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{{Short description|2001 aircraft emergency incident}}
'''Air Transat Flight 236''' was an ] route between ] and ] flown by ] Robert Piché and co-pilot Dick Dejager. On ], ], the flight ran out of fuel over the ] with 306 (293 passengers + 13 crew) people on board.
{{Use Canadian English|date=June 2020}}
{{Use mdy dates|date=April 2012}}
{{Infobox aircraft occurrence
| occurrence_type = Accident
| name = Air Transat Flight 236
| image = Airbus A330-243, Air Transat AN0062859.jpg
| image_upright = 1.15
| alt =
| caption = C-GITS, the aircraft involved, seen in 1999, 2 years before the incident
| date = {{start date|2001|08|24}}
| type = ] due to fuel leak
| site = ],<br/>], ], ]
| coordinates = {{Coord|42.733|N|23.083|W|type:event|display=inline,title}}
| occupants = 306
| passengers = 293
| crew = 13
| fatalities = 0
| injuries = 18 (16 minor, 2 major)
| survivors = 306
| aircraft_type = ]
| tail_number = C-GITS
| origin = ], ], ], Canada
| destination = ], ], Portugal
| operator = ]
| callsign = TRANSAT 236 HEAVY
| IATA = TS236
| ICAO = TSC236
}}


'''Air Transat Flight 236''' was a ] bound for ], Portugal, from ], Canada, that lost all engine power while flying over the ] on August 24, 2001. The ] ran out of fuel because of a fuel leak caused by improper maintenance. Captain ], 48, an experienced ] pilot, and ] Dirk DeJager, 28, glided the plane to a successful ] in the ], saving the lives of all 306 people (293 passengers and 13 crew) on board.<ref name="heroism">{{cite news|last=Crossette|first=Barbara|date=September 10, 2001|title=Jet Pilot Who Saved 304 Finds Heroism Tainted|work=The New York Times|url=https://www.nytimes.com/2001/09/10/world/jet-pilot-who-saved-304-finds-heroism-tainted.html|access-date=August 21, 2007|issn=0362-4331}}</ref> Most of the passengers on the flight were Canadians visiting Europe or Portuguese ]s returning to visit family in Portugal. This was also the longest ] without engines, gliding for nearly {{convert|65|nmi|km mi}}. Following this unusual aviation accident, this aircraft was nicknamed the "'''Azores Glider'''".
==Sequence of events==


== Aircraft ==
From the '''Air Transat press release''' dated October 17, 2004.
The aircraft involved was an Airbus A330-243 ] as C-GITS. The aircraft was just over two years old and was equipped with two ] engines.<ref>{{Cite web |title=ASN Aircraft accident Airbus A330-243 C-GITS Terceira-Lajes AFB, Azores (LFB) |url=https://aviation-safety.net/database/record.php?id=20010824-1 |access-date=2024-03-22 |website=aviation-safety.net}}</ref>


==Incident==
Flight TS 236 took off from Toronto at 8.52 pm (EST) on Thursday, August 23, 2001; it made an emergency landing at 6.45 am (UTC, or ]) on August 24, 2001, at ], ], ], ].
Flight 236 took off from Toronto at 00:52 (]) on Friday, August&nbsp;24, 2001 (local time: 20:52&nbsp;(]) on Thursday, August&nbsp;23), bound for Lisbon, Portugal, with 293&nbsp;passengers and 13 ] on board. The flight was flown by Captain ], who had 16,800&nbsp;hours of flight experience (with 796 of them on the Airbus A330),<ref name="report"/>{{rp|12}} and First Officer Dirk DeJager, who had 4,800&nbsp;flight hours (including 386&nbsp;hours on the Airbus A330).<ref name="report"/>{{rp|12}} The aircraft was a two-year-old ] ] as {{Airreg|C|GITS}} that had first flown on March&nbsp;17, 1999,<ref name="airfleets">{{cite web|url=http://www.airfleets.net/ficheapp/plane-a330-271.htm|title=Airbus A330 – MSN 271 – C-GITS: General information & flightlog|website=airfleets.net|access-date=June 16, 2018}}</ref> configured with 362&nbsp;seats and placed in service by Air Transat on April&nbsp;28, 1999.<ref name="airfleets"/> It was powered by two ] engines each capable of delivering {{convert|71100|lbf|kN|abbr=on}} ]. Leaving the gate in Toronto, the aircraft had {{convert|46.9|t|lb}} of fuel on board, {{convert|4.5|t|lb}} more than required by regulations.<ref name="report">{{cite web |date=December 17, 2004 |title=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 |url=http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-PT.pdf |access-date=December 26, 2016 |publisher=]}}</ref>


At 04:38 UTC (almost four hours into the flight), the aircraft began to leak fuel through a fracture that had developed in a fuel line to the no.&nbsp;2 (right) engine.<ref name="report"/>{{rp|23}} At 05:03&nbsp;UTC, more than four hours into the flight, the pilots noticed low oil temperature and high oil pressure on engine no.&nbsp;2.<ref name="report"/>{{rp|7,23}} Although these readings were an indirect result of the fuel leak, the pilots had no reason to consider that as a cause. Consequently, Captain Piché suspected they were false warnings and shared that opinion with Air Transat maintenance control centre in Montreal, which advised them to monitor the situation.<ref name="report"/>{{rp|56}}
There were 293 passengers and 13 crew members onboard. Sixteen passengers and two crew members were injured during the evacuation of the aircraft. All injuries were minor or very minor, except for two passengers who suffered serious, but non life-threatening, injuries. The aircraft was an ] manufactured in 1999, configured with 362 seats and put into service by Air Transat in April of 1999. Leaving the gate in Toronto, the aircraft had 47.9 tonnes of fuel on board; 5.5 tonnes over and above the fuel required by regulations.


