Flight 143 after landing at Gimli, Manitoba
|Date||July 23, 1983|
|Summary||Fuel exhaustion due to refueling error|
|Site||Emergency landing at Gimli Industrial Park Airport, Gimli, Manitoba |
|Aircraft type||Boeing 767-233|
|Flight origin||Montreal-Dorval International Airport|
|Stopover||Ottawa Macdonald–Cartier International Airport|
|Destination||Edmonton International Airport|
|Injuries||10 (minor, during evacuation)|
Air Canada Flight 143 was a scheduled domestic passenger flight between Montreal and Edmonton that ran out of fuel on July 23, 1983 at an altitude of 41,000 feet (12,000 m), midway through the flight. The crew was able to glide the Boeing 767 aircraft safely to an emergency landing at a former Royal Canadian Air Force base in Gimli, Manitoba, that had been turned into a motor racing track. This unusual aviation incident earned the aircraft the nickname "Gimli Glider".
The subsequent investigation revealed that a combination of company failures, human errors and confusion over unit measures had led to the aircraft being refuelled with insufficient fuel for the planned flight.
On July 22, 1983, Air Canada's Boeing 767 (registration C-GAUN, c/n 22520/47, fin 604) flew from Toronto to Edmonton where it underwent routine checks. The next day, it was flown to Montreal. Following a crew change, it departed Montreal as Flight 143 for the return trip to Edmonton (with a stopover in Ottawa), with Captain Robert (Bob) Pearson, 48, and First Officer Maurice Quintal, 36, at the controls. Captain Pearson was a highly experienced pilot, having accumulated more than 15,000 flight hours. First Officer Quintal was also very experienced, having logged over 7,000 hours of total flight time.
Running out of fuel
On July 23, 1983, Flight 143 was cruising at 41,000 feet (12,000 m) over Red Lake, Ontario. The aircraft's cockpit warning system sounded, indicating a fuel pressure problem on the aircraft's left side. Assuming a fuel pump had failed, the pilots turned it off, since gravity should feed fuel to the aircraft's two engines. The aircraft's fuel gauges were inoperative because of an electronic fault indicated on the instrument panel and airplane logs.
During the flight, the management computer indicated that there was still sufficient fuel for the flight but only because the initial fuel load had been incorrectly entered; the fuel had been calculated in pounds instead of kilograms by the ground crew and the erroneous calculation had been approved by the flight crew. This error meant that less than half the amount of intended fuel had been loaded. Because the incorrect fuel weight data had been entered into the system, it was providing incorrect readings. A few moments later, a second fuel pressure alarm sounded for the right engine, prompting the pilots to divert to Winnipeg. Within seconds, the left engine failed and they began preparing for a single-engine landing.
As they communicated their intentions to controllers in Winnipeg and tried to restart the left engine, the cockpit warning system sounded again with the "all engines out" sound, a long "bong" that no one in the cockpit could recall having heard before and was not covered in flight simulator training. Flying with all engines out was something that was never expected to occur and had therefore not been covered in training. Seconds later, with the right-side engine also stopped, the 767 lost all power, and most of the instrument panels in the cockpit went blank.
The 767 was one of the first airliners to include an electronic flight instrument system, which operated on the electricity generated by the aircraft's jet engines. With both engines stopped, the system went dead, leaving only a few basic battery-powered emergency flight instruments. While these provided sufficient information with which to land the aircraft, a vertical speed indicator – that would indicate the rate at which the aircraft was descending and therefore how long it could glide unpowered – was not among them.
On airliners the size of the 767, the engines also supply power for the hydraulic systems without which the aircraft cannot be controlled. Such aircraft are therefore required to compensate for this kind of power failure. With the 767, this is usually achieved through the automated deployment of a ram air turbine, a backup generator driven by a propeller rotating because of the forward motion of the aircraft, like a windmill. As the Gimli pilots were to experience on their landing approach, a decrease in this forward speed means a decrease in the power available to control the aircraft.
Landing at Gimli
In line with their planned diversion to Winnipeg, the pilots were already descending through 35,000 feet (11,000 m) when the second engine shut down. They immediately searched their emergency checklist for the section on flying the aircraft with both engines out, only to find that no such section existed. Captain Pearson was an experienced glider pilot, so he was familiar with flying techniques almost never used in commercial flight. To have the maximum range and therefore the largest choice of possible landing sites, he needed to fly the 767 at the optimal glide speed. Making his best guess as to this speed for the 767, he flew the aircraft at 220 knots (410 km/h; 250 mph). First Officer Maurice Quintal began to calculate whether they could reach Winnipeg. He used the altitude from one of the mechanical backup instruments, while the distance travelled was supplied by the air traffic controllers in Winnipeg, measuring the distance the aircraft's echo moved on their radar screens. In 10 nautical miles (19 km; 12 mi) the aircraft lost 5,000 feet (1,500 m), giving a glide ratio of approximately 12:1 (dedicated glider planes reach ratios of 50:1 to 70:1).
