Regional Jet 700 ER/LR (CRJ700)
Flight Crew Flight Instructor; Flight Crew Instrument; Flight Crew Multiengine; Flight Crew Air Transport Pilot (ATP)
Flight Crew Last 90 Days 150; Flight Crew Total 9800; Flight Crew Type 8000
Confusion; Distraction; Fatigue; Time Pressure; Communication Breakdown
ATC Issue All Types; Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy
Air Traffic Control Issued Advisory / Alert; Air Traffic Control Issued New Clearance; Flight Crew Became Reoriented; Flight Crew Overcame Equipment Problem
Aircraft; Human Factors
In retrospect; I should have called in fatigued that morning due to a 12 plus hour duty day the day prior; and interrupted sleep (due to numerous train horns during the night near the crew hotel) on our overnight on [the day before]. I screwed up several things on this flight; and at the time I didn't realize some of my errors; and also didn't understand why I was making the errors I was making. In retrospect with sleep and time I've reconstructed my errors.The first flight of the day was the First Officer's leg; and was uneventful. We changed planes and were given an aircraft with no APU and four other MEL deferrals.The inbound passengers debarked; with the exception of one wheelchair-bound passenger. A customer service agent with a wheelchair was called several times; both by the inbound crew; and us. During this time I reviewed the aircraft logbook; the maintenance status of the aircraft; and the flight release; as well as briefed my crew. Finally the wheelchair-bound passenger was off-loaded; and we began boarding our flight. This started us off late. Next; the Gate Agent could not move the jet-bridge until we disconnected the ground power; which we couldn't do until we had an engine running; and a main generator on-line. The engine couldn't be started without an air cart; and the ramp agents did not have one ready for us; so we had to wait on that as well. After everything came together; we completed our checklists; started the number two engine; and blocked out 17 minutes late.Since the company now publishes a monthly 'On-time' percentage summary for each pilot in each domicile to everybody in the company; if one is on the lower end of the 'On-time' percentage scale; it is viewed negatively; and pilots are encouraged to 'seek the counsel' of the pilots on the top of the scale to improve our percentages. So; in addition to unrecognized fatigue; I was now feeling self-induced pressure to make up the time we lost.On taxi out I instructed my First Officer to start the number one engine (a cross-bleed start; due to no APU). This is a very simple procedure; the bleed valves are closed; the operating engine accelerated to a N2 RPM which provides a minimum of 42 PSI in the pneumatic manifold (maximum of 80% N2 RPM). I pushed up the thrust lever to the point where we had about 45 PSI in the pneumatic manifold; and the First Officer initiated the start sequence. About this time an A320 was turning out in front of us; and the Ramp Controller advised us to give way to a B737 ahead. I wasn't paying attention to the start and was getting ready to key the microphone and ask the Ramp Controller if he meant the A320 in front of us; when I heard the single chime associated with a caution message being displayed on the EICAS. I looked down and saw a L START ABORT caution message; which is usually the indication one gets when the thrust lever is moved from SHUT-OFF to IDLE while the associated engine's ITT is still above 120 degrees C. At this point I looked up and saw the START valve light was still illuminated on the overhead panel and for whatever reason I pressed it (or so I thought; I don't have an answer as to why I did this - fatigue perhaps?). I told the First Officer to 'leave it on'; meaning the starter (but didn't communicate starter). The First Officer had dutifully placed the thrust lever in the SHUT-OFF position; but upon hearing me state 'leave it on'; he moved the thrust lever back to IDLE. Unfortunately the engine ITT started to rapidly climb as the engine's rpm's were decreasing; and I realized that I hadn't reselected the START button; but rather the STOP button. As the ITT went through about 800 degrees C; I shut off the thrust lever. I never saw a 'HOT' icon displayed on the N1 gauge icon. While this was occurring; and we were still rolling; I heard the ramp controller stating; 'He acknowledged holding short for you.' I looked outside and saw the B737 we had been instructed to hold for in front of us to our left. I stopped the airplane with more than enough room for the B737 to turn out in front of us. I then looked at the First Officer and told him to tell the Ramp Controller that we would need a few minutes to re-accomplish the start. We pulled over on the ramp and I set the brake. Since I hadn't seen a 'HOT' icon; I wanted to ensure we hadn't exceeded any ITT limitations; so I went into the MDC (Maintenance Diagnostic Computer) and reviewed the 'Engine Exceedances' section; and found nothing. Had we exceeded the START ITT limit I would have called Maintenance and written it up. I then instructed the First Officer to re-accomplish the cross-bleed start procedure; and instructed him to ensure he waited until the ITT was below 120 degrees C before he brought the thrust lever to IDLE. He did and the engine started uneventfully. The problem now was that we did not accomplish the 'L START ABORT' QRH procedure; which would have instructed us to motor the engine to reduce the ITT. I realized that en route and did review it; but that was after the fact; and not when it should have been done.I believe this situation was borderline dangerous. I was clearly less than 100% due to:1) Fatigue;2) Being hot (the cockpit was about 90 degrees F) due to the greenhouse effect of the cockpit windows; and not having the left air conditioning pack on (due to the left engine not being started at the gate);3) The self-induced time pressure;4) And my unsuccessful attempt to do three things at once;All of the conditions above were the cause of this situation.What I should have done (in addition to getting adequate rest); wasA) Aviate (taxi the airplane).B) Monitor and supervise the engine start (don't try to get into the middle of it).C) Communicate (effectively communicate to the First Officer and comply with the company's SOP and perform the required checklists when specified in the manual).Obviously I screwed up. I wasn't fit to be in the cockpit that morning and it showed.I'm thankful I didn't harm anyone or damage any equipment.Another lesson learned; if I haven't slept well; I'm going to call in fatigued in the future; I don't want to screw up like this again.
Fatigue and company pressure for on time operations were factors in a cluster of anomalous events for a CRJ-700 flight crew taxiing for takeoff with an inoperative APU.