===Indications of a fuel problem===
#It has been estimated that a fuel leak started at 4.38 am (UTC), approximately four hours into the flight.
#At 5.45 am (UTC, or Coordinated Universal Time) the pilots made a decision to divert the flight to the Azores.
#At 6.13 am (UTC) the right engine flamed out.
#At 6.26 am (UTC) the left engine flamed out. What followed is a 19-minute glide, over a distance of 65 nautical miles (approximately 120 km).
#At 6.45 am (UTC) or 2.45 am (EST) the aircraft landed at Lajes Airport, on the island of Terceira, at an estimated speed of 200 knots (370 km/h). An emergency evacuation of the aircraft was ordered and took place in 90 seconds.


#The fuel on board was decreasing at an unusual rate which was displayed in the Fuel-On-Board (FOB) quantity on the Engine Warning Display.
==Incident==
#The estimated fuel on board at destination would have been showing as decreasing indicating reduced fuel range.
Unknown to the pilots, the ] had developed a fuel leak in its right engine. During the course of the flight, the pilots had noticed a fuel imbalance between the fuel tanks in the left and right wings of the aircraft and had attempted to remedy this by opening a cross-feed valve between the tanks. This only caused fuel from the operational tank to be wasted through the leak in the other tank.
#The full forward transfer of the fuel in the trim tank was premature given the fuel load on departure from Toronto of {{convert|46900|kg|lb}}. A prolonged, 19-minute TRIM TANK XFR memo between 05:11 and 05:30, and then the TRIM TANK XFRD memo between 05:30 and 05:33 would have displayed this information.<ref name="US FAA">{{cite web |title=Air Transat Flight TSC236, C-GITS Lajes, Azores, Portugal August 24, 2001 |url=https://www.faa.gov/lessons_learned/transport_airplane/accidents/C-GITS |publisher=US Federal Aviation Administration |access-date=4 September 2023}}{{PD-notice}}</ref>


At 05:36 UTC, the pilots received a warning of fuel imbalance.<ref> MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES Aviation Accidents Prevention and Investigation Department 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 p 74</ref>
Without fuel, an airplane's engines cannot operate to provide thrust or power the electrical generators. As all large commercial aircraft, the flight controls of the Airbus are hydraulically powered: without operating engines the plane is dependent on the emergency ] to allow the aircraft to be flown.


Rather than referring to the appropriate checklists, the crew actioned procedures from memory, and this resulted in the cross-feeding of fuel into an already leaking engine.
The emergency turbine deploys automatically in the event of power loss, and provides enough power to operate the flight controls, basic instrumentation and radio. However, many important systems are not available in this situation, including flaps and main brakes. Additionally, an aircraft without operating engines cannot use ] to slow down.


The transferred fuel was lost through the fractured fuel line, which was leaking at about 13 tonnes per hour (more than 3.6&nbsp;kg/s). This caused a higher-than-normal fuel flow through the fuel-oil heat exchanger, which in turn led to a drop in oil temperature and a rise in oil pressure for the no.&nbsp;2 engine.<ref name="report" /><ref name="FOHE">{{cite web|url=http://www.rvs.uni-bielefeld.de/publications/compendium/incidents_and_accidents/Ladkin-AirTransat.pdf|title=Air Transat Flight 236: The Azores Glider|access-date=July 27, 2010}}</ref>


{{Location map+|North Atlantic|relief=1|caption=Flight 236's departure, original destination, and ultimate destination|width=200|places=
The pilots on the airplane, an ], were able to glide the plane to a landing at ], ] in the ]. The reported landing speed was 370 ], which is higher that the normal speed of 210 to 260 km/h. The incident had no fatalities, but there were some minor injuries. The favorable outcome of the incident was also due to the flight being rerouted on a more southerly route across the Atlantic due to congestion, bringing them closer to the Azores.
{{Location map~|North Atlantic|lon_dir=W|lat_dir=N|lat_deg=38|lat_min=45|lat_sec=20|lon_deg=27|lon_min=05|lon_sec=10|label=Azores|position=bottom}}
{{Location map~|North Atlantic|lon_dir=W|lat_dir=N|lat_deg=43|lat_min=42|lat_sec=59|lon_deg=79|lon_min=20|lon_sec=26|label=Toronto|position=top}}
{{Location map~|North Atlantic|lon_dir=W|lat_dir=N|lat_deg=38|lat_min=42|lat_sec=50|lon_deg=9|lon_min=8|lon_sec=21|label=Lisbon|position=top}}
}}

