FLC OF B737-300 JUST RETURNING FROM SICK LEAVE CROSSES RWY WITHOUT CLRNC DURING AFTER LNDG TAXI. SECOND ERROR OF THE DAY MADE ON DSCNT WHEN ALTDEV OCCURS.
Synopsis
FLC OF B737-300 JUST RETURNING FROM SICK LEAVE CROSSES RWY WITHOUT CLRNC DURING AFTER LNDG TAXI. SECOND ERROR OF THE DAY MADE ON DSCNT WHEN ALTDEV OCCURS.
Narrative
IN THE AFTERNOON MY COPLT AND I MET FOR THE FIRST TIME IN FLT OPS AND GOT ACQUAINTED. WE VERY QUICKLY DISCOVERED WE WERE BOTH COMING OFF SICK LEAVE. COINCIDENTALLY; WE BOTH HAD BEEN OFF FOR VERY SEVERE BACK PAIN. I HAD HURT MY BACK ON VACATION AND SHE HAD RECURRING BACK TROUBLE FROM A RECENT BACK SURGERY. WE HAD BOTH BEEN OFF OVER 3 WKS AND DISCUSSED THE NEED FOR ADDED CARE AND VIGILANCE IN OUR PLANNED FLTS FROM DEN TO ONT BACK TO DEN AND THEN TO BOI. I FLEW THE ONT TURN. EVERYTHING WENT VERY NICELY UNTIL AFTER I LANDED IN ONTARIO. IT WAS VFR WITH OVER 10 MI VISIBILITY. WE GOT DSNDED NICELY INTO THE BASIN BY THE CTLR AND GOT AN EARLY ILS RWY 26L CLRNC. WE WERE THE ONLY PLANE OPERATING AT ONT ARPT AT THE TIME. AS WE APCHED THE RWY I SAW THAT NO ONE WAS DEPARTING RWY 26R. I MADE A VERY NICE LNDG AND MY MIND GOT ENGROSSED WITH SMOOTHLY ROLLING OFF ONTO THE HIGH SPD TURNOFF AT TXWY K AND INTO THE GATE. I SPACED THE FACT THAT WE HAD TO CROSS RWY 26R. THE TWR CTLR SAID NOTHING AS WE ROLLED OUT. AS I TURNED TOWARD RWY 26R I SAW THE WHITE RWY EDGE LINES AND SUDDENLY REGAINED MY SITUATIONAL AWARENESS. I PRESSED THE BRAKES TO STOP. IN THE MEANTIME; NEITHER THE COPLT NOR THE JUMP SEATER (PLT) WARNED ME ABOUT MY APCH TO THE RWY. INSTEAD THE COPLT CALLED ON THE RADIO AND ANNOUNCED THAT WE WERE 'CLR' AND THE CTLR SAID CLRED TO THE GATE. I EASED UP ON THE BRAKES JUST AS THE NOSE OF THE ACFT WAS ABOUT TO CROSS THE FIRST RWY EDGE LINE IN RESPONSE TO THIS CLRNC. I TAXIED ACROSS RWY 26R AND IN TO THE GATE. AFTER WE WERE IN THE GATE; I REALIZED THAT THE CTLR WHO HAD GIVEN US CLRNC IN TO THE GATE WAS THE GND CTLR! WE NEVER RECEIVED CLRNC TO CROSS RWY 26R! THE COPLT FOR SOME UNKNOWN REASON HAD SWITCHED TO GND CTL BEFORE WE CROSSED RWY 26R AND WE LEFT THE TWR CTLR OUT IN THE COLD. ALL THIS WAS A VERY BAD ERROR. BOTH OF OUR BRAINS HAD TAKEN A LUNCH BREAK AT THE SAME TIME! THE TWR NEVER ASKED US TO CALL THEM SO I DON'T KNOW WHAT WILL COME OF IT. SERIOUS ERRORS ARE RARELY MADE IN MY COCKPITAND I FEEL REALLY BADLY WHEN THEY ARE; BUT THIS DAY WAS GOING TO BE A DOOZY. I WAS DESTINED TO MAKE 2 ERRORS IN 1 DAY. WE WERE CLRED INTO DEN VIA THE LARKS 1 ARR. IN CRUISE I HAD SET UP A VISUAL RTE INTO RWY 7 OFF OF THE LARKS BY CREATING A FIX 15 MI SHORT OF HUUGE AND GOING DIRECT FROM THERE TO SARAH ON THE ILS 7. THIS PROVIDED ME WITH A GOOD ESTIMATE OF OUR ARR TIME AND A PATH FOR VFR DSCNT PLANNING. I PUT HUUGE IN THE FIX PAGE SO THAT I COULD NAV THERE UNTIL WE GOT VECTORS FOR THE VISUAL. SINCE THERE WAS A FLT ATTENDANT IN