Captain
1300 – Deice started. 1314 – tactile touch completed .1332 – Pre take off tactile touch at at RW 24.
1333 – Take off Rwy 24 Immediately after takeoff from RW 24 TEB at approximately 100ft we experienced smoke in the cockpit coming from center pedestal area. The captain made an unexpected and immediate left turn back to the airport. I had advised ATC that we required a climb and vectors back to the airport. The captain stated he had ground contact while we were at an altitude of approximately 300ft and 160 knots. I offered verbal callout to climb and to add power. I proceeded to deploy my oxygen mask and wore it while smoke was still present. The captain began to configure to land rapidly. I had no visual contact with the runway as the aircraft was being configured for landing by the captain . We could not land so I Immediately said “my controls” and took control of the aircraft. I recovered by adding full power and configured for a normal climb. I asked ATC for vectors to an approach to 24 initially and ultimately determined I was going to land on RW19 once talking to approach in TEB due RW19 being the longer runway. I executed the ILS approach to RW19 TEB made a normal landing, and transferred controls back to the captain so that we could exit via taxiway Juliet. The fire crew reported they saw no Indication of fire from the exterior. We continued to the ramp, and the passengers were deplaned by the captain. Plane was parked and secured at TEB signature west at 1350.
First Officer
1332 – Tactile check at departure end RWY 24 Off:
1333 – RWY 24 At approximately 100 feet, FO called “smoke in the cockpit”. Emergency declared and return to airport. We had ground contact with the airport but unable to return visually to the airport. Control of aircraft transferred to FO. Climbed to 1500 feet and requested and accepted vectors to ILS RWY 19.
1342 – Landed without incident. After further inspection the cause of the smoke was determined to “most likely” have been from deicing fluid. For future consideration after a de-icing event, I recommend a discussion with the other crew member of the “possibility” of some smoke in the cockpit or cabin. This discussion may have helped us mitigate and process the emergency with more information available rather than a total surprise just after takeoff.
ERC Investigation Notes:
Status Notes Maintenance inspection conducted. Deicing fluid ingested in APU identified as a cause of smoke. Leak found in APU bleed lines. Repairs completed, aircraft back in service. Crew debriefed
Safety Takeaway:
With deicing season in full effect, crew members should always prepare for any emergency in any given moment. If an aircraft has to run the APU during de-icing, crewmembers should ensure the bleed is turned off. Otherwise, if fluid is ingested, it could lead to smoke or an unpleasant odor in the cabin when the airframe circulates hot compressed air from the APU.
Non-Compliance with CFRs, Policies/Procedures – Fuel Procedures
Upon landing in PHX the SIC gave the line attendant our fuel order of 270 gallons. We then helped the medical team load up and get on their way. We completed our post-flight duties and went inside the FBO. I (PIC) then gave the front desk our fuel order again and she entered it onto the computer. I then did an AEG fuel release and gave her the fuel release number. We then had around a 6 hour wait before the crew came back. We requested a GPU for engine start 30-45 minutes before the team arrived back to the airport. After about 15 minutes we requested the GPU again. The GPU was not delivered to the aircraft until approximately 5 minutes before the crew arrived. Checklists were accomplished but definitely rushed.
One pilot was inside setting up the avionics and loading the flight plan, while the other was outside loading the medical gear. Checking fuel quantity is located on the “Cockpit Preparation” checklist (Item 23 “Fuel Quantity…. Check/Balance). Clearly this step was missed. Approximately 5-10 minutes after departure we noticed we had not been fueled. We ran our numbers and had enough fuel to make it to SLC, but not land with the appropriate fuel reserve.
We made a fuel stop at GCN and the flight continued without incident. Upon landing in SLC I called [FBO/Fueling Service Company name] in Phoenix and spoke with 2 different people there. They did indeed have our fuel order and apologized for not fueling us.
ERC Investigation Notes:
Sole source. CRM and non compliance to GOM procedures were contributing factors.
Corrective Actions
Short Term: Counsel pilot(s) on checklist challenge/response and CRM, – discussion in pilot meeting – on challenge/response process “A Flight to Learn From” Long Term
Long Term: Include in training program and enforce “PRE-DEPARTURE CHECKLIST” to include reading quantities out loud and challenge/response process. (send memo to instructor pilots) *waiting on confirmation if completed Company planning to update GOM- Improve SIC program guidance to ensure high standards are being met while setting example for new pilots”
Safety Takeaway:
The FBO can be a busy, chaotic environment at times, and mistakes can be made by both line service personnel and crew. Remember: it is always the responsibility of the crewmembers to check their fueling levels prior to departure. This should be an emphasized checklist item for all operators.
ATC Call Sign Mismatch
In descent to KOMA, we were level at FL340. I was the flying pilot (FP) and we heard a clearance for us [call sign 1] to descend and maintain FL330. The NFP readback the clearance with an emphasis on the full call sign, because [call sign 2] was also on frequency going into KPWK from KOMA. Shortly after, ATC gave a frequency change to [CS2]. Upon reaching approximately FL335, Chicago Center called us and told us to maintain FL340. The NFP explained that we had been cleared to FL330 and that we had read back the clearance, but we would climb back to FL340. However, the controller stated that the clearance to FL330 was for [CS2], not [CS1}. NFP was relatively certain the call was for [CS1}. After landing, NFP called crew for [CS2]. They stated that they thought what they heard was for [CS1] to descend as well and did hear our readback. When [CS2] checked in with the new frequency, the controller asked them if they had been given FL330. They replied “negative”.
Suggestion Narrative: With multiple CAG aircraft, be sure to question ATC, even if there is a slight doubt by one pilot, whether or not it was your aircraft. I, as PF, had confidence in NPF’s confidence that the call was for us (and it very well could have been a mistake by ATC, this is unknown), but admittedly, I did not hear it clearly, and should have had NFP question ATC.
ERC Investigation Notes:
Sole source. Communication issue between ATC and another company aircraft.
Corrective Action
Company to send out read and initial – emphasis on querying ATC and staying vigilant.
Safety Takeaway:
Crew made the correct decision. Chicago airspace remains to be a busy airspace. Small details such as aircraft tail numbers can sound identical. If a clearance/instruction does not seem normal, always use DECIDE model.
Key to decision making – DECIDE Model
Detect: Recognize that a change or problem has occurred (e.g., call sign confusion).
Estimate: Assess the significance of the change and the need to react.
Choose: Select a desirable outcome for the flight.
Identify: Determine the specific actions needed to achieve that outcome (check call sign of aircraft and other aircraft).
Do: Take the necessary action(s)(confirm with ATC).
Evaluate: Assess the effects of the action taken and whether the situation is resolved or needs further attention (correct/execute if necessary).