At 05:45 UTC, the pilots decided to divert to ] in the ]. Initially there was a 14 degree heading deviation from their assigned heading of 230 degrees magnetic caused by the autopilot being in true heading mode. After 2 minutes Santa Maria Oceanic air traffic control radioed ‘Transat 236 heavy maintain 230 magnetic heading'. This transmission was not acknowledged, however the aircraft turned to the correct heading. They declared a fuel emergency with Santa Maria Oceanic air traffic control three minutes after the heading was corrected.<ref name="report" />

At 06:13 UTC, while still {{convert|150|nmi}} from Lajes and at {{convert|39000|ft|m}}, engine no.&nbsp;2 ] from fuel starvation.<ref name="report" /> Piché then initiated a descent to {{convert|33000|ft|m}}, which was the proper single-engine altitude for the weight of the plane at that time. Ten minutes later, the crew sent a ] to Santa Maria Oceanic air traffic control.<ref name="report" />

Thirteen minutes later, at 06:26 UTC and about {{convert|65|nmi}} from Lajes Air Base, engine no.&nbsp;1 also flamed out, requiring the plane to glide the remaining distance.<ref name="report"/>{{rp|8}} Without engine power, the plane lost its primary source of electrical power. The emergency ] deployed automatically to provide essential power for critical sensors and ]s to fly the aircraft as well as enough hydraulic pressure to operate the primary ] (without which the aircraft would be uncontrollable). The aircraft lost hydraulic power for the ], alternate brakes, and ]. The ] would still be powered, while the primary brakes would be able to operate a limited number of times using pressure stored in the brake ]. With neither engine running, there was no source of ] to maintain cabin pressurization. Five minutes later, at 06:31&nbsp;UTC, the oxygen masks dropped down in the passenger cabin.<ref name="report" />{{rp|9}}

Military air traffic controllers guided the aircraft to the airport with their radar system. The descent rate of the plane was about {{convert|2000|ft/min|0|abbr=on}}. They calculated they had about 15 to 20&nbsp;minutes left before they would be forced to ]. The air base was sighted a few minutes later. Piché executed one 360° turn, and then a series of "S" turns, to dissipate excess altitude.

At 06:45 UTC, the plane touched down hard, around {{convert|1030|ft|m|abbr=on}} past the threshold of runway&nbsp;33, at a speed around {{convert|200|kn}}, bounced once, and then touched down again, roughly {{convert|2800|ft|m|abbr=on}} from the threshold. Maximum emergency braking was applied and retained, and the plane came to a stop after a landing run that consumed {{convert|7600|ft|m|abbr=on}} of the {{convert|10000|ft|m|adj=on}} runway. Because the antiskid and brake modulation systems were inoperative,{{efn|The on/off cycling produced by the antiskid system would rapidly deplete the limited pressure in the brake accumulator if it remained operative.}} the eight ] locked up, the tires abraded and fully deflated within {{convert|450|ft|m|abbr=on}}, and the wheels themselves were worn down to the axle journals during rollout.<ref name="report"/>{{rp|11}}

Fourteen passengers and two crew members had minor injuries, while two passengers had serious injuries during the evacuation of the aircraft. The plane suffered structural damage to the main landing gear (from the hard touchdown and the abrasion of the locked wheels against the runway surface during the landing roll) and the lower ] (both structural deformation from the hard touchdown and various punctures from impact by pieces of debris shed from the main landing gear).


==Investigation== ==Investigation==
]The Portuguese ] (GPIAA) investigated the accident along with Canadian and French authorities.<ref name="Empty">] – S01E03 – {{YouTube|id=wPJaMfVQG9Q|title=Flying On Empty Air Transat flight 236}}</ref>
The investigation revealed the cause of the accident was a fuel leak in the number two engine, caused by an incorrect fitting part in the ] system being installed in the engine by Air Transat maintenance. The part did not maintain adequate clearance between the hydraulic lines and the fuel line. This allowed vibration in the hydraulic lines to eventually degrade the fuel line and cause the leak. Air Transat accepted responsibility for the incident and was fined $250,000 by the Canadian government.


The investigation revealed that the primary causal factors of the accident were crew actions in mishandling a fuel leak in the no. 2 engine.<ref>MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES Aviation Accidents Prevention and Investigation Department
Although pilot error was listed as one of the causes for the incident, it should be noted that it was the skill of the pilots which allowed the flight to land without fuel and causing only minor injuries and damages to the airplane (which is still in service). The pilots returned to a heroes' welcome in the Canadian press.
Accident Investigation Final Report
All Engines-out Landing Due to Fuel Exhaustion Air A330-243 marks C-GITS Lajes, Azores, Portugal
24 August 2001 </ref>


The fuel leak resulted from fitment of an incorrect part to the ] system by Air Transat maintenance staff as part of routine maintenance.<ref name="Empty"/> The engine had been replaced with a spare engine, lent by ], from an older model which did not include a hydraulic pump. Despite the lead mechanic's concerns, Air Transat authorized 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, of the order of millimetres from the intended part,<ref name="Empty"/> allowed chafing between the lines to rupture the fuel line, causing the leak.
The incident also led to a change in the checklists for the A330, stressing that crews should check that any fuel imbalance is not caused by a fuel leak before opening the cross-feed valve.


