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catch my altitude until 1600 feet and immediately pushed
the nose over but, it did not level off until 1800 feet....
In 17% of the TEB incidents, reporters cited missetting of
the altitude preselect feature as a contributing factor in
the incident. In one typical event,
■ ...Altitude selector was set at 2,000 feet. After departure
and in turn to 280 degrees, First Offi cer (myself)
misinterpreted information on MFD and I began climb
to 2,000 feet. Captain immediately called altitude and I
returned to 1,500 feet MSL...I believe altitude alerter would
have been better suited left at 1,500 feet rather than set to
fi nal altitude on departure.
Coupled with comments on setting of the altitude preselect
feature were observations on use of available automation
to prevent altitude deviations. One corporate Captain noted:
■ ATC...commented on the climb above the mandatory
altitude, chastised us, and cleared us to 2,000 feet. I
acknowledged and got a short lecture that we need to level
334
for traffi c overhead...First [conclusion] is use of the autopilot.
It’s uncommon and not considered a good operating practice
to select the autopilot in the fi rst 30 seconds of fl ight, but
doing so might have prevented this infraction.
Reporters cited a problematic TEB departure procedure in
9% of the incidents. As one corporate Captain noted:
■ A contributing issue is the complexity of the combined
SID and noise abatement procedures at TEB. They really
should be simplifi ed.
Observations
Review of the 173-report
set on TEB departure
incidents provided several
operational observations:
often refer to font size or format for the TEB
5 SID, ASRS analysts noted defi ciencies in both when
referencing the chart during data review.
• A misset altitude selector was cited in 17% of
occurrences. The Standard Operating Procedures and
pre-departure briefi ngs of many operators suggest that
the most restrictive altitude (i.e., 1,500 feet) be set for
all departures. This is sound advice. Note that there
may be a procedural catch here – when receiving a
clearance (e.g., N1234 cleared to the XYZ airport, via
the TEB 5 Departure, fl ight planned route, maintain
2,000 feet...) there is a tendency for crew to set in the
cleared altitude, i.e., 2,000 vs. 1,500.
• The intermediate level-off altitude of 1,500 feet on the
TEB 5 departures from Runways 24 and 19 is low in
order to avoid confl icts with EWR (Newark) arrivals.
Some crews of high performance aircraft operating at
low gross weight may experience “time compression”
during the initial climb. Several operators suggest that
crews of such aircraft brief a “power reduction” point,
consistent with noise abatement procedures, at an
altitude appropriate for their aircraft’s performance.
Collaborative Safety Action
To help reduce the number (and potential hazards) of
TEB SID incidents, the Teterboro Users Group (TUG),
FAA, NASA, industry, and others have initiated several
mitigation actions, including:
• Revised Teterboro SID charts provided by NACO and
Jeppesen in an effort to provide clearer, less cluttered
information.
• Awareness presentations at the TUG meetings.
• Providing posters and briefi ng sheet departure
procedure reminders at various Teterboro FBOs.
• Major fl ight training organizations such as Flight
Safety incorporating the TEB 5 SID in their training.
• A safety awareness article published in Professional Pilot.
• Although reporters did not
Number 335 November 2007
Air Carrier In-Close Approach
Change (ICAC) Events
At the request of NASA Ames Research Center’s Human
Systems Integration Division in early 2007, ASRS
performed a review of ASRS Database reports referencing
In-Close Approach Changes (ICAC) – also termed Late
Runway Change and Change in Runway. The ASRS
Database reports spanned the time period of January 1996
to the present. Three hundred thirteen (313) relevant air
carrier pilot-reported ICAC events were identified.
For the purposes of this analysis, an In-Close Approach
Change Event is defined as one in which an ATC
directed change from an originally assigned arrival,
approach, or runway assignment results in an
incident. Examples of these incidents are unstabilized
approaches, track or heading deviations, speed deviations,
controlled flight toward terrain (CFTT), loss of separation
or airborne conflicts, wake vortex encounters, loss of
aircraft control, breakdown in crew coordination, and
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