Air Transat Flight 236
The aircraft involved in the incident
|Date||August 24, 2001|
|Summary||In-flight fuel starvation caused by fuel leak following improper maintenance|
|Site||Lajes Air Force Base,
Terceira Island, Azores, Portugal
|Injuries (non-fatal)||18 (minor)|
|Aircraft type||Airbus A330-243|
|Flight origin||Toronto Pearson Int'l Airport
Toronto, Ontario, Canada
Air Transat Flight 236 was a transatlantic flight bound for Lisbon, Portugal from Toronto, Canada that lost all power while flying over the Atlantic Ocean on August 24, 2001. The Airbus A330-243 suffered a complete power loss due to a fuel leak caused by improper maintenance. Captain Robert Piché, 48, an experienced glider pilot, and First Officer Dirk de Jager, 28, flew the plane to a successful emergency landing in the Azores, saving all 306 people (293 passengers and 13 crew) on board.
Flight TS 236 took off from Toronto at 0:52 (UTC) on Friday, August 24, 2001 (local time: 8:52 pm (ET) on Thursday, August 23) bound for Lisbon, Portugal. There were 293 passengers and thirteen crew members on board. The aircraft was an Airbus A330 registered as C-GITS that first flew on March 16, 1999, configured with 362 seats and placed in service by Air Transat on April 28, 1999. Leaving the gate in Toronto, the aircraft had 46.9 tonnes of fuel on board, 4.5 tonnes more than required by regulations.[Note 1]
At 05:16 UTC, a cockpit warning system chimed and warned of low oil temperature and high oil pressure on engine #2. There was no obvious connection between an oil temperature or pressure problem and a fuel leak. Consequently, Captain Robert Piché, who had 16,800 hours of flight experience, and First Officer Dirk DeJager, who had 4,800 flight hours, suspected they were false warnings and shared that opinion with their maintenance control center, who advised them to monitor the situation.
At 05:36 UTC, the pilots received a warning of fuel imbalance. They followed a standard procedure to remedy the imbalance by transferring fuel from the left wing tank, to the near-empty right wing tank. Unbeknownst to the pilots, the aircraft had developed a fuel leak in a line to the #2 (right) engine. The fuel transfer caused fuel from the left wing tank to be lost through the leak in the line to the #2 engine. The fractured fuel line, which was leaking at about one gallon per second, caused a higher than normal fuel flow through the fuel-oil heat exchanger (FOHE), which in turn led to a drop in oil temperature and a rise in oil pressure for the #2 engine.
At 06:13 UTC, while still 135 miles (217 km) from Lajes, engine #2 flamed out because of fuel starvation. Captain Piché then initiated a descent to 33,000 feet (10,000 m), which was the proper single-engine altitude for the weight of the plane at that time. Ten minutes later, the crew sent a Mayday to Santa Maria Oceanic air traffic control.
Three minutes later, at 06:26 UTC and approximately 65 nautical miles (120 km) from Lajes Air Base, engine #1 also flamed out. Without engine power, the plane lost its primary source of electrical power. The emergency ram air turbine was deployed automatically to provide essential power for critical sensors and instruments to fly the aircraft. However, the aircraft lost its main hydraulic power, which operates the flaps, alternate brakes, and spoilers. The slats would still be powered, however, when the flaps #1 position was selected.
Military air traffic controllers guided the aircraft to the airport with their radar system. The descent rate of the plane was about 2,000 feet (600 metres) per minute. They calculated they had about 15 to 20 minutes left before they would be forced to ditch in the ocean. The air base was sighted a few minutes later. Captain Piché had to execute one 360 degree turn, and then a series of "S" turns, to dissipate excess altitude.
At 06:45 UTC, the plane touched down hard, approximately 1,030 feet (310 m) past the threshold of Runway 33, at a speed of approximately 200 knots (370 km/h), bounced once and then touched down again, approximately 2,800 feet (850 m) from the threshold. Maximum emergency braking was applied and retained, and the plane came to a stop 7,600 feet (2,300 m) from the threshold of that 10,000 feet (3,000 m) runway. Since they had lost the anti-skid and brake modulation systems, the eight main wheels locked up; its tires abraded and fully deflated within 450 feet (140 m). Fourteen passengers and two crew members suffered minor injuries, while two passengers suffered serious injuries during the evacuation of the aircraft. The plane suffered structural damage to the main landing gear and the lower fuselage.
The Portuguese Aviation Accidents Prevention and Investigation Department (GPIAA) investigated the incident along with Canadian and French authorities.