Air Transat accepted responsibility for the accident and was fined ]250,000 by the Canadian government, which {{As of|2009|lc=on}} was the largest fine in Canadian history.<ref name="Empty"/>
==Dramatization==
A documentary in the ''Mayday'' series called "Flying on Empty" was made about this incident and aired in ]. The National Geographic Channel's documentary series ''Air Crash Investigation'' also covered the incident in series 1 episode 6 entitled ''Flying on Empty''.


The conclusions reached in the accident report revealed that:
In addition, the story of Flight 236 was featured in ]'s cable network series "Air Emergency". The story was told by several passengers who were on the flight, and cockpit voice recordings gave actors playing the crew insight as to the events on the plane. Actual crew members declined to be interviewed for the program.

*The flight crew did not detect that a fuel problem existed until the Fuel ADV advisory was displayed and the fuel imbalance was noted on the Fuel ECAM page.
*The crew did not correctly evaluate the situation before taking action.
*The flight crew did not recognize that a fuel leak situation existed and carried out the fuel imbalance procedure from memory, which resulted in the fuel from the left tanks being fed to the leak in the right engine.
*Conducting the FUEL IMBALANCE procedure by memory negated the defence of the Caution note in the FUEL IMBALANCE checklist that may have caused the crew to consider timely actioning of the FUEL LEAK procedure.
*Although there were a number of other indications that a significant fuel loss was occurring, the crew did not conclude that a fuel leak situation existed – not actioning the FUEL LEAK procedure was the key factor that led to the fuel exhaustion.<ref>MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES
GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES
Aviation Accidents Prevention and Investigation Department 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 </ref>

Nevertheless, the pilots returned to a heroes' welcome from ] as a result of their successful unpowered landing. In 2002, Captain Piché was awarded the ] by the ].<ref>{{cite web|url=http://www.aero-news.net/index.cfm?do=main.textpost&id=8c64b4a7-4084-4f96-be6d-d141966b95ba|website=Aero News Network|publisher=Aero News Network|access-date=December 26, 2016|date=26 August 2002|title=Robert Piché Given Award}}</ref>

== Aftermath ==
Following the accident investigation, the French ] (DGAC) issued F-2002-548B, requiring a detailed fuel-leak procedure in the flight manual and the need for crews to be aware of this.<ref>{{Cite web|title=F-2002-548R2 : Fuel leak procedure|url=https://ad.easa.europa.eu/ad/F-2002-548R2|website=ad.easa.europa.eu|access-date=2020-05-06}}</ref> This was later cancelled and replaced by F-2005-195.<ref>{{Cite web|title=F-2005-195 Fuel - Fuel Leak procedure|url=https://ad.easa.europa.eu/ad/F-2005-195|website=ad.easa.europa.eu|access-date=2020-05-06}}</ref> The US ] (FAA) issued AD 2006-02-01, effective February 3, 2006, requiring new airplane flight manual procedures to follow in the event of a fuel leak for Airbus Model A330 and A340 aircraft.<ref>{{cite web |title=Airworthiness Directives; Airbus Model A330-200 and -300 Series Airplanes, Model A340-200 and -300 Series Airplanes, and Model A340-541 and A340-642 Airplanes |url=https://lessonslearned.faa.gov/AirTransat236/AD2006-02-01.pdf |publisher=US Federal Aviation Administration |access-date=4 September 2023 |archive-url=https://web.archive.org/web/20161222142741/https://lessonslearned.faa.gov/AirTransat236/AD2006-02-01.pdf |archive-date=22 December 2016}}</ref>

The accident led to the DGAC and FAA issuing an ] (AD),<ref>{{Cite web|title=Airbus Model A318-100, A319-100, A320- 200, A321-100|url=http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/3b2d4350048640a0862570e4006843e4!OpenDocument|publisher=Federal Aviation Administration|url-status=dead|archive-url=https://web.archive.org/web/20070313030807/http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgad.nsf/0/3b2d4350048640a0862570e4006843e4!OpenDocument|archive-date=March 13, 2007|access-date=2020-05-06}}</ref> requiring all operators of ] models ], ], ] and ] narrow-body aircraft to revise their flight manuals, stressing that crews should ensure that any fuel imbalance is not caused by a fuel leak before opening the cross-feed valve. The AD required all airlines operating these Airbus models to make revisions to the flight manuals 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 fuel is being expended beyond the specified fuel consumption rate of the engines. Rolls-Royce also issued a bulletin advising of the incompatibility of the relevant engine parts.