At this point, Quintal proposed landing at the former RCAF Station Gimli, a closed air force base where he had once served as a Royal Canadian Air Force pilot. Unbeknown to Quintal or to the air traffic controller, a part of the facility had been converted to a race track complex, now known as Gimli Motorsports Park. It included a road race course, a go-kart track, and a dragstrip. A Canadian Automobile Sport Clubs-sanctioned sports car race hosted by the Winnipeg Sports Car Club was underway at the time of the incident and the area around the decommissioned runway was full of cars and campers. Part of the decommissioned runway was being used to stage the race.
Without power, the pilots used a gravity drop, which causes gravity to lower the landing gear and lock it into place. The main gear locked into position, but the nose wheel did not; this later turned out to be advantageous. As the aircraft slowed on approach to landing, the ram air turbine generated less power, rendering the aircraft increasingly difficult to control.
As the runway drew near, it became apparent that the aircraft was coming in too high and fast, raising the danger of running off the runway before it could be stopped. The lack of hydraulic pressure prevented flap/slat extension that would have, under normal landing conditions, reduced the stall speed of the aircraft and increased the lift coefficient of the wings to allow the aircraft to be slowed for a safe landing. The pilots briefly considered a 360-degree turn to reduce speed and altitude, but decided that they did not have enough altitude for the manoeuvre. Pearson decided to execute a forward slip to increase drag and lose altitude. This manoeuvre is commonly used with gliders and light aircraft to descend more quickly without increasing forward speed.
Complicating matters was the fact that with both of its engines out, the plane made virtually no noise during its approach. People on the ground thus had no warning of the impromptu landing and little time to flee. As the gliding plane closed in on the runway, the pilots noticed that there were two boys riding bicycles within 1,000 feet (300 m) of the projected point of impact. Captain Pearson would later remark that the boys were so close that he could see the looks of sheer terror on their faces as they realized that a commercial airliner was bearing down on them.
Two factors helped avert disaster: the failure of the front landing gear to lock into position during the gravity drop, and the presence of a guardrail that had been installed along the centre of the decommissioned runway to facilitate its use as a race track. As soon as the wheels touched down on the runway, Pearson braked hard, blowing out two of the aircraft's tires. The unlocked nose wheel collapsed and was forced back into its well, causing the aircraft's nose to slam into, bounce off, and then scrape along the ground. This additional friction helped to slow the airplane and kept it from careening into the crowds surrounding the runway. After the aircraft had touched down, the nose began to scrape along the guardrail in the centre of the race track; Pearson applied extra right brake, which caused the main landing gear to straddle the guardrail creating additional drag that further reduced the speed. Air Canada Flight 143 came to a final stop on the ground 17 minutes after running out of fuel.
There were no serious injuries among the 61 passengers or the people on the ground. A minor fire in the nose area was extinguished by racers and course workers armed with fire extinguishers. As the aircraft's nose had collapsed onto the ground, its tail was elevated and there were some minor injuries when passengers exited the aircraft via the rear slides, which were not long enough to sufficiently accommodate the increased height.
The Aviation Safety Board of Canada (predecessor of the modern Transportation Safety Board of Canada) reported that Air Canada management was responsible for "corporate and equipment deficiencies". Their report praised the flight and cabin crews for their "professionalism and skill". It noted that Air Canada "neglected to assign clearly and specifically the responsibility for calculating the fuel load in an abnormal situation." It further found that the airline had failed to reallocate the task of checking fuel load (which had been the responsibility of the flight engineer on older aircraft flown with a crew of three.) The safety board also said that Air Canada needed to keep more spare parts, including replacements for the defective fuel quantity indicator, in its maintenance inventory as well as provide better, more thorough training on the metric system to its pilots and fuelling personnel. The final report of the investigation was published in April 1985.
Fuel quantity indicator system
The amount of fuel in the tanks of a Boeing 767 is computed by the Fuel Quantity Indicator System (FQIS) and displayed in the cockpit. The FQIS on the aircraft was a dual-processor channel, each independently calculating the fuel load and cross-checking with the other. In the event of one failing the other could still operate alone, but under these unusual circumstances the indicated quantity was required to be cross-checked against a floatstick measurement before departure. In the event of both channels failing, there would be no fuel display in the cockpit, and the aircraft would be considered non-serviceable and not authorized to fly.
