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|
Attributes | |
ACN | 599224 |
Time | |
Date | 200311 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : den.airport |
State Reference | CO |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Windshear Turbulence |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
Qualification | pilot : atp pilot : multi engine pilot : instrument pilot : cfi pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 56 flight time total : 5000 flight time type : 350 |
ASRS Report | 599224 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | incursion : landing without clearance non adherence : published procedure non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : insufficient time |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This event occurred at the end of a flight sequence that began the night before in oak, ca. The flight departed oak at XB05 and flew to cancun, mexico (mmun), spent approximately 2 hours on the ground unloading passenger, fueling and loading passenger, then went on to den, co. Scheduled block time was 9 hours 10 mins, actual block time was 8 hours 45 mins. The flight sequence was 'heavy crewed' (captain, first officer and international relief officer) due to scheduled block time exceeding 8 hours and the international nature of the operation. I was assigned to the flight as the in-flight relief officer and was occupying the right seat and performing PNF duties at the time of the event. The captain was in the left seat performing PF duties and the first officer was on the jumpseat. The event occurred on approach and landing to den. During our arrival into the den approach control airspace, we were assigned and vectored for 3 different runways -- first runway 17R, then runway 35R, then runway 35L (the runway we actually landed on). After approach control cleared us for the visual to runway 35L and we joined the final approach course, we were busy, still completing our approach and landing checklists. Coming down final approach, we experienced moderate turbulence, which had been reported, a significant left crosswind (approximately 15 KTS) and some minor shear (approximately 10-15 KTS airspeed change). Surface winds were reported out of the southwest at approximately 8 KTS. We landed uneventfully. However, upon rollout, I realized as I switched frequencys to call ground control, that the communication radio was still tuned to approach control and that we had never talked to tower, and thus never received a landing clearance. At that time I switched to tower frequency, stated our position as 'exiting runway 35L,' and was cleared by tower to the ramp. There were no further communications with ATC. Here are the factors that I believe were causal to this event: 1) fatigue. We left the hotel in oak at XA00 pm PST and landed at XA00 am MST and during that time flew almost 9 hours. We all admitted that we were functioning at significantly reduced mental capacity during approach to den. 2) contributing to the fatigue of the trip itself is a longer-term fatigue that comes from the way our trip sequences are scheduled. In a typical week of flying, we may have a 'red-eye' overnight trip, followed by a trip with an early morning departure, followed by a trip with an afternoon or evening departure. I personally find it impossible for my body clock to adapt at all when there is no consistency in trip departure times within a week of flying (we fly a week on/week off schedule typically). 3) we were running behind in performing checklists. We were still performing our approach checklist as we were being vectored for final. This checklist is normally done at FL180 during descent. Additionally, the captain decided to delay extension of landing gear due to following traffic in order to maintain higher airspeed. This meant we were performing our landing checklist later during final approach than usual. 4) environmental factors (left quartering crosswind, turbulence, shear), combined with 3) above, plus the 3 successive runway assignments, caused a 'compression of events' into the limited time-frame of the final approach, as we dealt with tuning navigation radios, communicating, checklists, and the physical maneuvering of the airplane.
Original NASA ASRS Text
Title: B757 FLT CREW LWOC AT DEN.