This was the longest ] without engines.<ref>{{Cite web|date=2020-08-14|title=How a civilian aircraft in distress set a world glider record|url=https://www.wearethemighty.com/mighty-history/aircraft-set-world-glider-record/|access-date=2021-05-25|website=We Are The Mighty|language=en-US}}</ref> The aircraft was repaired and returned to service with Air Transat in December 2001,{{citation needed|date=July 2018}} with the nickname "Azores Glider".<ref name="FOHE" /> It was placed into storage on March 17, 2020 because of the ]. On October 18, 2021, the aircraft made its last flight with Air Transat and was subsequently returned to the lessor ]. The aircraft was re-registered as N271AD, and scrapped at end-of-life in May 2024. <ref>{{Cite web|title=N271AD AERCAP AIRBUS A330-200| url=https://www.planespotters.net/airframe/airbus-a330-200-n271ad-aercap/rzq0zr |access-date=2024-12-23|website=planespotters.net|language=en-US}}</ref> <ref>{{Cite web|title=Air Transat Fleet Details|url= https://www.airfleets.net/flottecie/Air%20Transat-stored-a330.htm |access-date=2024-12-23|website=airfleets.net |language=en-US}}</ref>

Margaret McKinnon, a ] ] student at Baycrest Health Sciences in Toronto at the time, was a passenger on her honeymoon on Flight 236. She and her colleagues recruited 15 other passengers in a study of ] (PTSD), published in August 2014 in the academic journal '']'', which compared details recalled by passengers with PTSD with those recalled by passengers without PTSD and with a control group.<ref>{{cite web|url=https://www.cbc.ca/news/health/ptsd-clues-gleaned-from-passengers-on-terrifying-flight-1.2734768|title=PTSD clues gleaned from passengers on terrifying flight|date=August 14, 2014|website=]}}</ref><ref>{{Cite journal|last1=McKinnon|first1=Margaret C.|last2=Palombo|first2=Daniela J.|last3=Nazarov|first3=Anthony|last4=Kumar|first4=Namita|last5=Khuu|first5=Wayne|last6=Levine|first6=Brian|date=July 1, 2015|title=Threat of Death and Autobiographical Memory – A Study of Passengers From Flight AT236|journal=]|publisher=]|language=en|volume=3|issue=4|pages=487–502|doi=10.1177/2167702614542280|pmid=26167422|issn=2167-7026|pmc=4495962}}</ref><ref>{{cite journal| url=https://www.wired.com/story/remember-disaster-without-being-shattered-ptsd-covid/ |title=How to Remember a Disaster Without Being Shattered by It|date=February 23, 2021|journal=]|last1=Hayasaki|first1=Erika}}</ref>

==Dramatizations==
* The events of Flight 236 were featured in "Flying on Empty", a ] (2003) episode of the Canadian TV series '']''<ref>{{Cite episode|title=Flying on Empty|series=]|network=] / ]|season=1|number=6|year=2003}}</ref> (called ''Air Emergency'' and ''Air Disasters'' in the U.S. and ''Air Crash Investigation'' in the UK and elsewhere around the world). The flight was also included in a ''Mayday'' ] (2007) ''Science of Disaster'' special titled "Who's Flying the Plane?"<ref>{{Cite episode|title=Who's Flying the Plane?|series=]|network=] / ]|season=6|number=3|year=2007}}</ref>
* ] produced a report on the incident with the title "On a Wing and a Prayer", which first aired in the U.S. on August 7, 2005.<ref>{{cite web|url=http://www.tvguide.com/tvshows/msnbc-reports/episode-4853462/390086/|title=On a Wing and a Prayer (download)|work=MSNBC Reports|access-date=March 26, 2018}}</ref>
* The story of Robert Piché is depicted in the 2010 ] biographical drama film '']'' culminating with the events on Flight 236.<ref name="cinoche">{{cite web|title=''Entre ciel et terre'' review|url=http://www.cinoche.com/films/piche-entre-ciel-et-terre/index.html|website=cinoche.com|language=fr|url-status=live|archive-url=https://web.archive.org/web/20100722104525/http://www.cinoche.com/films/piche-entre-ciel-et-terre/index.html|archive-date=July 22, 2010|access-date=July 1, 2010}}</ref> Captain Piché is portrayed by both ]-winning actor ] and his son Maxime LeFlaguais.


==See also== ==See also==
{{Portal|Canada|Portugal|Aviation}}
*], involving a ] emergency landing without fuel.
*], the "Miracle on the Hudson" – glided after both engines were disabled by a bird strike
*], the "Gimli Glider" – glided after running out of fuel
*] – glided after water ingestion in both engines in a storm
*]

==Notes==
{{notelist}}

==References==
{{reflist}}


==External links== ==External links==
* from the ] (, , <!--, --><!-- -->)
*
* {{in lang|pt}}
*
*"" ( ). '']''. October 17, 2004.
*{{ASN accident|id=20010824-1}}
* *
*"." ]<!--Old URL: http://www.cbc.ca/stories/2001/08/25/world/airtransat_010825-->. Sunday August 26, 2001.
]
* {{in lang|fr}}
]
*
]
* on ]

<br />
{{Aviation accidents and incidents in Portugal}}
{{Aviation accidents and incidents in 2001}}

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Latest revision as of 18:51, 31 December 2024

2001 aircraft emergency incident

Air Transat Flight 236
C-GITS, the aircraft involved, seen in 1999, 2 years before the incident
Accident
DateAugust 24, 2001 (2001-08-24)
SummaryFuel exhaustion due to fuel leak
SiteLajes Airport/Air Force Base,
Terceira Island, Azores, Portugal
42°43′59″N 23°04′59″W / 42.733°N 23.083°W / 42.733; -23.083
Aircraft
Aircraft typeAirbus A330-243
OperatorAir Transat
IATA flight No.TS236
ICAO flight No.TSC236
Call signTRANSAT 236 HEAVY
RegistrationC-GITS
Flight originToronto Pearson International Airport, Toronto, Ontario, Canada
DestinationPortela Airport, Lisbon, Portugal
Occupants306
Passengers293
Crew13
Fatalities0
Injuries18 (16 minor, 2 major)
Survivors306