Because inconsistencies had been found with the FQIS in other 767s, Boeing had issued a service bulletin for the routine checking of this system. An engineer in Edmonton duly did so when the aircraft arrived from Toronto following a trouble-free flight the day before the incident. While conducting this check, the FQIS failed and the cockpit fuel gauges went blank. The engineer had encountered the same problem earlier in the month when this same aircraft had arrived from Toronto with an FQIS fault. He found then that disabling the second channel by pulling the circuit breaker in the cockpit restored the fuel gauges to working order albeit with only the single FQIS channel operative. In the absence of any spares he simply repeated this temporary fix by pulling and tagging the circuit breaker.
A record of all actions and findings was made in the maintenance log, including the entry; "SERVICE CHK – FOUND FUEL QTY IND BLANK – FUEL QTY #2 C/B PULLED & TAGGED...". This reports that the fuel gauges were blank and that the second FQIS channel was disabled, but does not make clear that the latter fixed the former.
On the day of the incident, the aircraft flew from Edmonton to Montreal. Before departure the engineer informed the pilot of the problem and confirmed that the tanks would have to be verified with a floatstick. In a misunderstanding, the pilot believed that the aircraft had been flown with the fault from Toronto the previous afternoon. That flight proceeded uneventfully with fuel gauges operating correctly on the single channel.
On arrival at Montreal, there was a crew change for the return flight back to Edmonton. The outgoing pilot informed Captain Pearson and First Officer Quintal of the problem with the FQIS and passed along his mistaken belief that the aircraft had flown the previous day with this problem. In a further misunderstanding, Captain Pearson believed that he was also being told that the FQIS had been completely unserviceable since then.
While the aircraft was being prepared for its return to Edmonton, a maintenance worker decided to investigate the problem with the faulty FQIS. To test the system he re-enabled the second channel, at which point the fuel gauges in the cockpit went blank. Before he could disable the second channel, however, he was called away to perform a floatstick measurement of fuel remaining in the tanks, leaving the circuit breaker tagged (which masked the fact that it was no longer pulled). The FQIS was now completely unserviceable and the fuel gauges were blank.
On entering the cockpit, Captain Pearson saw what he was expecting to see: blank fuel gauges and a tagged circuit breaker. Pearson consulted the master minimum equipment list (MMEL), which indicated that the aircraft was not legal to fly with blank fuel gauges but due to a misunderstanding, Pearson believed that it was safe to fly if the amount of fuel was confirmed with measuring sticks.
The 767 was still a very new aircraft, having flown its maiden flight in September 1981. C-GAUN was the 47th Boeing 767 off the production line, and had been delivered to Air Canada less than four months previously. In that time period there had been 55 changes to the MMEL, and some pages were blank pending development of procedures.
Because of this unreliability, it had become practice for flights to be authorized by maintenance personnel. To add to his own misconceptions about the condition the aircraft had been flying in since the previous day, reinforced by what he saw in the cockpit, Pearson now had a signed-off maintenance log that it had become custom to prefer over the MMEL.
At the time of the incident, Canada was in the process of converting to the metric system in the aviation sector. As part of this process, the new 767s being acquired by Air Canada were the first to be calibrated for metric units (litres and kilograms) instead of Imperial units (gallons and pounds). All other aircraft were still operating with Imperial units. For the trip to Edmonton, the pilot calculated a fuel requirement of 22,300 kilograms (49,200 lb). A floatstick check indicated that there were 7,682 litres (1,690 imp gal; 2,029 US gal) already in the tanks. To calculate how much more fuel had to be added, the crew needed to convert the volume (litres) in the tanks to a mass (kilograms), subtract that figure from 22,300 kg and convert the result back into a volume. In previous times, this task would have been completed by a flight engineer, but the 767 was the first of a new generation of airliners that flew with only a pilot and co-pilot.
The volume of jet fuel varies with temperature. In this case, the mass of a litre of fuel was 0.803 kg, so the correct calculation was:
- 7,682 litres × 0.8 kg/L = 6,169 kg = mass of fuel already on board
- 22,300 kg − 6,169 kg = 16,131 kg = mass of additional fuel required, or
- 16,131 kg ÷ (0.8 kg/L) = 20,088 litres = volume of additional fuel required
The ground crew, however, used the incorrect conversion factor of 1.77, the mass of a litre of fuel in pounds, and this error was not noticed by the flight crew. The conversion factor provided on the refueller's paperwork was one that had always been used in the past, when Air Canada's fleet had been imperial-calibrated. The calculation that they actually performed was:
- 7,682 litres × 1.77 lb/L = 13,597 lb (because of the incorrect conversion factor, this quantity was interpreted incorrectly as 13,597 kg already on board)
- 22,300 kg − 13,597 kg = 8,703 kg = mass of additional fuel required
- 8,703 kg ÷ (1.77 lb/L) = 4,917 L kg/lb = volume of additional fuel required (because of the incorrect conversion factor, this quantity was interpreted incorrectly as 4,917 L)
Instead of taking on the 20,088 litres of additional fuel that they required, they instead took on only 4,917 litres. The use of the incorrect conversion factor led to a total fuel load of only 22,300 pounds (10,100 kg) rather than the 22,300 kilograms that was needed. This was approximately half the amount required to reach their destination. Knowing the problems with the FQIS, Captain Pearson double-checked their calculations but was given the same incorrect conversion factor and came up with the same erroneous figures.
