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Of these 173 TEB departure incidents reviewed by ASRS,
90% involved corporate-type aircraft operations. Over
75% of incidents occurred on Runway 24 departures. An
altitude overshoot occurred in 66% of the incidents. And a
confl ict was reported with EWR arrivals in 4% of incidents.
The following incident involving a corporate jet fl ight crew
is representative of those reported to ASRS.
■ Departing TEB we were assigned the TEB 5 departure.
Second In Command [SIC] was left seat and fl ying. After
conducting a noise abatement takeoff we climbed to 1,500
feet and made the right turn to a 280-degree heading.
I was head down completing the after takeoff checklist
when I heard the altitude alerter. Looking up, the SIC was
climbing through 1,700 feet. I noticed that we were only
2.8 DME instead of the required 4.5 DME for climbing to
2,000 feet MSL. I instructed the SIC to descend back to
1,500 feet MSL until the 4.5 DME then climb to 2,000 feet.
ATC called and indicated that we climbed too early. The
departure was properly briefed.
As refl ected in the above incident, ATC intervened in 52%
of the TEB incidents reported to ASRS. The fl ight crew
initiated a return to clearance in 32% of incidents.
Contributing Factors
ASRS analysts who reviewed the TEB report set identifi ed
16 categories of factors that contributed to the incidents.
The following chart shows the leading categories of
contributing factors.
Contributing Factor % of
Report Set
Flight crew “behind aircraft” 36%
Breakdown in CRM 32%
Distraction 20%
Misset Altitude Preselect 17%
Misinterpreted/misunderstood SID chart 17%
“Forgot” clearance/SID 16%
Reporter cites problematic procedure 9%
A Monthly Safety Bulletin from
The Offi ce of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
August 2007 Report Intake
Air Carrier/Air Taxi Pilots 2694
General Aviation Pilots 954
Controllers 97
Cabin/Mechanics/Military/Other 306
TOTAL 4051
ASRS Alerts Issued in August 2007
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 8
Airport facility or procedure 10
ATC procedure or equipment 12
Chart, publication, or nav database 2
Total 32
WEN KRA VIRRA LA ETUOR
NEWARK INTL
TETERBORO
Not to Scale
250°
4.5 DME
TEB
22R22L
19
24
At 800'
280° hdg
At 1500'
High Density Airspace and Traffi c Mix
Breakdowns in Crew Resource Management (CRM)
were a factor in almost a third of the TEB incidents. The
Captain of an air taxi fl ight ruefully acknowledged overdependence
on a highly competent First Offi cer:
■ ...I, as Captain, depended on my First Offi cer, who is
highly experienced and has fl own out of TEB many times,
to read the departure and set up the panel. He did not
notice the 1,500 foot level-off and put 2,000 feet in the
altitude window. I made the error of not cross-checking the
departure...Two people need to be present when copying ATC
clearances and both should review departure procedures.
For the crew of a lifeguard fl ight, rushing to get their
aircraft off the ground led to their missing the initial
altitude level-off (1,500 feet MSL) on the TEB departure.
■ ...We were advised of our mistake by Departure...
This was a lifeguard fl ight and time was of a critical
nature. The medical team arrived 45 minutes earlier than
scheduled which created a hurry-up atmosphere. Even
though I, the Pilot Flying, briefed the departure with my
co-pilot, in the rush of things we got caught up and missed
the level-off at the required altitude...It doesn’t matter how
many times we have fl own into this airport in the past
(which we do on a regular basis), we should...pay more
attention to our departure procedures.
Distraction was cited as a contributing factor in 20% of the
TEB incidents. In one instance, a corporate crew departing
Runway 24 experienced distraction when concentrating on
adherence to the noise abatement procedure.
■ ... The captain and I discussed the SID and noise
abatement procedures several times before departure. This
aircraft had a noise violation with another crew recently,
so we wanted to make sure we followed the noise abatement
procedure. This procedure has the aircraft climb at a
slower speed – V2+10 – and reduce power after 300 feet and
climb at a steeper angle... After takeoff I became distracted
from watching my airspeed and reducing power. I didn’t
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