By PAUL KORING
POSTED AT 5:58 AM EDT Monday, Oct 18, 2004
The harrowing, engines-out, emergency landing of a Canadian airliner
that ran out of fuel over the Atlantic Ocean three years ago could have
been avoided if the Air Transat pilots had followed established
fuel-leak procedures, the official report into the accident concludes.
Instead of a near-disaster, a routine diversionary landing with plenty
of fuel remaining would have resulted if proper produces were followed,
Portugal's Aviation Accidents Prevention and Investigation Department
Passengers aboard Air Transat's Airbus A-330 cheered and applauded
Captain Robert Piché as a hero after he slammed the unpowered jet onto
the runway at Lajes air base in the Azores after gliding for 19 minutes
after the second engine failed.
But accident investigators determined that the pilots turned a fuel leak
into a near-disaster by failing to recognize it and trying to correct
from memory -- rather than by following a checklist -- what they
believed was a weight imbalance, during which time they pumped tonnes of
The Globe and Mail obtained a copy of the Portuguese final report into
the Aug. 24, 2001, accident. The report is expected to be released
Efforts to contact Air Transat yesterday for comment about the findings
Capt. Piché's extraordinary airmanship, including making a steep,
360-degree turn only a few kilometres from the threshold of the Lajes
runway to lose sufficient height, then gliding to a landing, impressed
the Portuguese investigators.
"The captain's skill in conducting the engines-out glide to a successful
landing averted a catastrophic accident and saved the lives of the
passengers and crew," the report says.
However, the report makes clear that such heroics would not have been
needed had the pilots shut down the right-side engine (where the fuel
was leaking) or had not pumped tonnes of fuel from the undamaged left
wing into the right-wing tanks, from where it was poured overboard at
more than three kilograms a second.
"Either of these actions would have conserved the fuel in the left-wing
tanks and allowed for a landing at Lajes with the left engine
operating," the report says.
Instead, "opening the crossfeed valve put the fuel in the left tank at
risk, and initiated a worsening of the serious fuel-leak situation."
The crew failed to comprehend that the aircraft had a major fuel leak,
even after the second engine died.
"Notwithstanding indications that there had been a massive loss of fuel,
the crew did not believe that there was an actual fuel leak," the report
says. Instead, the crew believed they were dealing with a computer
Details of the flight-crew conversations were lost to investigators
because the pilots inadvertently recorded over the 90-minute cockpit
voice tape after the landing.
Investigators established that fuel began leaking from the twin-engined,
wide-bodied jet more than an hour before the pilots noticed anything
amiss. When they did, they treated the problem as a fuel imbalance and
failed to heed the checklist warning of fuel-leak possibility.
They did not call up the checklist on the computer screen, relying
instead on memory for their actions. Fifteen minutes later, with the
fuel level dropping alarmingly and below the minimum needed to reach
Lisbon, the crew elected to divert to the Azores. But they continued to
transfer the dwindling fuel from the left wing to the leaking right
At 6:13 a.m., with the aircraft more than 240 kilometres from Lajes, the
right-side engine flamed out for lack of fuel. At 6:23, the crew radioed
a full-scale mayday. Flight attendants were told to prepare the
passengers for a ditching. Three minutes later, more than 100 kilometres
from the nearest land, the left engine flamed out. During the next 19
minutes, in darkness and with only limited instruments, Capt. Piché
nursed the unpowered aircraft to a landing.
Investigators determined that the fuel leak was caused by improper
installation of the right-side engine nearly a week earlier. Air Transat
technicians, dealing with a slightly different model of Rolls-Royce
engine than they were familiar with, had improperly attached fuel and
hydraulic lines to the engine. The lines chafed, eventually fracturing
the fuel line.
The report says that the Air Transat flight crew were inadequately
prepared to recognize and deal with fuel leaks.
"The flight crew members had never experienced a fuel leak situation
during operations or training," the report says, adding the "lack of
training in the symptoms of fuel-leak situations resulted in this crew
not being adequately prepared."
Link to Earlier Extensive Coverage