A C750 captain admitted that he improperly programmed his automation, against the advice of his firs...

Attributes
ACN	610228
Time
Date	200403
Day	Wed
Local Time Of Day	1201 To 1800
Place
Locale Reference	navaid : teb.vor
State Reference	NJ
Altitude	msl bound lower : 1500 msl bound upper : 1740
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : n90.tracon tower : teb.tower
Operator	general aviation : corporate
Make Model Name	Citation X
Operating Under FAR Part	Part 91
Flight Phase	climbout : intermediate altitude
Route In Use	departure sid : teb5
Flight Plan	IFR
Person 1
Affiliation	company : corporate
Function	flight crew : captain oversight : pic
Qualification	pilot : multi engine pilot : atp
Experience	flight time last 90 days : 80 flight time total : 15000 flight time type : 1500
ASRS Report	610228
Person 2
Affiliation	company : corporate
Function	flight crew : first officer
Events
Anomaly	altitude deviation : overshoot non adherence : far non adherence : published procedure non adherence : company policies non adherence : clearance other spatial deviation
Independent Detector	other controllera other flight crewa
Resolutory Action	flight crew : returned to assigned altitude flight crew : returned to original clearance
Consequence	other
Supplementary
Problem Areas	Flight Crew Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Departing teb on teb 5 SID. SID requires aircraft to maintain 1500 ft MSL until passing teb DME 4.5 mi fix then allows a climb to 2000 ft. Overhead arrival path to ewr airport requires aircraft departing teb to remain at the published altitudes (1500 ft and then 2000 ft) until cleared to a higher altitude by ATC. The altitude alerter was set to 2000 ft instead of 1500 ft. The flight director command and altitude alerter warning were programmed for 2000 ft instead of 1500 ft. As we approached 1500 ft, instead of leveling off first, we began our turn to 280 degrees per the SID. We maintained less than 200 KTS being below class B airspace. The attention paid to the heading change of 40 degrees and the speed control allowed us to climb to 1740 ft MSL. The aircraft was being hand flown. ATC and the first officer both advised of the 1500 ft requirement. We immediately returned to 1500 ft until passing the appropriate climb point which was the teb 4.5 DME fix. The climb from 1500 ft to 1740 ft occurred between the 3.9 and 4.4 mile distance from the teb VOR. We had carefully briefed the departure and the first officer suggested the alerter be set to 1500 ft instead of 2000 ft. Having flown the departure many times, I felt 2000 ft was satisfactory. (How wrong I was.) our SOP's were proper, the execution of them was less so. We had not been rushed, nor was weather a factor. In retrospect, I failed to follow a long held belief that the altitude alerter is a stop sign and should be used in just that way. Being familiar with the aircraft, the airport and the departure let me fall into a poor situation awareness mode. Through the efforts of my first officer and ATC, we were able to minimize the altitude excursion. Clearly the lesson learned is that familiarity and a problem free environment are no guarantee that mistakes will not still happen. The alerter is a stop sign and an early warning device. I was truly humbled by the experience.

Original NASA ASRS Text

Title: A C750 CAPT ADMITTED THAT HE IMPROPERLY PROGRAMMED HIS AUTOMATION, AGAINST THE ADVICE OF HIS FO, CAUSING AN ALT HDG DEV WHEN FLYING THE TEB SID.

Narrative: DEPARTING TEB ON TEB 5 SID. SID REQUIRES ACFT TO MAINTAIN 1500 FT MSL UNTIL PASSING TEB DME 4.5 MI FIX THEN ALLOWS A CLB TO 2000 FT. OVERHEAD ARR PATH TO EWR ARPT REQUIRES ACFT DEPARTING TEB TO REMAIN AT THE PUBLISHED ALTS (1500 FT AND THEN 2000 FT) UNTIL CLRED TO A HIGHER ALT BY ATC. THE ALT ALERTER WAS SET TO 2000 FT INSTEAD OF 1500 FT. THE FLT DIRECTOR COMMAND AND ALT ALERTER WARNING WERE PROGRAMMED FOR 2000 FT INSTEAD OF 1500 FT. AS WE APCHED 1500 FT, INSTEAD OF LEVELING OFF FIRST, WE BEGAN OUR TURN TO 280 DEGS PER THE SID. WE MAINTAINED LESS THAN 200 KTS BEING BELOW CLASS B AIRSPACE. THE ATTN PAID TO THE HDG CHANGE OF 40 DEGS AND THE SPEED CTL ALLOWED US TO CLB TO 1740 FT MSL. THE ACFT WAS BEING HAND FLOWN. ATC AND THE FO BOTH ADVISED OF THE 1500 FT REQUIREMENT. WE IMMEDIATELY RETURNED TO 1500 FT UNTIL PASSING THE APPROPRIATE CLB POINT WHICH WAS THE TEB 4.5 DME FIX. THE CLB FROM 1500 FT TO 1740 FT OCCURRED BETWEEN THE 3.9 AND 4.4 MILE DISTANCE FROM THE TEB VOR. WE HAD CAREFULLY BRIEFED THE DEP AND THE FO SUGGESTED THE ALERTER BE SET TO 1500 FT INSTEAD OF 2000 FT. HAVING FLOWN THE DEP MANY TIMES, I FELT 2000 FT WAS SATISFACTORY. (HOW WRONG I WAS.) OUR SOP'S WERE PROPER, THE EXECUTION OF THEM WAS LESS SO. WE HAD NOT BEEN RUSHED, NOR WAS WEATHER A FACTOR. IN RETROSPECT, I FAILED TO FOLLOW A LONG HELD BELIEF THAT THE ALT ALERTER IS A STOP SIGN AND SHOULD BE USED IN JUST THAT WAY. BEING FAMILIAR WITH THE ACFT, THE ARPT AND THE DEP LET ME FALL INTO A POOR SIT AWARENESS MODE. THROUGH THE EFFORTS OF MY FO AND ATC, WE WERE ABLE TO MINIMIZE THE ALT EXCURSION. CLEARLY THE LESSON LEARNED IS THAT FAMILIARITY AND A PROB FREE ENVIRONMENT ARE NO GUARANTEE THAT MISTAKES WILL NOT STILL HAPPEN. THE ALERTER IS A STOP SIGN AND AN EARLY WARNING DEVICE. I WAS TRULY HUMBLED BY THE EXPERIENCE.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.

A C750 captain admitted that he improperly programmed his automation, against the advice of his first officer, causing an altitude heading deviation when flying the teb SID.