Narrative:

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.

Google
 

Original NASA ASRS Text

Title: B777 flight crew reported they missed Before-Start checklist items due to long duty day and fatigue.

Narrative: 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.

Data retrieved from NASA's ASRS site 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.