Air Transat Flight 236 was a transatlantic flight bound for Lisbon, Portugal, from Toronto, Canada, that lost all engine power while flying over the Atlantic Ocean on August 24, 2001. The Airbus A330 ran out of fuel because of a fuel leak caused by improper maintenance. Captain Robert Piché, 48, an experienced glider pilot, and First Officer Dirk DeJager, 28, glided the plane to a successful emergency landing in the Azores, saving the lives of all 306 people (293 passengers and 13 crew) on board. Most of the passengers on the flight were Canadians visiting Europe or Portuguese expatriates returning to visit family in Portugal. This was also the longest passenger aircraft glide without engines, gliding for nearly 65 nautical miles (120 km; 75 mi). Following this unusual aviation accident, this aircraft was nicknamed the "Azores Glider".

Aircraft

The aircraft involved was an Airbus A330-243 registered as C-GITS. The aircraft was just over two years old and was equipped with two Rolls-Royce Trent 772B-60 engines.

Incident

Flight 236 took off from Toronto at 00:52 (UTC) on Friday, August 24, 2001 (local time: 20:52 (ET) on Thursday, August 23), bound for Lisbon, Portugal, with 293 passengers and 13 crew on board. The flight was flown by Captain Robert Piché, who had 16,800 hours of flight experience (with 796 of them on the Airbus A330), and First Officer Dirk DeJager, who had 4,800 flight hours (including 386 hours on the Airbus A330). The aircraft was a two-year-old Airbus A330-243 registered as C-GITS that had first flown on March 17, 1999, configured with 362 seats and placed in service by Air Transat on April 28, 1999. It was powered by two Rolls-Royce Trent 772B-60 engines each capable of delivering 71,100 lbf (316 kN) thrust. Leaving the gate in Toronto, the aircraft had 46.9 tonnes (103,000 lb) of fuel on board, 4.5 tonnes (9,900 lb) more than required by regulations.

At 04:38 UTC (almost four hours into the flight), the aircraft began to leak fuel through a fracture that had developed in a fuel line to the no. 2 (right) engine. At 05:03 UTC, more than four hours into the flight, the pilots noticed low oil temperature and high oil pressure on engine no. 2. Although these readings were an indirect result of the fuel leak, the pilots had no reason to consider that as a cause. Consequently, Captain Piché suspected they were false warnings and shared that opinion with Air Transat maintenance control centre in Montreal, which advised them to monitor the situation.

Indications of a fuel problem

  1. The fuel on board was decreasing at an unusual rate which was displayed in the Fuel-On-Board (FOB) quantity on the Engine Warning Display.
  2. The estimated fuel on board at destination would have been showing as decreasing indicating reduced fuel range.
  3. The full forward transfer of the fuel in the trim tank was premature given the fuel load on departure from Toronto of 46,900 kilograms (103,400 lb). A prolonged, 19-minute TRIM TANK XFR memo between 05:11 and 05:30, and then the TRIM TANK XFRD memo between 05:30 and 05:33 would have displayed this information.

At 05:36 UTC, the pilots received a warning of fuel imbalance.

Rather than referring to the appropriate checklists, the crew actioned procedures from memory, and this resulted in the cross-feeding of fuel into an already leaking engine.

The transferred fuel was lost through the fractured fuel line, which was leaking at about 13 tonnes per hour (more than 3.6 kg/s). This caused a higher-than-normal fuel flow through the fuel-oil heat exchanger, which in turn led to a drop in oil temperature and a rise in oil pressure for the no. 2 engine.

Air Transat Flight 236 is located in North AtlanticAzoresAzoresTorontoTorontoLisbonLisbonclass=notpageimage| Flight 236's departure, original destination, and ultimate destination

At 05:45 UTC, the pilots decided to divert to Lajes Air Base in the Azores. Initially there was a 14 degree heading deviation from their assigned heading of 230 degrees magnetic caused by the autopilot being in true heading mode. After 2 minutes Santa Maria Oceanic air traffic control radioed ‘Transat 236 heavy maintain 230 magnetic heading'. This transmission was not acknowledged, however the aircraft turned to the correct heading. They declared a fuel emergency with Santa Maria Oceanic air traffic control three minutes after the heading was corrected.

At 06:13 UTC, while still 150 nautical miles (280 km; 170 mi) from Lajes and at 39,000 feet (12,000 m), engine no. 2 flamed out from fuel starvation. 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.