The flight management computer (FMC) measures fuel consumption, allowing the crew to keep track of fuel burned as the flight progresses. It is normally updated automatically by the FQIS, but in the absence of this facility it can be updated manually. Believing he had 22,300 kg of fuel on board, this is the figure the captain entered.
Because the FMC would reset during the stopover in Ottawa, the captain had the fuel tanks measured again with the floatstick while there. In converting the quantity to kilograms, the same incorrect conversion factor was used, leading him to believe he now had 20,400 kg of fuel; in reality, he had less than half that amount.
Following Air Canada's internal investigation, Captain Pearson was demoted for six months, and First Officer Quintal was suspended for two weeks for allowing the incident to happen. Three maintenance workers were also suspended. In 1985 the pilots were awarded the first ever Fédération Aéronautique Internationale Diploma for Outstanding Airmanship. Several attempts by other crews who were given the same circumstances in a simulator at Vancouver resulted in crashes. Quintal was promoted to captain in 1989. Pearson remained with Air Canada for ten years and then moved to flying for Asiana Airlines; he retired in 1995. First Officer Quintal died at age 68 on September 24, 2015, in Saint-Donat, Quebec.
The aircraft was temporarily repaired at Gimli and flew out two days later to be fully repaired at a maintenance base in Winnipeg. Following a successful appeal against their suspensions, Pearson and Quintal were assigned as crew members aboard another Air Canada flight.
After almost 25 years of service, C-GAUN flew its last revenue flight on January 1, 2008. On January 24, 2008, the Gimli Glider took its final voyage, AC7067, from Montreal Trudeau to Tucson International Airport before flying to its retirement in the Mojave Desert in California.
Flight AC7067 was captained by Jean-Marc Bélanger, a former head of the Air Canada Pilots Association, while captains Robert Pearson and Maurice Quintal were on board to oversee the flight from Montreal to California's Mojave Airport. Also on board were three of the six flight attendants who were on Flight 143.
On July 23, 2008, the 25th anniversary of the incident, pilots Pearson and Quintal were celebrated in a parade in Gimli, and a mural was dedicated to commemorate the landing.
In April 2013, the Gimli Glider was offered for sale at auction, by a company called Collectable Cars, with an estimated price of CA$2.75–3 million. However, bidding only reached CA$425,000 and the lot was unsold.
According to a website dedicated to saving the aircraft, the Gimli Glider was scrapped in early 2014. Parts of the metal fuselage were made into luggage tags and are offered for sale by a California company, Moto Art.
In June 2017, a permanent museum exhibit of the event opened in Gimli. The exhibit includes a cockpit mock-up flight simulator and also sells memorabilia of the event.
In popular culture
Four years after the incident, Canada Post issued a postage stamp commemorating Air Canada. The image on the stamp showed a Boeing 767 as a glider, with no engines. Comparison to photographs of a 767 from a similar viewpoint show that engines would have been visible if they had been present.
The 1995 television movie Falling from the Sky: Flight 174 is loosely based on this event.
The Discovery Channel Canada / National Geographic TV series Mayday covered the incident in a 2008 episode titled Gimli Glider. The episode featured interviews with survivors and a dramatic recreation of the flight.
- Korean Air Cargo Flight 6316
- Air Transat Flight 236
- List of airline flights that required gliding
- Mars Climate Orbiter, which was lost because of a navigation error when a subcontractor used US customary units (pound-seconds) instead of the metric units (newton-seconds) as specified by NASA.
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Air Canada said yesterday that its Boeing 767 jet ran out of fuel in mid-flight last week because of two mistakes in calculating the amount of fuel that would be required for the trip because the 767 was the airline's first aircraft to use metric measurements. After both engines lost power, the pilots made what is now thought to be the first successful emergency "dead stick" landing of a commercial jetliner.
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(The dragstrip began in the middle of the runway with the guardrail extending towards 32L's threshold) Pearson applied extra right brake so the main gear would straddle the guardrail.
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- Engineering Disasters – Lessons to be Learned, Don Lawson, ASME Press, 2005, ISBN 0-7918-0230-2, pages 221–29 deal specifically with Gimli Glider.