B777 Undifferentiated or Other Model
Flight Crew Instrument; Flight Crew Air Transport Pilot (ATP); Flight Crew Multiengine
Time Pressure; Situational Awareness; Fatigue; Communication Breakdown; Distraction
Deviation / Discrepancy - Procedural Published Material / Policy; Ground Event / Encounter Other / Unknown
Human Factors
The incident occurred during starting procedures for the second flight of the day. The first flight leg duration was 6+38 flight time; plus a 2 hour call out for a total duty time of 8+38. The second flight did not begin for 1+05 after that for a total duty time of 9 hours 43 minutes prior to the incident occurring. The flight crew consisted of the left seat Captain (Pilot Flying) who was being evaluated and flew the previously mentioned flight; the right seat Captain (Pilot Monitoring) who was evaluating and stated that he had not flown as right seat pilot monitoring in some time; the [Relief Pilot] who flew the previously mentioned flight which was the first flight off of [line check] training; and; a FAA inspector/examiner who was evaluating as well. There was a non-flying; supernumerary who arrived to the plane late. Once the non-crew members were briefed on safety and the doors were closed; the flight crew began its normal procedures reviewing the route of flight; the FMS entries and other associated tasks. At that time ground crew contacted the cockpit requesting pushback. Normally the flight deck requests to pressurize and then push back. After pushback the ground crew cleared to start engines; where the left seat Captain called for engine start. When the right engine started multiple EICAS messages alerted the crew and it was recognized that the aircraft hydraulics were not pressurized and the fuel pumps not engaged due to the checklists and flows having been omitted. The Captains recognized their mistake and corrected it with the appropriate flows and checklists. There are multiple causal factors to the incident. One factor is fatigue for two of the 3 crew members; having approximately a 10 hour work period preceding the incident. Another factor was lack of recognition of deviation from procedure by all crew members; allowing the ground crew to influence flight operations. Another factor was the inexperience of the [Relief Pilot] performing the duties that were normally accomplished by 2 crew members and having minimal training in those areas. The final causal factor is having a fatigued crew being evaluated and that evaluator being evaluated. With the anxiety of evaluation; a 3 person crew with one being inexperienced; beginning on hour 10 of the workday; the compounding factors aligned for a breakdown in safety.If evaluations are to occur; the recommendation would be for the first flight of the day; to reduce fatigue and anxiety. Also having more than one crew member evaluated at the same time is not recommended. Finally; if an evaluation is occurring; if one of the crew members has not completed 100 hours consolidation of experience; there should be a 4th crew member to assist with safety and procedure.
When the time came for push back I omitted the procedure of pressurizing hydraulics and calling for the before start checklist. After the right engine was started there were several EICAS messages related to hydraulics and fuel. Then saw the hydraulic pumps and fuel pumps were not on and I realized my mistake. Then the before start flow and the before start checklist were completed which cleared the EICAS messages. All of this was my mistake. I did not intentionally decide to deviate from or omit any procedure. During the cockpit preflight there were several changes. The SABLE changed three times which required a new flight plan. The ATC clearance changed and then there was a runway change. These are things I normally deal without overlooking procedures. My sleep and work schedule contributed to my oversight of procedures. I failed to recognize my fatigue. I do not know of any changes that could be made or have suggestions that could have prevented this incident. I should not have hesitation to call fatigued.
B777 flight crew reported they missed Before-Start checklist items due to long duty day and fatigue.