Thirteen minutes later, at 06:26 UTC and about 65 nautical miles (120 km; 75 mi) from Lajes Air Base, engine no. 1 also flamed out, requiring the plane to glide the remaining distance. Without engine power, the plane lost its primary source of electrical power. The emergency ram air turbine deployed automatically to provide essential power for critical sensors and flight instruments to fly the aircraft as well as enough hydraulic pressure to operate the primary flight controls (without which the aircraft would be uncontrollable). The aircraft lost hydraulic power for the flaps, alternate brakes, and spoilers. The slats would still be powered, while the primary brakes would be able to operate a limited number of times using pressure stored in the brake accumulator. With neither engine running, there was no source of bleed air to maintain cabin pressurization. Five minutes later, at 06:31 UTC, the oxygen masks dropped down in the passenger cabin.

Military air traffic controllers guided the aircraft to the airport with their radar system. The descent rate of the plane was about 2,000 ft/min (610 m/min). 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. Piché executed one 360° turn, and then a series of "S" turns, to dissipate excess altitude.

At 06:45 UTC, the plane touched down hard, around 1,030 ft (310 m) past the threshold of runway 33, at a speed around 200 knots (370 km/h; 230 mph), bounced once, and then touched down again, roughly 2,800 ft (850 m) from the threshold. Maximum emergency braking was applied and retained, and the plane came to a stop after a landing run that consumed 7,600 ft (2,300 m) of the 10,000-foot (3,000 m) runway. Because the antiskid and brake modulation systems were inoperative, the eight main wheels locked up, the tires abraded and fully deflated within 450 ft (140 m), and the wheels themselves were worn down to the axle journals during rollout.

Fourteen passengers and two crew members had minor injuries, while two passengers had serious injuries during the evacuation of the aircraft. The plane suffered structural damage to the main landing gear (from the hard touchdown and the abrasion of the locked wheels against the runway surface during the landing roll) and the lower fuselage (both structural deformation from the hard touchdown and various punctures from impact by pieces of debris shed from the main landing gear).

Investigation

Air Transat Flight 236 after the emergency landing

The Portuguese Aviation Accidents Prevention and Investigation Department (GPIAA) investigated the accident along with Canadian and French authorities.

The investigation revealed that the primary causal factors of the accident were crew actions in mishandling a fuel leak in the no. 2 engine.

The fuel leak resulted from fitment of an incorrect part to the hydraulics system by Air Transat maintenance staff as part of routine maintenance. The engine had been replaced with a spare engine, lent by Rolls-Royce, from an older model which did not include a hydraulic pump. Despite the lead mechanic's concerns, Air Transat authorized 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, of the order of millimetres from the intended part, allowed chafing between the lines to rupture the fuel line, causing the leak.

Air Transat accepted responsibility for the accident and was fined C$250,000 by the Canadian government, which as of 2009 was the largest fine in Canadian history.

The conclusions reached in the accident report revealed that:

  • The flight crew did not detect that a fuel problem existed until the Fuel ADV advisory was displayed and the fuel imbalance was noted on the Fuel ECAM page.
  • The crew did not correctly evaluate the situation before taking action.
  • The flight crew did not recognize that a fuel leak situation existed and carried out the fuel imbalance procedure from memory, which resulted in the fuel from the left tanks being fed to the leak in the right engine.
  • Conducting the FUEL IMBALANCE procedure by memory negated the defence of the Caution note in the FUEL IMBALANCE checklist that may have caused the crew to consider timely actioning of the FUEL LEAK procedure.
  • Although there were a number of other indications that a significant fuel loss was occurring, the crew did not conclude that a fuel leak situation existed – not actioning the FUEL LEAK procedure was the key factor that led to the fuel exhaustion.

Nevertheless, the pilots returned to a heroes' welcome from the Canadian press as a result of their successful unpowered landing. In 2002, Captain Piché was awarded the Superior Airmanship Award by the Air Line Pilots' Association.

Aftermath

Following the accident investigation, the French Directorate General for Civil Aviation (DGAC) issued F-2002-548B, requiring a detailed fuel-leak procedure in the flight manual and the need for crews to be aware of this. This was later cancelled and replaced by F-2005-195. The US Federal Aviation Administration (FAA) issued AD 2006-02-01, effective February 3, 2006, requiring new airplane flight manual procedures to follow in the event of a fuel leak for Airbus Model A330 and A340 aircraft.

The accident led to the DGAC and FAA issuing an airworthiness directive (AD), requiring all operators of Airbus models A318, A319, A320 and A321 narrow-body aircraft to revise their flight manuals, stressing that crews should ensure that any fuel imbalance is not caused by a fuel leak before opening the cross-feed valve. The AD required all airlines operating these Airbus models to make revisions to the flight manuals 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 fuel is being expended beyond the specified fuel consumption rate of the engines. Rolls-Royce also issued a bulletin advising of the incompatibility of the relevant engine parts.

This was the longest passenger aircraft glide without engines. The aircraft was repaired and returned to service with Air Transat in December 2001, with the nickname "Azores Glider". It was placed into storage on March 17, 2020 because of the COVID-19 pandemic. On October 18, 2021, the aircraft made its last flight with Air Transat and was subsequently returned to the lessor AerCap. The aircraft was re-registered as N271AD, and scrapped at end-of-life in May 2024.

