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Wrong Fuel Indicator Caused Tuninter ATR 72 Crash  
User currently offlineCURLYHEADBOY From Italy, joined Feb 2005, 940 posts, RR: 2
Posted (9 years 3 weeks 5 days 9 hours ago) and read 14256 times:

First evidence from the investigation:

Both ATR and the Italian Safety Board (ANSV) agree that at least one atr42 fuel indicator was mounted on the crashed aircraft (which was a 72), causing wrong fuel reading and leading to fuel exhaustion.  Wow!

The aircraft ditched at sea off the coast of Sicily after both engines failed, 16 casualties.

This seems a gross mistake to me! How could such a thing happen???  Confused


If God had wanted men to fly he would have given them more money...
46 replies: All unread, showing first 25:
 
User currently offlineDogfighter2111 From United Kingdom, joined Nov 2004, 1968 posts, RR: 1
Reply 1, posted (9 years 3 weeks 5 days 9 hours ago) and read 14237 times:

Bad maintenance. Things go wrong with aircraft a lot. I was watching a TV program and they said that there is hardly ever 100% of the aircraft functioning properly when in flight. Basically, what i am trying to say is that this was one of those times when a mandatory part is required to function properly.

Thanks
Mike


User currently offlineAogdesk From United States of America, joined Jun 2004, 935 posts, RR: 3
Reply 2, posted (9 years 3 weeks 5 days 8 hours ago) and read 14209 times:

And as in any incident or accident, investigators will conclude that not a single point of failure (fuel indicator) but a series of discrete failures and events led to the crash.

User currently offlineApathoid From , joined Dec 1969, posts, RR:
Reply 3, posted (9 years 3 weeks 5 days 7 hours ago) and read 14116 times:

Source please.


Mindless filler...mindless filler...mindless filler...


User currently offlineOPNLguy From , joined Dec 1969, posts, RR:
Reply 4, posted (9 years 3 weeks 5 days 7 hours ago) and read 14089 times:

Quoting Apathoid (Reply 3):
Source please.

http://www.ansa.it/main/notizie/fdg/...2220212018/200509062220212018.html

In Italian... (Use babelfish.com to translate)

Apparently, an ATR-72 part, andnot an ATR-42 part was installed the night before in Tunis.


User currently offlineM404 From United States of America, joined Nov 2003, 2227 posts, RR: 5
Reply 5, posted (9 years 3 weeks 5 days 6 hours ago) and read 14026 times:
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Aside from the size difference in acft can anyone specify the differance in indictors? Was this the fuel totalizer that shows just that, the total on board or a fuel tank gauge?


Less sarcasm and more thought equal better understanding
User currently offlineOPNLguy From , joined Dec 1969, posts, RR:
Reply 6, posted (9 years 3 weeks 5 days 6 hours ago) and read 13982 times:

Quoting OPNLguy (Reply 4):
Apparently, an ATR-72 part, and not an ATR-42 part was installed the night before in Tunis.

My not-so-high-speed fingers managed to mangle that: should have been:

"Apparently, an ATR-42 part, and not an ATR-72 part was installed the night before in Tunis."


User currently onlineEZEIZA From Argentina, joined Aug 2004, 4967 posts, RR: 25
Reply 7, posted (9 years 3 weeks 5 days 6 hours ago) and read 13921 times:

Quoting OPNLguy (Reply 6):
"Apparently, an ATR-42 part, and not an ATR-72 part was installed the night before in Tunis."

This is terrible! It seems like one of the most avoidable accidents I've heard of. One thing is to have a malfunction of any sort, that happens, and always will, but something so basic as this should just not happen...  mad 



Carp aunque ganes o pierdas ...
User currently offlinePPVRA From Brazil, joined Nov 2004, 8964 posts, RR: 39
Reply 8, posted (9 years 3 weeks 5 days 5 hours ago) and read 13881 times:

Shouldn't the ground crew have noticed the low amount of fuel? Maybe the "cheap" gas bill?


