTEL AND WERE BUSY GETTING FUEL; PWR CART; COFFEE; ICE; CATERING; ETC. OUR PAX ARRIVED BUT WE WERE NOT QUITE FINISHED. I COMPLETED EVERYTHING I COULD IN THE COCKPIT WHILE THE OTHER PLT TOOK CARE OF THE BILL. WE ARE BOTH CAPTS ON THE ACFT. I WAS THE SENIOR CAPT. THE OTHER PLT HAD JUST COMPLETED HIS PIC CHK IN THE ACFT A FEW WKS EARLIER. THIS WAS MY LEG AND I WAS THE PIC. AFTER LOADING THE PAX AND STARTING ENGS WE WERE READY FOR TAXI. GND CTL AT TETERBORO ASSIGNED US TO RWY 24. THIS CHANGED OUR DEP PROC. WE DECIDED TO ADDRESS THAT CHANGE WHILE TAXIING. JUST AS WE HAD STARTED OUR TAXI GND CTL ADVISED US TO CONTACT CLRNC DELIVERY FOR A CHANGE IN OUR CLRNC. THE COPLT DID SO AND COPIED THE NEW CLRNC. IT WAS THE SAME SID BUT FROM A DIFFERENT RWY AND THE ROUTING WAS DIFFERENT. THIS REQUIRED CHANGING THE NAV BOXES AND THE GPS. IT WAS A SHORT TAXI SO WE HELD SHORT OF RWY 24 AS WE COMPLETED THE CHKLIST AND RESET THE BOXES. THE TAXI CHKS AND BEFORE TKOF CHKS WERE HURRIED. TWR CLRED US TO BACK TAXI ON THE RWY TO THE END AND TO EXPEDITE SINCE THERE WAS AN ACFT TURNING FINAL. ONE OF THE TAXI CHKS IS 'FLT INSTS AND ALTIMETERS.' NORMALLY THE ALTIMETERS ARE SET BEFORE ENG START AFTER THE LATEST ATIS IS RECEIVED. I DID NOT DO THIS IN MY HURRY GETTING THE AIRPLANE READY. HOWEVER THE INSTS ARE DOUBLE CHKED IN THE TAXI. THIS CHK CAME AT THE SAME TIME GND CTL CALLED US TO CONTACT CLRNC DELIVERY FOR A NEW ROUTING. THE CURRENT ALTIMETER AT TETERBORO WAS 29.45. THE COPLT CALLED FOR THE CHK; CALLED OUT THE ALTIMETER SETTING AND SAID 'SET R.' HE SET HIS ALTIMETER TO 29.45. I REPLIED 'SET L' AFTER CHKING MY INSTS AND SETTING MY ALTIMETER TO WHAT I THOUGHT WAS 29.45. THE ALTIMETER ON OUR ARR INTO TETERBORO 2 DAYS EARLIER WAS 30.22. WHEN I REACHED UP AND CHANGED THE ALTIMETER I CHANGED IT TO 30.45. IN THE RUSH I MISSED SEEING THE 30 WHEN IT SHOULD HAVE BEEN 29. I ALSO MISSED THE FACT THAT THE ALTIMETER WAS NOT READING ARPT ELEVATION BUT SOMETHING MUCH HIGHER. OUR ALTIMETERS HAVE 1 NEEDLE WITH A DIGITAL READOUT IN THE MIDDLE. THE TETERBORO FOUR DEP CALLS FOR RWY HEADING TO 1500 FT THEN A R TURN TO 280 DEGS. ALSO A NOISE ABATEMENT PROC IS CALLED FOR. AFTER PASSING THE 4.5 DME OF TEB YOU THEN CLB TO 3000 FT AND THEN AS ASSIGNED BY ATC WITH VECTORS TO THE FIRST FIX; IN THIS CASE; COATE INTXN. I MADE THE TKOF; USING MAX PWR AND CLBED AT REF PLUS 10 TO 1500 FT. HOWEVER; SINCE MY ALTIMETER WAS SET WRONG; READING HIGH; I REACHED 1500 FT INDICATED VERY QUICKLY. MY FIRST CLUE SOMETHING WAS WRONG. BY THE TIME I LEVELED OFF I WAS INDICATING 2000 FT. MY ACTUAL ALT WAS ONLY 1200 FT DUE TO THE WRONG SETTING. I MADE THE TURN TO 280 DEGS AND DSNDING IMMEDIATELY TO 1500 FT INDICATED. AS I LEVELED OUT I LOOKED AT THE DME READING 2.0 MI. DURING THE TURN AND DSCNT WE WERE HANDED OFF TO DEP. THE COPLT WAS COMPLETING THE AFTER TKOF CHKS AND CHANGING FREQS. HE DID NOT NOTICE HIS ALTIMETER READING 700 FT. HE RPTED IN AND RPTED LEVEL AT 1500 FT. HE WAS LOOKING AT MY ALTIMETER. THIS IS NORMAL PROC SINCE THE PLT ALTIMETER IS CORRECTED AND THE COPLT ALTIMETER IS NOT. I NOTICED THAT WE SEEMED TOO LOW TO THE GND. IT JUST DIDN'T LOOK RIGHT. MY SECOND CLUE. I CHKED MY ALTIMETER; 1500 FT. DEP CALLED AND ASKED WHAT OUR ALT WAS; AND THAT HE SHOWED US AT 600 FT. THE COPLT CHKED MY ALTIMETER AND REPLIED; 1500 FT. IT WAS AT THIS TIME; WHEN THE CTLR SAID 600 FT; THAT I CHKED THE COPLT ALTIMETER AND SAW 700 FT. THE DME WAS AT 3.5. I LOOKED AT MY ALTIMETER AND SAW THE MISTAKE. THE CTLR CLRED US TO CLB TO 8000 FT. I BEGAN MY CLB AS I REACHED UP AND CHANGED MY ALTIMETER TO THE CORRECT SETTING. AT NO TIME DID I NOTICE WHAT THE RADAR ALTIMETERWAS READING. THE REMAINDER OF THE FLT WAS WITHOUT INCIDENT. THE COPLT DID NOT SEE THE MISTAKE AND DID NOT KNOW ANYTHING WAS WRONG UNTIL I INFORMED HIM ON THE GND AFTER THE FLT. WE DID NOT COME NEAR ANY OTHER ACFT AND DID NOT COME NEAR ANY OBSTACLES ON THE GND. OUR TKOF AND DEP DIDN'T EVEN SET OFF ANY NOISE SENSORS AROUND TETERBORO ARPT. HOWEVER; I WAS WELL BELOW THE MINIMUM SAFE ALT FOR THE AREA I WAS IN. I INTEND TO CHANGE OUR CHKLIST TO INCLUDE 'FLT INSTS AND ALTIMETERS -- SET AND XCHKED.' ALSO I WILL ADD SETTING THE RADAR ALTIMETERS TO THE MSA FOR THE DEP. AS ALWAYS; I CONTINUE TO LEARN IN AVIATION.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.