G200 FLT CREW OVERSHOOTS PUBLISHED ALT ON THE TEB 5 DEP. FO SET THE WRONG ALT IN THE ALT PRE-SELECTOR.

Date: 2006-02 · Aircraft: Gulfstream G200 (IAI 1126 Galaxy)

Anomalies: deviation-altitude-overshoot|deviation-track-heading-all-types|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy

Synopsis

G200 FLT CREW OVERSHOOTS PUBLISHED ALT ON THE TEB 5 DEP. FO SET THE WRONG ALT IN THE ALT PRE-SELECTOR.

Narrative

WHILE DEPARTING TEB I WAS ISSUED AN IFR CLRNC THAT INCLUDED THE TEB 5 DEP FROM RWY 24. THIS DEP IS A RWY HEADING CLB UNTIL REACHING 1500 FT; THEN A R TURN TO 280 DEGS AND A CLB TO 2000 FT AFTER PASSING THE TEB 4.5 DME. DURING THE DEP AT APPROX 700-900 FT; WHILE THE CAPT WAS HAND FLYING; THE FO ENGAGED THE HEADING MODE THAT HAD BEEN PRESET PRIOR TO TAKEOFF TO 280 DEGS. HE ALSO TURNED THE ALT PRE-SELECTOR UP IMMEDIATELY THEREAFTER. ON THIS PRE-SELECTOR; IF IT IS PULLED OUT IT DIALS UP OR DOWN IN 100 FT INCREMENTS; IF IT IS PUSHED IN IT DIALS UP OR DOWN IN 1000 FT INCREMENTS. THINKING IT WAS PULLED OUT HE ROTATED IT UP 5 CLICKS; IN REALITY IT WAS PUSHED IN. SO THIS RESULTED IN THE ALT PRE-SELECT GOING TO 6000 FT INSTEAD OF 2000 FT. BY THE TIME HE CONFIRMED THE DIAL IN ON HIS INSTRUMENTS IT WAS TOO LATE. THE FLT DIRECTOR WAS COUPLED AND WAS GIVING COURSE AND ALT GUIDANCE TO THE FLYING PLT WHICH HE WAS FOLLOWING. HE CAUGHT THE ERRORS BUT ONLY AFTER THE ACFT REACHED 2200-2400 FT. HE IMMEDIATELY CORRECTED BY DESCENDING TO 1500 FT WHERE SHORTLY AFTER HE WAS GIVEN VECTORS AND A CLB BY ATC AND CONTINUED WITH THE DEPARTURE. THE FO ENGAGED THE HEADING SELECT PREMATURELY; PRIOR TO 1500 FT AND ALSO TURNED UP THE ALT PRE-SELECT PRIOR TO THE 4.5 DME. CLBING OUT STEEPLY FOR NOISE AVOIDANCE AND ACCELERATING RAPIDLY IN A HIGH DENSITY TFC AREA WHILE GOING THROUGH THE AFTER TKOF CHKLIST HAD THE FLYING PLT'S WORKLOAD AT A VERY HIGH LEVEL. THIS CONTRIBUTED TO HIS DELAY IN RECOGNIZING THE FO'S ACTIONS AND TAKING NECESSARY CORRECTIVE ACTION. WITH THE ADVANTAGE OF HINDSIGHT THERE ARE SEVERAL THINGS THAT SHOULD HAVE BEEN DONE DIFFERENTLY. 1) THE FO IS A RELATIVELY LOW TIME PLT WITH MINIMAL EXPERIENCE IN HIGH DENSITY AREAS OF OPERATION. THE PRE-TAKEOFF BRIEFING BY THE CAPT INCLUDED A THOROUGH REVIEW OF THE CLRNC INCLUDING THE SID. WHEN ASKED IF HE HAD ANY QUESTIONS; THE FO SAID HE DIDN'T AND STATED THAT HE UNDERSTOOD IT. WITH THAT HINDSIGHT ADVANTAGE THE CAPT SHOULD HAVE ASKED THE FO TO THEN EXPLAIN IT BACK TO THE CAPT WITH NOT ONLY A PROCEDURAL EXPLANATION BUT ALSO AN OPERATIONAL ONE AS WELL. THIS WOULD HAVE INCLUDED WHAT HE WAS GOING TO BE DOING WITH THE HEADING AND ALT SELECTORS AND WHEN. 2) INSTEAD OF ACCEPTING THE DEFAULT HEADING ON THE FLT DIRECTOR DURING THE TAKEOFF; WHICH IS A WINGS LEVEL CLB; AND PRE-SETTING THE HEADING BUG TO 280 DEGS IT WOULD HAVE DECREASED THE FLT DECK WORKLOAD AND DECREASED AND POSSIBILITY OF ERROR BY USING THE HEADING MODE SET TO RWY HEADING FOR TAKEOFF AND THEN ONLY AFTER REACHING 1500 FT ROTATE THE HEADING BUG TO 280 DEGS. 3) ALWAYS CONFIRM THE CORRECT POSITION OF THE 2 POSITION ALT SELECTOR. 4) ANOTHER THOUGHT WOULD BE TO ENGAGE THE AUTOPLT EARLIER WHICH COULD HAVE BEEN DONE IN ACCORDANCE WITH THE ACFT FLT MANUAL. THE ACFT WOULD HAVE STILL FOLLOWED THE FLT DIRECTOR BUT THE DECREASED WORKLOAD ON THE FLYING PLT WOULD HAVE PROBABLY RESULTED IN QUICKER RECOGNITION AND CORRECTIONS OF THE ERRORS. THE FMS IS A UNIVERSAL UNS 1-C WITH THE REST OF THE EFIS AND INTERFACE SYSTEM BEING COLLINS.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.