"If goods do not cross borders, soldiers will" - Frederic Bastiat
User currently offlineEMBQA From United States of America, joined Oct 2003, 9364 posts, RR: 11
Reply 9, posted (9 years 3 weeks 5 days 5 hours ago) and read 13851 times:

Sounds more like a fuel probe issue and not a gauge. The gauge only shows what the probe tells it. If you miss calabrate or install the wrong probe in the wrong location it will give you false readings.


"It's not the size of the dog in the fight, but the size of the fight in the dog"
User currently offlineStirling From Italy, joined Jun 2004, 3943 posts, RR: 21
Reply 10, posted (9 years 3 weeks 5 days 4 hours ago) and read 13805 times:

I tend to agree with EMBQA.
But it only opens up more questions....

The probe sends to the gauge the fuel level as a mV. (let's just say it does)

So let's just say this probe sends to the gauge the following values:

-42 FULL = 4mV = 40 gallons
-72 FULL = 4mV = 80 gallons

So in this example, hypothetically, if the guage in -42 cockpit was receiving 4mV from the sensor, it would indicate Full, when in fact, it was only half full.
Either because they had a -72 sensor, or the sensor was faulty, maybe it was picking up an overload current?
But wouldn't that have tripped the breakers?

It's not this simple in reality, I just tried to illustrate how different parts from seemingly similar aircraft can mess things up.

Questions.

Did not the re-fueling crew notice? Or did they just stop fueling when the FO waved them since as far as he was concerned his instruments showed full?

Does Turinter operate both ATR 42 and 72?

Who does their maintenence? Was it done in Italy? When was it last done? Because if it has been awhile...it would have shown up on it's very first flight after leaving the shed; would it not? It had to have made it from Tunis, so did they bring fuel with them so they wouldn't need to gas up in Italy...this maybe makes sense.

How did one odd-ball part get into the supply chain?

Are the investigators certain it was a wrong part?


Still Many Questions left unanswered



Delete this User
User currently offlineRojo From Spain, joined Sep 2000, 2455 posts, RR: 9
Reply 11, posted (9 years 3 weeks 5 days 4 hours ago) and read 13789 times:

Quoting EZEIZA (Reply 7):
This is terrible! It seems like one of the most avoidable accidents I've heard of. One thing is to have a malfunction of any sort, that happens, and always will, but something so basic as this should just not happen...

I will give the number one spot of avoidable accidents to Aeroperu's B757 crash in the Atlantic Ocean back in 1996. Someone forgot to take the masking tape from the static ports after the aircraft was washed and polished and therefore caused wrong readings in the instruments and the death of 70 people...

More attention to detail!!!


User currently offlineF27XXX From , joined Dec 1969, posts, RR:
Reply 12, posted (9 years 3 weeks 5 days 3 hours ago) and read 13767 times:

where was it flying frm/to?

User currently offlineCURLYHEADBOY From Italy, joined Feb 2005, 940 posts, RR: 2
Reply 13, posted (9 years 3 weeks 4 days 21 hours ago) and read 13586 times:

Quoting F27XXX (Reply 12):
where was it flying frm/to?

Was routing Bari Palese , BRI (Italy) - Djerba, DJE (Tunisia).

Quoting Stirling (Reply 10):
The probe sends to the gauge the fuel level as a mV. (let's just say it does)

So let's just say this probe sends to the gauge the following values:

-42 FULL = 4mV = 40 gallons
-72 FULL = 4mV = 80 gallons

So in this example, hypothetically, if the guage in -42 cockpit was receiving 4mV from the sensor, it would indicate Full, when in fact, it was only half full.
Either because they had a -72 sensor, or the sensor was faulty, maybe it was picking up an overload current?
But wouldn't that have tripped the breakers?

That's what happened, apparently. Anyway i agree the wrongly installed device was probably the probe and not the indicator itself.

Quoting Stirling (Reply 10):
Are the investigators certain it was a wrong part?