THE COCKPIT ABOUT THE TIME I PUT THIS IN THE FMC I COMPLETELY FORGOT TO BRIEF THE COPLT ON WHAT I DID. SINCE SHE HAD NEVER FLOWN WITH ME BEFORE SHE WASN'T FAMILIAR WITH WHAT I DID. AS WE STARTED OUR DSCNT ON THE ARR; I BRIEFED A VISUAL TO RWY 7 WHICH WAS INDICATED ON THE ATIS. THERE WERE HIGH SCATTERED CUMULO NIMBUS IN THE AREA AND THE VISIBILITY WAS GREATER THAN 10 MI. WE HAD BEEN CLRED TO 13000 FT BY THE FIRST APCH CTLR WHO MENTIONED NOTHING ABOUT WHICH RWY TO EXPECT. AS WE APCHED 20 MI BEFORE HUUGE WE DISCUSSED A SMALL CELL THAT WE SAW VISUALLY AND ON THE WX RADAR (SMALL WITH GREEN AND SMALL YELLOW CTR). THE CELL WAS NOT DEVELOPING AND WAS NOT VERY HIGH. I WAS NOT CONCERNED BUT THE COPLT WAS. AS WE WERE PASSING MY '15 MI SHORT OF HUUGE FIX' I PROCEEDED TO FLY TOWARD HUUGE MANUALLY WITH FLT DIRECTOR AND AUTOTHROTTLES OFF. THE COPLT GOT CONFUSED ABOUT WHERE WE SHOULD BE GOING. I WAS EXPLAINING IT TO HER JUST AS THE CTLR TURNED US OVER TO THE NEXT CTLR. ALSO I WAS APCHING THE 13000 FT CLRED ALT. THIS CTLR TOLD US WE WOULD BE GOING TO RWY 16 AND TO TURN L TO 010 DEG HDG. I STARTED THE TURN AND THE COPLT ASKED ME IF I WANTED TO TURN YET BECAUSE OF THE CELL. I HAD ALREADY STARTED BUT THEN HESITATED TO CONSIDER WHAT SHE HAD SAID. IN THE MEANTIME I WAS DSNDING THROUGH 13000 FT. SHE DID NOT MAKE THE NORMAL ALT CALL AND I WAS DISTR AND MISSED THE ALT ALERT. THE COPLT CAUGHT THE ALT BUST AT ABOUT 12500 FT AND QUICKLY CLBED UP TO 13000 FT AND PROCEEDEDDOWNWIND ON A VECTOR. THE CTLR AGAIN SAID NOTHING ABOUT THE INCIDENT. AGAIN; BOTH OF OUR BRAINS WERE OUT TO LUNCH; WAY BEHIND THE AIRPLANE. LACK OF EXPERIENCE AS A TEAM WAS A FACTOR HERE. HOWEVER; AFTER DISCUSSING THE SITS IN BOTH OF OUR 'ERRORS IN 1 DAY;' AND GETTING COMMON FEELINGS ABOUT HOW OUR MINDS WERE FUNCTIONING; WE CAME TO THE CONCLUSION THAT HAVING SEVERE PAIN FOR SEVERAL WKS AND THEN COMING TO WORK ONLY DAYS AFTER THAT PAIN HAS SUBSIDED IS NOT A GOOD IDEA! DURING TIMES OF GREAT PHYSICAL PAIN; THE BRAIN DOES MANY THINGS TO PROTECT ITSELF AND THE BODY FROM THE PAIN. THE SENSORY CIRCUITS TO THE BRAIN SEEM TO BE MODIFIED SO THE PAIN IS REDUCED. THE BRAIN CHANGES THE MENTAL OUTLOOK OF THE MIND TO DULL THE EFFECTS OF THE PAIN. THE MIND CHANGES THE INVOLUNTARY PHYSICAL MOVEMENTS OF THE BODY TO HELP PREVENT PAIN. THE SLEEP CYCLE IS CHANGED TO PREVENT PAIN FROM INTERFERING WITH THE SLEEP AND THE DREAMS SEEM TO CHANGE. A PERSON'S THOUGHTS SEEM TO BE MORE INWARD. HE DOESN'T SEE ALL THAT IS GOING ON AROUND HIM WHEN HE IS SUFFERING PAIN. AFTER THE PAIN IS GONE; I BELIEVE IT TAKES MORE THAN A FEW DAYS FOR ALL THESE BRAIN ADAPTATIONS TO GET UNRAVELED AND BACK TO NORMAL. THE COPLT AND I FLEW FOR 4 DAYS TOGETHER RIGHT AFTER THIS; AND EACH DAY OUR PERFORMANCE IMPROVED. WITH DILIGENCE WE WERE ABLE TO PREVENT ANY MORE ERRORS.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.