Margaret McKinnon, a postdoctoral psychology student at Baycrest Health Sciences in Toronto at the time, was a passenger on her honeymoon on Flight 236. She and her colleagues recruited 15 other passengers in a study of post-traumatic stress disorder (PTSD), published in August 2014 in the academic journal Clinical Psychological Science, which compared details recalled by passengers with PTSD with those recalled by passengers without PTSD and with a control group.

Dramatizations

  • The events of Flight 236 were featured in "Flying on Empty", a season-one (2003) episode of the Canadian TV series Mayday (called Air Emergency and Air Disasters in the U.S. and Air Crash Investigation in the UK and elsewhere around the world). The flight was also included in a Mayday sixth season (2007) Science of Disaster special titled "Who's Flying the Plane?"
  • MSNBC produced a report on the incident with the title "On a Wing and a Prayer", which first aired in the U.S. on August 7, 2005.
  • The story of Robert Piché is depicted in the 2010 French Canadian biographical drama film Piché: The Landing of a Man culminating with the events on Flight 236. Captain Piché is portrayed by both Genie Award-winning actor Michel Côté and his son Maxime LeFlaguais.

See also

Notes

  1. The on/off cycling produced by the antiskid system would rapidly deplete the limited pressure in the brake accumulator if it remained operative.

References

  1. Crossette, Barbara (September 10, 2001). "Jet Pilot Who Saved 304 Finds Heroism Tainted". The New York Times. ISSN 0362-4331. Retrieved August 21, 2007.
  2. "ASN Aircraft accident Airbus A330-243 C-GITS Terceira-Lajes AFB, Azores (LFB)". aviation-safety.net. Retrieved March 22, 2024.
  3. ^ "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" (PDF). Portuguese Aviation Accidents Prevention and Investigation Department. December 17, 2004. Retrieved December 26, 2016.
  4. "Canadian Civil Aircraft Register (C-GITS)". Transport Canada.
  5. ^ "Airbus A330 – MSN 271 – C-GITS: General information & flightlog". airfleets.net. Retrieved June 16, 2018.
  6. "Air Transat Flight TSC236, C-GITS Lajes, Azores, Portugal August 24, 2001". US Federal Aviation Administration. Retrieved September 4, 2023.Public Domain This article incorporates text from this source, which is in the public domain.
  7. MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES Aviation Accidents Prevention and Investigation Department 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 p 74
  8. ^ "Air Transat Flight 236: The Azores Glider" (PDF). Retrieved July 27, 2010.
  9. ^ Mayday – S01E03 – Flying On Empty Air Transat flight 236 on YouTube
  10. MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES Aviation Accidents Prevention and Investigation Department Accident Investigation Final Report All Engines-out Landing Due to Fuel Exhaustion Air A330-243 marks C-GITS Lajes, Azores, Portugal 24 August 2001
  11. MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES Aviation Accidents Prevention and Investigation Department 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
  12. "Robert Piché Given Award". Aero News Network. Aero News Network. August 26, 2002. Retrieved December 26, 2016.
  13. "F-2002-548R2 : Fuel leak procedure". ad.easa.europa.eu. Retrieved May 6, 2020.
  14. "F-2005-195 Fuel - Fuel Leak procedure". ad.easa.europa.eu. Retrieved May 6, 2020.
  15. "Airworthiness Directives; Airbus Model A330-200 and -300 Series Airplanes, Model A340-200 and -300 Series Airplanes, and Model A340-541 and A340-642 Airplanes" (PDF). US Federal Aviation Administration. Archived from the original (PDF) on December 22, 2016. Retrieved September 4, 2023.
  16. "Airbus Model A318-100, A319-100, A320- 200, A321-100". Federal Aviation Administration. Archived from the original on March 13, 2007. Retrieved May 6, 2020.
  17. "How a civilian aircraft in distress set a world glider record". We Are The Mighty. August 14, 2020. Retrieved May 25, 2021.
  18. "N271AD AERCAP AIRBUS A330-200". planespotters.net. Retrieved December 23, 2024.
  19. "Air Transat Fleet Details". airfleets.net. Retrieved December 23, 2024.
  20. "PTSD clues gleaned from passengers on terrifying flight". CBC.ca. August 14, 2014.
  21. McKinnon, Margaret C.; Palombo, Daniela J.; Nazarov, Anthony; Kumar, Namita; Khuu, Wayne; Levine, Brian (July 1, 2015). "Threat of Death and Autobiographical Memory – A Study of Passengers From Flight AT236". Clinical Psychological Science. 3 (4). SAGE Publications: 487–502. doi:10.1177/2167702614542280. ISSN 2167-7026. PMC 4495962. PMID 26167422.
  22. Hayasaki, Erika (February 23, 2021). "How to Remember a Disaster Without Being Shattered by It". wired.com.
  23. "Flying on Empty". Mayday. Season 1. Episode 6. 2003. Discovery Channel Canada / National Geographic Channel.
  24. "Who's Flying the Plane?". Mayday. Season 6. Episode 3. 2007. Discovery Channel Canada / National Geographic Channel.
  25. "On a Wing and a Prayer (download)". MSNBC Reports. Retrieved March 26, 2018.
  26. "Entre ciel et terre review". cinoche.com (in French). Archived from the original on July 22, 2010. Retrieved July 1, 2010.

External links


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