On special request of James Berry: AIR TRANSAT FLIGHT 236: FLYING ON EMPTY (this is a true story based on official reports and Air Crash Investigation, written by myself) August 23rd, 2001, Toronto International Airport, Canada, 7:34PM. Canada is in the summer holiday season. The airport is filled with people leaving on a holiday. Air Transat flight 236 will be doing just that. The plane, an Airbus A330-200, is bound for Lisbon, Portugal with 239 passengers, eleven cabin crew members and two pilots aboard. Most of these passengers are Canadian, visiting Europe. The others are Portuguese heading home. The plane is being flown by young First-Officer Dirk De Jager (28). The Captain on the airplane is the very experienced Robert Piché. Both pilots are familiarized with all the technology that comes with it. The flight-deck of the Airbus A330 is ultramodern. Computers and thousands of sensors monitor all the flight systems and critical instruments every second of the flight, from the moment the engines are fired up until they’re being shut down again. In this report, it will become clear how confused a flight crew can be when these systems display unusual readings. At 8:20PM, the plane leaves Toronto with over 46 tons of fuel on board, heading towards Lisbon. The weather forecast for the Atlantic crossing is good. It should be a smooth flight. To avoid possible nasty weather, Air Traffic Control notices the pilots that they will send them sixteen miles off course to the south. This will play a crucial part in the accident. As the Captain speaks to his passengers that the plane has reached its cruising altitude, they settle down for the long Atlantic crossing. A flight of a little over eight hours. As for the men in the cockpit, there is no time for sleep. The general rule for Atlantic crossings is that every 30 minutes they have to double check their position and check if there is still enough fuel on board against their flight plan. Despite all the computerized systems, checking if the fuel is accurate requires human abilities. First-Officer De Jager calculates there is 11.2 tons in both the right and left fuel tank and more fuel in the rear tanks and center tanks. At this point, everything goes as planned. It goes on like that for the first five hours of the flight. But at 5:16AM, one of the computers detects something that isn’t right. It is immidiately displayed to the pilots. The warning on the screen says: “ENGINE 2: OIL TEMP LOW/OIL PRESSURE HIGH”. The pilots are confused. This reading makes no sense as it is theoretically not possible to have a low oil temperature and at the same time a high oil pressure. The only way this reading could be possible is if the oil would be contaminated… with jet fuel. But at the time, this reading was so rare that it wasn’t written down in any manual and the pilots didn’t know that fuel could cause the problem. They are getting so confused, they start to believe that the plane is suffering from a computer error. But still, they keep monitoring the systems very carefully. In the passenger cabin, no one knows about the problem in the cockpit. Twenty minutes later after the first warning, a second warning shows up. This time it reads “FUEL IMBALANCE MONITOR”. The warning on the fuel monitor system shows that the fuel level in the right wing tank is significantly lower than the fuel level in the left wing tank. They want to try to overcome the problem by activating the ‘X CROSS-FEED’ switch. This switch opens a valve between the two tanks allowing fuel to flow from one tank to the other. But before they do that they must be sure the problem is not caused by something more serious, such as a fuel leak. Then the Captain makes a terrible mistake: as they had checked their fuel just fifteen minutes ago and came to the conclusion everything was fine, they rule out a fuel leak. In fact, the leak is huge.. As the pilots do not receive any further warning about a problem, they think their problem is solved. But Co-pilot De Jager is suspicious and decides to carry out a fuel check. What he discovers is dramatic. The fuel quantity has dropped dramatically in fifteen minutes. At this point, they realize they’re plane is leaking fuel fast. Captain Piché sends two stewardesses to check if they can see fuel leaking out of the wing but as it is night, they can’t see anything, even with a flashlight. The pilots now check their fuel every five minutes instead of thirty. And they come to a horrific discovery: they are no longer able to make it to Lisbon and they have to divert. The problem is… they’re in the middle of the Atlantic Ocean. But they are in luck for the first time since the problems started. The military base of Lajes, should be within their reach. In the cabin, passengers still have no indication