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|
|IATA flight No.||AC143|
|ICAO flight No.||ACA143|
|Call sign||AIR CANADA 143|
|Flight origin||Montreal-Dorval International Airport|
|Stopover||Ottawa Macdonald–Cartier International Airport|
|Destination||Edmonton International Airport|
Air Canada Flight 143 was a Canadian 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 successfully glided the Boeing 767 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 accident is commonly blamed on mistaking pounds for kilograms, which resulted in the aircraft carrying only 45% of its required fuel load. However, the units error was the last in a series of failures that aligned in a Swiss cheese model to cause the accident.
The Boeing 767 had a Fuel Quantity Indication System with two redundant channels, but a design flaw caused it to fail if only one channel failed. This caused a much higher failure rate than expected. The FQIS on the aircraft had failed, and Air Canada's only spare FQIS had also failed. A technician applied a temporary workaround to the aircraft's FQIS and logged the repair, but another technician misunderstood the logbook entry and undid the repair. The Boeing 767 may not be flown with inoperative fuel gauges, but a miscommunication led the flight crew to fly using only a dripstick measurement of the fuel tanks. The crew needed to enter the fuel quantity into the flight computer in kilograms , but they mistakenly did the calculation with the density of jet fuel in pounds/litre. The aircraft ran out of fuel halfway to Edmonton, where Air Canada maintenance staff were waiting to install a working FQIS that they had borrowed from another airline.
The Board of Inquiry found fault with Air Canada procedures, training, and manuals. It recommended the adoption of fueling procedures and other safety measures that were already being used by US and European airlines. The Board also recommended the immediate conversion of all Air Canada aircraft from Imperial units to metric units, since a mixed fleet was more dangerous than an all-Imperial or an all-metric fleet.
On July 22, 1983, Air Canada Boeing 767 C-GAUN, underwent routine checks in Edmonton. The technician found a defective Fuel Quantity Indication System, so he disabled the defective channel and made an entry in the logbook. The next morning, Captain John Weir and co-pilot Captain Donald Johnson were told about the problem. Since the FQIS was operating on a single channel, a dripstick reading was taken to obtain a second measurement of fuel quantity. Weir converted the dripstick reading from centimetres to litres to kilograms, finding that it agreed with the FQIS. The plane flew to Toronto and then Montreal without incident.
At Montreal, Captain Bob Pearson and First Officer Maurice Quintal took over the airplane for Flight 143 to Ottawa and Edmonton. During the handover, Weir told Pearson that there was a problem with the FQIS, and Pearson decided to take on enough fuel to fly to Edmonton without refueling in Ottawa. Meanwhile, an avionics technician had entered the cockpit and read the logbook. While waiting for the fuel truck, he enabled the defective channel and performed an FQIS self-test. Distracted by the arrival of the fuel truck, he left the channel enabled after the FQIS failed the self-test. Pearson entered the cockpit to find the FQIS blank, as he expected.
After taking a dripstick measurement, Pearson converted the reading from centimetres to litres to kilograms. However, he did his calculation with the density of jet fuel in pounds/litre instead of kilograms/litre. Since the FQIS was not operational, he entered the reading into the flight management computer (FMC), which tracked the amount of fuel remaining in kilograms. The airplane flew to Ottawa without incident, where another dripstick measurement was taken and converted using the density in pounds/litre. Since the aircraft appeared to have enough fuel to reach Edmonton, no fuel was loaded at Ottawa.
Running out of fuel
While Flight 143 was cruising over Red Lake, Ontario at 41,000 feet (12,000 m), the aircraft's cockpit warning system sounded, indicating a fuel pressure problem on the aircraft's left side. Assuming that a fuel pump had failed, the pilots turned off the alarm, knowing that the engine could be gravity-fed in level flight. A few seconds later, the fuel pressure alarm also sounded for the right engine. This prompted the pilots to divert to Winnipeg.
Within seconds, the left engine failed and the pilots 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 sharp "bong" that no one in the cockpit could recall having heard before. Seconds later, the right-side engine also stopped and the 767 lost all power. Flying with all engines out was something that was never expected to occur, so it had never been covered in training.
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 and most of the screens went blank, leaving only a few basic battery-powered emergency flight instruments. While these provided sufficient information to land the aircraft, the backup instruments did not include a vertical speed indicator that could be used to determine how far the aircraft could glide.
On the Boeing 767, the control surfaces are so large that the pilots cannot move them with muscle power alone. Instead, the hydraulic systems are used to multiply the forces applied by the pilots. Since the engines supply power for the hydraulic systems, the aircraft was designed with a ram air turbine, a backup generator that converts the air flowing past the airplane into electricity. As the Gimli pilots reduced speed for landing, the reduced airflow also meant a decrease in the hydraulic power available.
Landing at Gimli
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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 optimum 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, measured by the aircraft's radar echo observed at Winnipeg. 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 pilot for the Royal Canadian Air Force. Unbeknownst 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 main power, the pilots used a gravity drop, which allows 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 reduced power generated by the ram air turbine rendered the aircraft increasingly difficult to control.