They first investigated the fuel system, since it appeared that the aircraft was out of fuel when it ditched (Wings floating easily, no fuel tracks in the water) and they immediately noticed that the part number of the device (media say the indicator but, again, it was probably the probe) was wrong (an Atr42 part).

Also, the part was substituted the day before because it was malfunctioning.

The pilot (who survived) says he made some unplanned refuelling prior to takeoff, so it appears he was pretty sure he had enough fuel.

Maintenance was performed in Tunisia, Tuninter operates both ATR42 and 72 AFAIK.

[Edited 2005-09-07 11:58:31]


If God had wanted men to fly he would have given them more money...
User currently offlineOrion737 From , joined Dec 1969, posts, RR:
Reply 14, posted (9 years 3 weeks 4 days 21 hours ago) and read 13574 times:

Did the first officer or a member of the cabin crew survive? Was the ATR72 bcarrying 2 cabin staff members? Are all the surviving passengers recovering well?

User currently offlineCURLYHEADBOY From Italy, joined Feb 2005, 940 posts, RR: 2
Reply 15, posted (9 years 3 weeks 4 days 21 hours ago) and read 13549 times:

Quoting Orion737 (Reply 14):
Did the first officer or a member of the cabin crew survive? Was the ATR72 bcarrying 2 cabin staff members? Are all the surviving passengers recovering well?

Both pilots survived with minor injuries, the surviving passengers are also out of the hospital and recovering well. Sadly both cabin crew members died.



If God had wanted men to fly he would have given them more money...
User currently offlineShenzhen From United States of America, joined Jun 2003, 1710 posts, RR: 2
Reply 16, posted (9 years 3 weeks 4 days 21 hours ago) and read 13539 times:

This is quite strange, as the fueler would have been infrormed to upload X amount of fuel, and if that amount wasn't uploaded, the discrepancy should have been noted (if the airplane refuel system had an automatic shutoff), as they also use their own guages as a cross check.

Generally speaking of course.. as each airport in every country is different.


User currently offlineCURLYHEADBOY From Italy, joined Feb 2005, 940 posts, RR: 2
Reply 17, posted (9 years 3 weeks 4 days 21 hours ago) and read 13526 times:

Quoting Shenzhen (Reply 16):
This is quite strange, as the fueler would have been infrormed to upload X amount of fuel, and if that amount wasn't uploaded, the discrepancy should have been noted

This is very true, and i'm sure the refuelling staff in BRI will soon have some headache.

Nevertheless this already happened, IIRC the famous "Gimli Glider" incident was caused by wrong refuelling...



If God had wanted men to fly he would have given them more money...
User currently offlineBestWestern From Hong Kong, joined Sep 2000, 7165 posts, RR: 57
Reply 18, posted (9 years 3 weeks 4 days 20 hours ago) and read 13470 times:

Very similar issue in Ireland in 2003 on an ATR42 - Fuel exhaustion due to faulty gague leading to the shut down of one engine in flight.

The Irish avation authority had quite a detailed report here http://www.aaiu.ie/AAIUviewitem.asp?id=6875&lang=ENG&loc=1652


"The aircraft was in the cruise, routing from Luton Airport (EGGW) in the UK, to Galway (EICM), when the RH engine spooled down and stopped. The crew made a PAN call to Shannon ATC. They initially considered diverting to Dublin (EIDW) or Belfast (EGAA) but these were closed due to fog. They then decided to divert to Shannon (EINN) and landed there safely on one engine. The Investigation subsequently found that the RH engine stopped because the fuel tank feeding this engine was empty. The Investigation makes six Safety Recommendations.



The world is really getting smaller these days
User currently offlineAR1300 From Argentina, joined Feb 2005, 1740 posts, RR: 3
Reply 19, posted (9 years 3 weeks 4 days 20 hours ago) and read 13449 times:

Quoting F27XXX (Reply 12):
where was it flying frm/to?



