Not good for Air Transat and the pilot...

http://news.airwise.com/stories/2004/10/1098162021.html

October 19, 2004

The Canadian pilot who was hailed as a hero for gliding a packed, powerless airliner to an emergency landing in the Azores three years ago made mistakes that allowed all the jet's fuel to drain out through an engine leak, a Portuguese aviation agency said on Monday.

Portugal's Aviation Accidents Prevention and Investigation Department also said improper replacement of a Rolls-Royce engine on the Airbus A330 jet, which was operated by Canadian charter flight operator Air Transat, led to the fuel leak.

Air Transat is owned by leisure travel company Groupe Transat A.T.

Captain Robert Piche avoided calamity for the Air Transat flight's 306 passengers and crew when he flew the big jet for 65 nautical miles (120 km, 75 miles) without power, gliding silently through darkened skies to make a landing-gear-crunching landing at the Lajes Airport in Terceira.

The only injuries -- to 16 passengers and two crew members -- came during the evacuation of the plane on the Lajes runway.

In a statement, Air Transat said it has since improved its maintenance and flight-operations training and procedures.

Piche said the report represents the final chapter in the incident and he would not comment further.

Piche's deft command of the flight's last 19 minutes, when the jet was without engine power, has been cited as one of the finest piloting achievements in modern aerospace.

But in its 103 page report on the "all engines-out landing," the agency suggested Piche's heroics may not have been needed if the crew had followed proper procedures in detecting and dealing with a fuel leak in the right engine.

FAILED TO FOLLOW CHECKLIST

The investigating agency said the crew did not correctly evaluate the engine leak situation, and then did not follow the proper checklist.

Instead of shutting down the fuel lines leading to the right engine, the crew cross-fed fuel from the left engine tanks to the source of the leak. That allowed all of the jet fuel to drain.

"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," the agency said.

The report details the events that led up to the August 24, 2001, flight from Toronto to Lisbon, which took off with more than enough fuel to reach its intended destination.

Problems began days earlier when Air Transat's maintenance crew replaced the jet's right engine with one that had not been retrofitted for an updated configuration.

Air Transat technicians did not review a Rolls-Royce service bulletin that would have indicated a hazard in mismatching fuel and hydraulic lines, the agency said.

As a result, a fuel inlet tube on the newly installed right engine failed after chafing and hard contact with a hydraulic line, the agency said.

About four hours into the flight, the crew noticed unusual oil readings in the right engine, and then a fuel imbalance between the left and right inner-wing tanks.

As the fuel problem worsened, the flight crew diverted to the Azores. About 150 nautical miles from Lajes, the right engine flamed out. Some 13 minutes later, the left engine followed suit.

Flying without engine power, the passenger cabin dark save for emergency lighting, Piche made a 360 degree left turn and other maneuvers to lose altitude. He brought the Airbus down to the Lajes runway, but it bounced back into the air.

On the second hard touchdown, emergency braking locked up the main wheels. The tires quickly shredded and deflated. The wheels began wearing down to their metal bearing journals, causing sparks and small fires.

Evacuation of the jet took only 90 seconds, but some passengers had to be "aggressively encouraged" to leave, while others tried to take their carry-on baggage with them, the agency said.

(Reuters)