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Air Transat 'Glider' Pilot Made Errors - Report

Wed Oct 20, 2004 10:20 pm

Not good for Air Transat and the pilot...

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.


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.

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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 2:18 am

It sounds like everyone made mistakes at Air Transat.

I just hope that the lessons have been learned.

I this Air Transat's first incident, I do not recall any others.

They will not be joining my avoid list.
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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 2:28 am

Does anyone know what the aircraft's registration was?
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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 2:46 am

It was C-GITS.

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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 3:13 am

Whilst we must leave it to the experts to determine the cause of the incident and apportion blame, I think it stinks of the classic "combination of factors" that resulted in failure and it would be wrong to attribute all blame to Captain Piche and his co-pilot even if they did make a misjudgement. It started in the maintenance and the irregular replacement of an engine, and I think the engineers and Air Transat maintenance and management are as guilty as the flight deck crew.

Did not the problems with Eastern TriStar that crashed into the Everglades start with a faulty instrument that distracted the flight crew's attention? This and other similar incidents all point to a combination of errors and misjudgements resulting in a major incident.

There was an interesting documentary recently shown on Channel 5 in the UK that gave an insight into the Azores incident.

I have asked the question before in a previous thread, but nobody answered, does the A330 in this incident hold the record for the longest powerless flight of a large passenger aircraft?

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RE: Air Transat 'Glider' Pilot Made Errors - Repor

Thu Oct 21, 2004 3:18 am

This near-accident was featured on the National Geographic show "Air Emergency" some time ago, and they called out these same errors on the show. Apparently the captain assumed the strange fuel readings he was getting were caused by a computer problem. He didn't believe his instruments. This is a mistake you see a lot in accidents that end up being attributed to pilot error - pilots not trusting their instruments, not following procedures and instead trying to fly based on instinct. You can't do that in a large airliner.

They did try to check for a fuel leak by looking for any visible streams of fuel off the wing, but it was dark and they couldn't see anything. No doubt this helped convince the captain that it was a computer problem. The first officer, as I recall, was more concerned than the captain but was overruled.

Still, it was great skill in the end to land this plane safely. It doesn't quite make up for the earlier mistakes but it is a bit of redemption. I don't think this captain is the hero he was originally made out to be, but when things got really tough he did manage to get it together and save a lot of people from his own mistake.
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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 3:47 am

"I this Air Transat's first incident, I do not recall any others"

37.000 gallons of jet fuel came out of the plane because of the leak.
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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 4:52 am

On the site it says:

"The aircraft sustained minor damage during the landing, including damage to the landing gear as twelve tires exploded upon touchdown."

So they even blew the spare tires inside the cargo hold? Boy that really WAS a hard landing then...

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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 5:20 am

I agree with others that this is really a link of mistakes that formed a chain that led to the incident. It's wrong to single out any one link and blame it specifically. In the end, the chain was broken by the pilot saving the passengers and his plane. Remember, "every landing is a good landing if you can walk away from it."

However, this does raises the issue of the need (or not) of a third crew member, even on short transatlantic flights. I, for one, believe a second officer is needed.
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RE: Air Transat 'Glider' Pilot Made Errors - Repor

Thu Oct 21, 2004 10:00 am

They will not be joining my avoid list.
There are many, many more reasons to avoid this airline: service, seat pitch and attitude come to mind.

Notwithstanding my personal aversion to the airline, I salute Captain Piche's obvious skill and credit him with saving the lives of the pax and crew aboard the aircraft.

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RE: Air Transat 'Glider' Pilot Made Errors - Report

Thu Oct 21, 2004 11:57 pm

I do not know if reply 9 reflects a general perception.

My avoid list is primarily safety based. I am wary of airlines that keep
losing aircraft, or where there is an accident and the airline will not accept responsibility for it.

An example of the former is China Airlines and Egyptair of the latter. I know that the outcome of the investigation pointed to pilot action, but the airline/Egyptain Govt and Family, (who seemed to be linked to the government) blamed practically every one but little green men.

An airline that will not accept their responsibility is unlikely to learn from it.
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RE: Air Transat 'Glider' Pilot Made Errors - Report

Fri Oct 22, 2004 12:33 am

Full report (in english and .dpf) is available here:


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