Quoting CURLYHEADBOY (Reply 13):
Was routing Bari Palese , BRI (Italy) - Djerba, DJE (Tunisia).

I think he meant the Aeroperu 757.
Aeroperu 603 was coming from SCL, making a stop over in LIM on the route to LAX.The plane fell on the Pacific Ocean,as the crew fighted to fly the plane blinfolded due to the aformentioned ground staff error.

Mike



They don't call us Continental for nothing.
User currently offlineGreasespot From Canada, joined Apr 2004, 3084 posts, RR: 20
Reply 20, posted (9 years 3 weeks 4 days 20 hours ago) and read 13434 times:

Quoting CURLYHEADBOY (Reply 13):
Anyway i agree the wrongly installed device was probably the probe and not the indicator itself.

Um The article says Gauge not probe, so I am wondering how someone who is not connected to tuniter air or the investigation can make such a statment that it was a probe and not a gauge.

They said the wrong gauge was installed the night before which would be easy to determine as the Maintenance release tag would indicate the PN of the gauge and would be in the A/C records. If it was the probe it would have cause a problem before this. Now it has been a while since I worked on an ATR but a fuel probe replacement is not an overnight maintenance item. If they changed this the AC would have been down longer than overnight.

GS



Sometimes all you can do is look them in the eye and ask " how much did your mom drink when she was pregnant with you?"
User currently offlineBackfire From Germany, joined Oct 2006, 0 posts, RR: 0
Reply 21, posted (9 years 3 weeks 4 days 20 hours ago) and read 13362 times:

Quoting BestWestern (Reply 18):
Very similar issue in Ireland in 2003 on an ATR42 - Fuel exhaustion due to faulty gague leading to the shut down of one engine in flight.

That's not actually true. The captain of that aircraft screwed up the refuelling because he didn't know how to operate the manual fuelling system on the ATR, and dumped the entire fuel uplift into one wing.

The aircraft had plenty of fuel on board, just all in one wing tank rather than equally shared between the two.

The faulty fuel gauge was simply a red herring. The crew knew about the fault - the issue was that the functioning fuel gauge was subsequently assumed to be faulty as well, because it showed zero fuel in one of the wing tanks, when in fact it was reading correctly.


User currently offlineCure From Italy, joined Sep 2005, 227 posts, RR: 0
Reply 22, posted (9 years 3 weeks 4 days 17 hours ago) and read 12846 times:

I read on Repubblica of Aug 8 2005, page 5 (www.repubblica.it, though I can't find it right now), that the aircraft left Tunis saturday, empty and full of fuel, at 12:05pm, came to BRI (Bari) at 2:05pm, underwent a routine-technical inspection made by the crew and rampers for 20 min, and took off as loaded- UG1151 at 2:35pm to DJE. Documents showed a small refill of kg 240 of fuel ordered by the captain in Bari, "since the plane was already almost full".
When I first read the article this question already came to my mind: wich is the fuel consumption of an empty ATR72 (cockpit and cabin crew of 3) on the leg DJE-BRI?
From my ignorant point of view just 240 kg of fuel consumption is not imaginable on such a leg, wich leads my thoughts to a suspect of bad interpretation of the captain (beside malfunctioning gauges...)

Can anyone add informations and know-how?...

thanks


User currently offlineDAYflyer From United States of America, joined Sep 2004, 3807 posts, RR: 3
Reply 23, posted (9 years 3 weeks 4 days 17 hours ago) and read 12808 times:

I would hate to be the mechanic who worked on that bird! Can you immagine how terrible it would feel to know you caused the deaths of so many people?


One Nation Under God
User currently offlineCURLYHEADBOY From Italy, joined Feb 2005, 940 posts, RR: 2
Reply 24, posted (9 years 3 weeks 4 days 17 hours ago) and read 12693 times:

Quoting Cure (Reply 22):
From my ignorant point of view just 240 kg of fuel consumption is not imaginable on such a leg, wich leads my thoughts to a suspect of bad interpretation of the captain (beside malfunctioning gauges...)

