P180 CAPT FAILS TO COMPREHEND TEB 5 SID AND CLBS TO 2000 FT PRIOR TO TEB 4.5 DEM.

Date: 2008-07 · Aircraft: P180 Avanti

Anomalies: deviation-altitude-overshoot|deviation-discrepancy-procedural-published-material-policy

Synopsis

P180 CAPT FAILS TO COMPREHEND TEB 5 SID AND CLBS TO 2000 FT PRIOR TO TEB 4.5 DEM.

Narrative

WHILE DEPARTING ON THE TEB 5 DEP; WE FAILED TO MAINTAIN 1500 FT ON THE DEP INSTEAD CLBING TO 2000 FT. IT WAS A PERFECT EXAMPLE OF A HUMAN FACTORS INCIDENT. I HAVEN'T FLOWN MUCH IN THE PAST YEAR; AM IN A NEW ACFT AND HAVE ONLY BEEN TO TEB ONCE BEFORE. I WAS FLYING WITH A PLT WHO IS VERY FAMILIAR WITH TEB BUT NEW TO THIS ACFT'S AVIONICS. OUR PAX CAME OUT TO THE ACFT A LITTLE EARLIER THAN EXPECTED WHICH CAUSED US TO RUSH A BIT TO CATCH UP ON ALL OF OUR PREFLT PREPARATIONS. IN PARTICULAR; I MIS-READ AND MIS-BRIEFED THE DEP -- I UNDERSTOOD IT TO BE A CLB TO 1500 FT THEN A CLBING R TURN TO 280 DEGS AND 2000 FT -- I MISSED THE FACT THAT THERE WAS A LEVEL-OFF AT 1500 FT UNTIL 4.5 DME. AS I BRIEFED THE DEP MY PM ASKED ME IF I WANTED 1500 FT OR 2000 FT IN THE ALTITUDE PRESELECT. BECAUSE OF MY CONFUSION ABOUT THE LEVEL OFF; I ASKED FOR 2000 FT. HE ALSO SHOWED ME THAT HE HAD PROGRAMMED THE FMS FOR THE DEP; WE FAILED TO NOTICE THAT THE SELECTION ON THE PFD WAS 'LOC' FROM THE ILS THAT WE HAD JUST DONE. WE DISCUSSED THE POSSIBILITY OF HAVING THE FMS FLY THE DEP. AFTER TAKEOFF WE SELECTED 'NAV' ON THE FCP BUT THE FLT DIRECTOR INDICATED A TURN IN THE WRONG DIRECTION. I CONTINUED TO HAND FLY WHILE THE PM TRIED TO FIGURE OUT WHY THE FLT DIRECTOR SHOWED THE INCORRECT TURN. UPON REACHING 1500 FT I BEGAN THE TURN TO 280 DEGS AND CONTINUED THE CLB TO 2000 FT WITHOUT PERFORMING THE LEVEL-OFF. HE NOTICED THAT I WAS CONTINUING THE CLB AND STATED 'ALTITUDE.' I MIS-UNDERSTOOD HIS CALLOUT TO MEAN THAT HE WAS CONCERNED ABOUT MY LEVEL-OFF AT 2000 FT. HE AGAIN SAID 'ALTITUDE' AND I SAID I WAS LEVELING OFF. HE THEN PUSHED ON THE CTL WHEEL MOMENTARILY -- I STILL DIDN'T UNDERSTAND. AT THAT POINT ATC CALLED AND ASKED FOR OUR ALTITUDE. IT WAS THEN THAT I REALIZED THAT I SHOULD HAVE LEVELED OFF AT 1500 FT. ATC TOLD US TO MAINTAIN THE 2000 FT AND TURN TO A HDG. THERE WERE SEVERAL CONTRIBUTING FACTORS STARTING WITH OUR UNFAMILIARITY OF THE AVIONICS; MY UNFAMILIARITY WITH THE AIRSPACE; AND RUSHING THROUGH THE BRIEFING WITHOUT COMPLETE VERIFICATION OF UNDERSTANDING.

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