that something is wrong. But in the cockpit, the fuel readings are getting worse. At 5:48AM, First-Officer De Jager radios Santa Maria Air Traffic Control Center with the message: “Santa Maria Control, Air Transat 236… We’re declaring a fuel emergency. Requesting immediate divert to Lajes Air Force Base.” 6:13AM. Now disaster strikes real hard. Engine number two, the right engine, runs out of fuel and shuts down. The pilots now find themselves in a situation in which no pilot has ever been before: they are about to become a giant glider in the middle of the Atlantic. To compensate for the loss of engine number 2, they set MAX power on engine number one. But on one engine, they can’t keep flying at their high altitude. They must descent very quickly. Due to the loss of engine n°2, the electrical power partly shuts down as well, causing the lights in the passenger cabin to flicker. At this point, the passengers know something isn’t right. 6:26AM. Now Engine N°1 also runs out of fuel. They are now a big glider in the sky. With Lajes still 1h30min away, it seems impossible. Co-Pilot De Jager calls Santa Maria again but with a nastier message: ‘Santa Maria Center Control, Air Transat 236… We’re gliding”. Passengers in the cabin start writing letters to their loved ones and praying that they can walk away from it. Also, with all engines gone the power is gone as well. But the A330 has one last line of defence: the RAM air turbine is a small propeller that will automatically deploy when both engines failed. It provides very limited power resource and hydraulics to control the airplane’s controls and gives very basic and crucial flight instruments. With no engines, the plane loses 1000 feet for every travelled five kilometers. They can reach Lajes but if the pilots make even one tiny mistake, they will have to make a forced water landing on the open Atlantic. In case they run out of options and they will have to land their plane on the water, they ask the passengers to put on their life vests and prepare for an emergency landing on the water. But landing on the water is very dangerous. The chances of survival on impact, are close to zero. Jetliners are not designed to land on the water. The resistance of the water could cause the plane to break apart and drawn the passengers inside. At Lajes Airport, the Fire Departement and other emergency services prepare for the crash landing of the incoming A330. For the pilots, there is absolutely no room for error. Missing the runway would be dramatic. As they descent towards the airport, their airspeed increases dangerously. If they go too fast, they might overshoot the runway and still end up severely wounded or worse. They need to find a way to descent and slow down, quickly. They finally manage to slow down. At 200 knots, they can lower their landing gear. As the hydraulics provided by the RAM air turbine is reserved for the flight controls, it doesn’t bring down the landing gear. They will have to use the emergency lever bringing down the gear using earth’ gravity. Also all the braking systems such as: flaps, spoilers and thrust reversers are out of order. In other words, even if they make it onto the runway, the danger will be far from over. They must land at a very low speed. 6:46AM: Air Transat flight 236 crashlands on the runway of Lajes airport, way too fast. Now the pilots’ new goal is stopping the plane before they reach the end of the runway, or they will fall into a cliff making a 400 foot drop into the ocean. Using foot brakes only, the pilots manage to make the plane stop in the middle of the runway. Everyone is ordered to leave the airplane as quickly as possible. When the crew starts to count heads they come to the best of discoveries ever: everyone survived. Now the investigation starts. The first questions that are being asked are: how could a state of the art airplane simply run out of fuel in mid Atlantic? The Aviation Accidents Prevention and Investigation Department (Portugal) investigates the case in cooperation with Canadian and French authorities. They discover that the accident was caused by the installation of an incorrect part in the hydraulics system of the Airbus A330. During a complete maintenance procedure, the maintenance crew discovered that the number two engine was too old and had to be replaced. They replaced it with an older version lent by Rolls-Royce. But this older type of engine did not include a hydraulic pump. Despite the lead mechanics 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 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. Eric Auxier Morgan Miesse Nassim Ouairem Mark Stoorza Mary Ann Laverty Daniel Dunne Hadee Alhassanawi
Posted on: Wed, 21 Jan 2015 00:01:20 +0000
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