A DEV FROM THE TEB 5 DEP PROC OCCURS WHEN THE CREW MISINTERPRETS THE REQUIREMENTS DEPICTED FOR THE PROC.
Synopsis
A DEV FROM THE TEB 5 DEP PROC OCCURS WHEN THE CREW MISINTERPRETS THE REQUIREMENTS DEPICTED FOR THE PROC.
Narrative
WE WERE CLRED FOR AND FLEW THE TEB 5 DEP HAVING TAKEN OFF FROM RWY 24. AFTER TAKEOFF; WE FLEW THE RWY HDG TO 1500 FT AND THEN WAITED UNTIL DME 4.5 FROM TEB VOR TO BEGIN OUR TURN TO 280 DEGS. THE CTLR GAVE US A SCOLDING OVER THE RADIO; AS WE APPARENTLY DID NOT COMPLY WITH THE DEP PROC. BOTH MY FO AND I WERE IN AGREEMENT THAT WE DID EXACTLY WHAT THE PROC CALLED FOR AND COULD NOT FIGURE OUT AT THAT TIME WHAT IT WAS THAT WE DID NOT FOLLOW THE PROC. UNFORTUNATELY; I ALLOWED THIS TO DISTRACT ME; WHICH VIOLATED OUR STERILE COCKPIT RULE BELOW 10000 FT; AS WE HAD NOT YET REACHED 10000 FT WHILE ALL OF THIS WAS GOING ON. MY FO HAD THE PRESENCE OF MIND TO RECOGNIZE IT AND BRING IT TO MY ATTENTION. WE THEN WAITED UNTIL CRUISE TO DO SOME RESEARCH. IT IS ALSO IMPORTANT TO NOTE THAT WE WERE USING THE COMMERCIAL CHART VERSION OF THE TEB 5. IT WASN'T UNTIL WE LOOKED AT THE GOVT VERSION THAT IT CLICKED WHAT WE HAD DONE WRONG. WE BOTH HAD IT IN OUR HEADS THAT THE TURN TO 280 WASN'T TO BE DONE UNTIL REACHING DME 4.5 FROM TEB VOR. WE WENT BACK TO THE COMMERCIAL CHART; AFTER HAVING READ THE PROC IN THE GOVT CHART; AND IT WAS RIGHT THERE IN PLAIN SIGHT AND WE REALIZED THAT WE HAD MISINTERPRETED THE PROC. IT IS ALSO IMPORTANT TO NOTE THAT A NOTICE HAD BEEN SENT OUT IN REGARDS TO THIS DEP PROC REITERATING HOW IT WAS TO BE DONE. WE EVEN HAVE THIS POSTED IN OUR OFFICE AT HOME BASE. HOWEVER; I HAVEN'T DONE A TEB TRIP IN A WHILE AND WAS DISTR BY TOO MANY OTHER THINGS DURING PREFLT (IE: CUSTOMER SVC CONCERNS; FUELING; ETC) TO REMEMBER TO LOOK AT THAT POSTING. THE FACT THAT THIS NOTICE HAD BEEN SENT OUT TELLS ME THAT THIS IS NOTHING NEW; AND THAT THIS PROC HAD BEEN MISINTERPRETED BEFORE. IN FACT; IT PROBABLY HAS BEEN MISINTERPRETED JUST AS WE HAD DONE IT; MANY TIMES BEFORE NOW. THAT DOESN'T EXCUSE ANYONE WHO HAS MESSED IT UP; BUT IT DOES BRING UP SOME CONCERNS. SOMEHOW; THERE IS SOMETHING IN THE PRESENTATION OF THE PROC THAT CAUSES PLTS TO MISUNDERSTAND THE PROC. THAT BEING THE CASE; MAYBE A BIGGER PICTURE SHOULD BE LOOKED AT AS TO WHY THIS HAPPENS. SOME OF THE FACTORS TO CONSIDER WOULD BE: A) IS THE PROC TOO COMPLICATED FOR SUCH A BUSY; HIGH-PRESSURE ENVIRONMENT? AND COULD IT BE SIMPLIFIED? B) IS THE POSTING OF THE NOTICE EFFECTIVE ENOUGH TO CORRECT THE PROBS THAT TEB IS HAVING WITH THIS DEP? C) IS THERE A BETTER WAY TO PRESENT THE DEP PROC TEXT SO THAT MISINTERPRETATION DOESN'T CONTINUE TO BE A PROB? D) IS TEB TOO BUSY? E) SHOULD IT BE ENCOURAGED THAT PLACES LIKE FLT SCHOOL X AND FLT SCHOOL Y INCLUDE THIS SPECIFIC DEP PROC IN THEIR TRAINING? F) HOW CAN CREWS AND FLT DEPARTMENTS IMPROVE THEIR CRM OR SOP'S TO BETTER HANDLE COMPLEX DEPS? ALSO TO FINISH THE STORY; DESPITE NOT EXECUTING THE PROC CORRECTLY AND BEING SCOLDED; AT NO TIME DID WE RECEIVE A TA OR A RA FROM OUR TCAS (WHICH IS THE MOST CURRENT TCASII). THE CTLR HOWEVER DID INFORM US THAT THE 'LARGER JET OFF OUR L SIDE WAS NOT HAPPY.' THAT WOULD IMPLY TO ME THAT HE MAY HAVE RECEIVED A TA OR AN RA; HOWEVER; WE DID NOT; AND THE CTLR DID NOT INFORM US THAT THE OTHER ACFT HAD RECEIVED A TA OR RA FROM HIS TCASII. WHAT I HAVE LEARNED FROM THIS EXPERIENCE IS THAT IT IS IMPORTANT TO PAY ATTENTION TO THE DETAILS OF THOSE PROCS AND REVIEW THEM PRIOR TO FLT AND THEN AGAIN JUST BEFORE TAKEOFF. I HAVE ALSO LEARNED THAT IT IS IMPORTANT TO STAY IN A 'NORMAL' ROUTINE SO THAT SOLID PATTERNS OF ACTION ARE FOLLOWED EACH TIME; AND IF SOMETHING DISTRACTS A CREW AND TAKES THEM OUT OF THE NORMAL FLOW OF EVENTS; TO RETURN TO NORMAL AS MUCH AS POSSIBLE TO KEEP THINGS AS SAFE AS POSSIBLE.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.