As the plane drew near the runway, it became apparent that the aircraft was coming in too high and fast, raising the danger of the 767 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 airliner to be slowed for a safe landing. The pilots briefly considered a 360-degree turn to reduce speed and altitude, but they 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, performed by "crossing the controls" (applying rudder in one direction and ailerons in the other direction) is commonly used in gliders and light aircraft to descend more quickly without increasing forward speed, but it is practically never executed in large jet airliners outside of rare circumstances like those of this flight.
Complicating matters yet further 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 advance warning of the impromptu landing and little time to flee. As the gliding plane closed in on the decommissioned 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 repurposed runway to facilitate its use as a drag race track. As soon as the wheels touched down on the runway, Pearson braked hard, skidding and promptly 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 crashing into the crowds surrounding the runway. After the airliner had touched down, the nose began to scrape along the guardrail in the centre of the race track, creating additional frictional drag that contributed to the plane's deceleration; Pearson applied extra right brake, which caused the main landing gear to straddle the guardrail. 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. 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. A minor fire in the nose area was extinguished by racers and course workers equipped with portable fire extinguishers.
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 indication system
The amount of fuel in the tanks of a Boeing 767 is computed by the Fuel Quantity Indication 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 in that case, 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. The flight to Montreal 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 again, 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 in which the aircraft had been flying 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.
Miscalculation during fueling
In older aircraft that flew with a three-person crew, the flight engineer kept a fuel log and supervised the fueling. The Boeing 767 belonged to a new generation of aircraft that flew with only a pilot and co-pilot, but Air Canada had not clearly assigned responsibility for supervising the fueling.:64–65 On the day of the accident, two technicians and two pilots worked on the calculation in Montreal. One technician stopped after he found that he wasn't making any progress. Another technician was using a piece of paper that he had in his pocket, and he stopped when he ran out of space. First Office Quintal did the calculation by hand, and Captain Pearson checked the arithmetic with his Jeppesen slide rule.:40–41
Since the FQIS was not working, Captain Pearson decided to take on enough fuel to reach Edmonton without refueling at Ottawa.:26 The flight plan showed that 22,300 kilograms (49,200 lb) of fuel was required for the flight from Montreal to Ottawa to Edmonton. A dripstick check found that there were 7,682 litres (1,690 imp gal; 2,029 US gal) of fuel already in the tanks. To calculate how much fuel the airplane had to take on, he needed to convert the volume (litres) to mass (kilograms), subtract that figure from 22,300 kg, and convert the result back into volume.:41 The density in metric units was 0.803 kg/L, so the correct calculation would have been:
- 7,682 litres × 0.803 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 ÷ (0.803 kg/L) = 20,088 litres = volume of additional fuel required
At the time of the incident, Canada's aviation sector was in the process of converting from Imperial units to the metric system. As part of this process, the new 767s being acquired by Air Canada were the first to be calibrated for metric units.:63–64 The fueler reported that the density of jet fuel at the time was 1.77, which was in pounds/litre since other Air Canada aircraft used pounds. Pearson and Quintal both used the density of jet fuel in lb/L without converting to kg/L::40–41
- 7,682 litres × 1.77 lb/L = 13,597 lb = misinterpreted as kilograms of fuel already on board
- 22,300 kg − 13,597 kg = 8,703 kg = incorrect mass of additional fuel required
- 8,703 kg ÷ (1.77 lb/L) = 4,917 L·kg/lb = misinterpreted as litres of additional fuel required
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 of the amount required to reach their destination.
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 the fuel quantity can also be entered manually. Because the FMC would reset during the stopover in Ottawa, the captain had the fuel tanks measured again with the dripstick. There were 11,430 litres of fuel in the tanks, and the fueler gave the density as 1.78. Repeating the same error, Captain Pearson determined that he had 20,400 kg of fuel and entered this number into the FMC. However, he actually had 20,400 lb (9950 kg) of fuel.:42–43
The previous flight from Edmonton to Montreal had avoided the error. The fueler at Edmonton knew the density of jet fuel in kg/L, and he calculated the correct number of litres to pump into the tanks. He testified that it was a "regular practice of his" to do such calculations. When fueling was complete, Captains Weir and Johnson checked the figures. The captain knew "from previous experience" the density of jet fuel in kg/L. He also had a working FQIS, which agreed with his calculations.:43–44
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 the age of 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 the full repair, the aircraft was returned to service with Air Canada. Following a successful appeal against their suspensions, Pearson and Quintal were assigned as crew members aboard another Air Canada flight.
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.
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, MotoArt.
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.
- Korean Air Cargo Flight 6316
- Air Transat Flight 236
- Ethiopian Airlines Flight 961
- Hapag-Lloyd Flight 3378
- TACA Flight 110
- Ural Airlines Flight 178
- US Airways Flight 1549
- Cathay Pacific Flight 780
- British Airways Flight 38
- 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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- Debooy, Erin (December 16, 2015). "Boeing 767 that landed near Gimli being repurposed into luggage tags". Interlake Spectator, Postmedia. Gimli, Manitoba. Retrieved January 9, 2016.
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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.