Narrative: THIS EVENT OCCURRED AT THE END OF A FLT SEQUENCE THAT BEGAN THE NIGHT BEFORE IN OAK, CA. THE FLT DEPARTED OAK AT XB05 AND FLEW TO CANCUN, MEXICO (MMUN), SPENT APPROX 2 HRS ON THE GND UNLOADING PAX, FUELING AND LOADING PAX, THEN WENT ON TO DEN, CO. SCHEDULED BLOCK TIME WAS 9 HRS 10 MINS, ACTUAL BLOCK TIME WAS 8 HRS 45 MINS. THE FLT SEQUENCE WAS 'HVY CREWED' (CAPT, FO AND IRO) DUE TO SCHEDULED BLOCK TIME EXCEEDING 8 HRS AND THE INTL NATURE OF THE OP. I WAS ASSIGNED TO THE FLT AS THE INFLT RELIEF OFFICER AND WAS OCCUPYING THE R SEAT AND PERFORMING PNF DUTIES AT THE TIME OF THE EVENT. THE CAPT WAS IN THE L SEAT PERFORMING PF DUTIES AND THE FO WAS ON THE JUMPSEAT. THE EVENT OCCURRED ON APCH AND LNDG TO DEN. DURING OUR ARR INTO THE DEN APCH CTL AIRSPACE, WE WERE ASSIGNED AND VECTORED FOR 3 DIFFERENT RWYS -- FIRST RWY 17R, THEN RWY 35R, THEN RWY 35L (THE RWY WE ACTUALLY LANDED ON). AFTER APCH CTL CLRED US FOR THE VISUAL TO RWY 35L AND WE JOINED THE FINAL APCH COURSE, WE WERE BUSY, STILL COMPLETING OUR APCH AND LNDG CHKLISTS. COMING DOWN FINAL APCH, WE EXPERIENCED MODERATE TURB, WHICH HAD BEEN RPTED, A SIGNIFICANT L XWIND (APPROX 15 KTS) AND SOME MINOR SHEAR (APPROX 10-15 KTS AIRSPD CHANGE). SURFACE WINDS WERE RPTED OUT OF THE SW AT APPROX 8 KTS. WE LANDED UNEVENTFULLY. HOWEVER, UPON ROLLOUT, I REALIZED AS I SWITCHED FREQS TO CALL GND CTL, THAT THE COM RADIO WAS STILL TUNED TO APCH CTL AND THAT WE HAD NEVER TALKED TO TWR, AND THUS NEVER RECEIVED A LNDG CLRNC. AT THAT TIME I SWITCHED TO TWR FREQ, STATED OUR POS AS 'EXITING RWY 35L,' AND WAS CLRED BY TWR TO THE RAMP. THERE WERE NO FURTHER COMS WITH ATC. HERE ARE THE FACTORS THAT I BELIEVE WERE CAUSAL TO THIS EVENT: 1) FATIGUE. WE LEFT THE HOTEL IN OAK AT XA00 PM PST AND LANDED AT XA00 AM MST AND DURING THAT TIME FLEW ALMOST 9 HRS. WE ALL ADMITTED THAT WE WERE FUNCTIONING AT SIGNIFICANTLY REDUCED MENTAL CAPACITY DURING APCH TO DEN. 2) CONTRIBUTING TO THE FATIGUE OF THE TRIP ITSELF IS A LONGER-TERM FATIGUE THAT COMES FROM THE WAY OUR TRIP SEQUENCES ARE SCHEDULED. IN A TYPICAL WK OF FLYING, WE MAY HAVE A 'RED-EYE' OVERNIGHT TRIP, FOLLOWED BY A TRIP WITH AN EARLY MORNING DEP, FOLLOWED BY A TRIP WITH AN AFTERNOON OR EVENING DEP. I PERSONALLY FIND IT IMPOSSIBLE FOR MY BODY CLOCK TO ADAPT AT ALL WHEN THERE IS NO CONSISTENCY IN TRIP DEP TIMES WITHIN A WK OF FLYING (WE FLY A WK ON/WK OFF SCHEDULE TYPICALLY). 3) WE WERE RUNNING BEHIND IN PERFORMING CHKLISTS. WE WERE STILL PERFORMING OUR APCH CHKLIST AS WE WERE BEING VECTORED FOR FINAL. THIS CHKLIST IS NORMALLY DONE AT FL180 DURING DSCNT. ADDITIONALLY, THE CAPT DECIDED TO DELAY EXTENSION OF LNDG GEAR DUE TO FOLLOWING TFC IN ORDER TO MAINTAIN HIGHER AIRSPD. THIS MEANT WE WERE PERFORMING OUR LNDG CHKLIST LATER DURING FINAL APCH THAN USUAL. 4) ENVIRONMENTAL FACTORS (L QUARTERING XWIND, TURB, SHEAR), COMBINED WITH 3) ABOVE, PLUS THE 3 SUCCESSIVE RWY ASSIGNMENTS, CAUSED A 'COMPRESSION OF EVENTS' INTO THE LIMITED TIME-FRAME OF THE FINAL APCH, AS WE DEALT WITH TUNING NAV RADIOS, COMMUNICATING, CHKLISTS, AND THE PHYSICAL MANEUVERING OF THE AIRPLANE.
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.