The investigation revealed the cause of the incident was a fuel leak in the #2 engine, caused by an incorrect part installed in the hydraulics system by Air Transat maintenance staff. Air Transat maintenance staff had replaced the engine as part of routine maintenance, using a spare engine, lent by Rolls-Royce, from an older model. This borrowed engine did not include a hydraulic pump. Despite the lead mechanic's concerns, Air Transat ordered the use of a part from a similar engine, an adaptation that did not maintain adequate clearance between the hydraulic lines and the fuel line. This lack of clearance — in the order of millimeters from the intended part — allowed vibration in the hydraulic lines to rupture the fuel line, causing the leak. Air Transat accepted responsibility for the incident and was fined 250,000 Canadian dollars by the Canadian government, which as of 2009[update] was the largest fine in Canadian history.
Although pilot error was listed as one of the lead causes for the incident, it was the skill of the pilots, and of the military Air Traffic Controller 1st Sgt. José Ramos, that enabled the flight to land without fuel. The pilots returned to a heroes' welcome from the Canadian press.
The incident also led to the French Directorate General for Civil Aviation (DGAC) and Federal Aviation Administration (FAA) issuing an Airworthiness Directive, forcing all operators of Airbus model A318-100, A319-100, A320-200, A321-100, A321-200, and A320-111 aircraft to change the flight manual, stressing that crews should check that any fuel imbalance is not caused by a fuel leak before opening the cross-feed valve. The French Airworthiness Directive (AD) required all airlines operating these Airbus models to make revisions to the Flight Manual before any further flights were allowed. The FAA gave a 15-day grace period before enforcing the AD. Airbus also modified its computer systems; the on-board computer now checks all fuel levels against the flight plan. It now gives a clear warning if more fuel is being lost than the engines can consume. Rolls-Royce also issued a bulletin advising of the incompatibility of the affected engine parts.
MSNBC also produced a report on the incident, entitled "A Wing and A Prayer".
The story of Robert Piché is depicted in the 2010 French Canadian biographical drama film Piché: The Landing of a Man (Piché: Entre ciel et terre, FR) culminating with the events on Flight 236. Captain Piché is portrayed by both Genie Award-winning actor Michel Côté and his son Maxime LeFlaguais.
Dr. Margaret McKinnon, who was a postdoctoral psychology student at Baycrest Health Sciences in Toronto at the time, was a passenger on Flight 236 on her honeymoon. She and colleagues recruited 15 other passengers to do a study on PTSD which was published in August 2014 in the journal Clinical Psychological Science comparing details recalled by passengers with PTSD to passengers without PTSD and a control group.
- US Airways Flight 1549 ("Miracle on the Hudson")
- Air Canada Flight 143 ("Gimli Glider")
- List of airline flights that required gliding
- TSC236 was planned to depart CYYZ at 00:10 UTC1, with 47.9 metric tons of fuel, which included a 5.5 tons over and above the fuel required by regulations for the planned flight; the actual take-off time was at 00:52 with a reported 46.9 tons of fuel on board.
- Crossette, Barbara (September 10, 2001). "Jet Pilot Who Saved 304 Finds Heroism Tainted". The New York Times. Retrieved August 21, 2007.
- "Flying on Empty," Mayday
- "Accident Investigation Final Report - All Engines-out Landing Due to Fuel Exhaustion - Air Transat Airbus A330-243 marks C-GITS, Lajes, Azores, Portugal, 24 August 2001". Portuguese Aviation Accidents Prevention and Investigation Department. Retrieved January 2013.
- "Air Transat Flight 236: The Azores Glider" (PDF). Retrieved July 27, 2010.
- "ASN Aircraft accident Airbus A330-243 C-GITS Terceira-Lajes AFB, Azores (LFB)". Retrieved January 2013.
- Diário Insular OnLine [dead link]
- Airbus Model A318-100, A319-100, A320- 200, A321-100
- "Entre ciel et terre review (in French)". cinoche.com. Archived from the original on July 22, 2010. Retrieved July 1, 2010.
- PTSD clues gleaned from passengers on terrifying flight
- Accident Investigation Final Report from the Portuguese Aviation Accidents Prevention and Investigation Department (Archive, Alternate link, Alternate Link #2)
- Report profile (Portuguese)
- "Air Transat Flight TS 236 of August 24, 2001 - Air Transat welcomes investigation findings and recommendations" (Archive). Air Transat. October 17, 2004.
- Accident description at the Aviation Safety Network
- News report on logistical issues after the incident
- "Grateful passengers praise Air Transat pilot." CBC News. Sunday August 26, 2001.
- Captain Robert Piché's Official Website (French)
- PTSD clues gleaned from passengers on terrifying flight