It appears that those 240kg were extra fuel (maybe some strong headwind was expected on route) added. Of course there must have been some bad interpretation, but this was likely caused by wrong instrument reading.

The chain of events looks like this:

-Mechs mounted an Atr42 fuel gauge on a -72
-Both cockpit and ground crews didn't identify or underestimated the problem
-Aircraft took off with less fuel than necesary
-Engines flamed out enroute

[Edited 2005-09-07 16:02:48]


If God had wanted men to fly he would have given them more money...
25 1aMLA : I flew on Tuniters ATR's for years and started to recongize most of the cabin crew, so it's sad that a couple of them are dead now, it's very sad. I w
26 Post contains links and images AIR MALTA : Tuninter is now banned from flying over Italy... Very sad news!!! http://www.alertnet.org/thenews/newsdesk/L07592551.htm That is the begininng of the
27 Stirling : Very important observation... Usually, in cases like this, it isn't just one event that leads to tragic consequences, but rather an interconnected ch
28 Okie : My observation is that the probe output is calibrated for its length with scaling done at the gauge. In a hypothetical situation that for instance wit
29 CURLYHEADBOY : Stirling, Okie: Thanks for your professional observations, even though we're speculating I have the feeling that the final findings will be very close
30 Francoflier : Wait a sec... It seems that only one fuel indicator (or gauge) was not rightfully installed. OK. What about the other one? I don't know the ATR, but l
31 CURLYHEADBOY : Francoflier, This is still not clear, we're in the first phase of the investigation. Some say one wrong fuel indicator was installed, others say both.
32 HT1000 : FDAU and DFDR are supplied by batteries in case of both DC GEN loss.
33 Post contains images CURLYHEADBOY : Who knows better than you? I stand corrected BTW, what's your thought on this accident, since you fly this type?
34 Stirling : Good point. There isn't a single gauge measuring the total fuel load, but rather; each tank has it's own gauge, like a lorrie, (semi/long-haul truck.
35 Celticmanx : The ATR's have two digital fuel gauges for each tank: one on the cockpit and the other one in the refuelling control panel in the RH side of the plane
36 HT1000 : According to JP Airline-Fleets the aircraft was TS-LBB ATR 72-202 MSN 258 Built in 1992 Delivered in March 1992 As far as you know which quantity of
37 Celticmanx : How much fuel did they really have before the return flight if the amount showed in the gauge was not the actual one? That was the second step of a nu
38 Post contains links CURLYHEADBOY : This clarifies some of the questions we were asking ourselves, have a read if you're interested. http://www.ansv.it/En/Detail.asp?ID=524
39 TS-IOR : Is it official and effective that Tuninter is now banned from the Italian airspace ? A nightmare for any Tunisian airline to be banned from the adjace
40 Okie : The wing tanks of the ATR-72 and ATR-42 differ in terms of max fuel capacity and shape; as a consequence the FQIs for the ATR-72 and for the ATR-42 ar
41 AIR MALTA : Yes it is unfortunately official... It is a nightmare for an airline for which Italy makes for 60% of its operation... All flights are now operated b
42 TS-IOR : The mechanicer that may had made the mistake would face tough pursues. Such a mess reaches the interest of the highest Tunisian administration, the pr
43 ME AVN FAN : if true, whomever caused this has to be prosecuted for multiple killing by negligence " target=_blank>http://www.alertnet.org/thenews/news...1.htm no
44 Backfire : Ultimately this aircraft didn't crash because the fuel gauge was reading incorrectly. It crashed because there was no fuel left in the tanks. An aircr
45 TS-IOR : The indicators had been installed the day before the accident, and before the journey to Bari, the aircraft should have made a TUN-DJE domestic flight
46 CURLYHEADBOY : They didn't ban all Tunisian aircrafts, just Tuninter. If an airline suffers a crash and there is some first evidence indicating that poor maintenanc
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