Author Topic: Amazing feat of pilotage.... or stupidity? (Read 739 times)

gofaster · « **on:** October 22, 2004, 07:20:57 AM »

From my weekly AvWeb email

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Official Report: Pilots Failed To Detect Fuel Leak...
The pilots of an Air Transat Airbus A330 that glided to a landing in the Azores in August 2001 responded incorrectly to a fuel leak over the Atlantic Ocean, according to the official report on the incident, released Monday. The pilots, reacting to what they thought was a fuel imbalance, fed fuel into the leak, and soon succeeded in inadvertently pumping all their fuel overboard, far from land. The report said the pilots acted from memory rather than utilizing a checklist, so they never saw a "Caution" note in the Fuel Imbalance checklist that might have caused them to consider that the real problem was not an imbalance but a fuel leak. "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," according to the report. The fuel leak was the ultimate result of an improperly installed fuel line that fractured.

...But They Saved The Airplane...
However, the report also found that there was not a "clear, unambiguous indication or warning that a critical fuel leak existed," and the pilots had never experienced such a situation during operations or training. The investigators also said that Capt. Robert Piché's skill in conducting the subsequent engines-out dead-stick landing saved the lives of the 306 passengers and crew on board. The glide began at about 18,000 feet, lasted 19 minutes, and traversed 65 nm. Air Transat CEO Allen Graham said, "Since the occurrence we have reviewed our training programs and enhanced our processes, in terms of both maintenance and flight operations. ... This event is unique in our history." Piché became famous in Canada after the flight. He was awarded a Medal of Honour by the Quebec government, he wrote a best-selling book about his career, and a TV movie was made about him. Reports that he had once served prison time for drug-running seemed to only enhance his legend. He continues to work for Air Transat and frequently spoke about his experience to the public. When the accident report was released, he issued a statement saying it "confirms that the August 24, 2001, occurrence was the result of a chain of events, and identifies the risk factors involved. ... I feel that with the release of this report, the final chapter of this story has come to a close, and I will make no more comments at this time."

I gotta admit, to dead-stick a jumbo for 19 minutes from Angels 18, 65 nm long, to a safe landing is pretty good. Airbus A330s aren't exactly Schweitzers.

deSelys · « **Reply #1 on:** October 22, 2004, 07:41:37 AM »

I agree, they maybe made a mistake, but they did an awesome job to get themselves out of the corner.

They should use this case as a 'why you should follow the checklist' prime example, and as a 'even if you f****d-up, never give up' reminder.

Still WTG to the Air Transat crew.

TheDudeDVant · « **Reply #2 on:** October 22, 2004, 07:42:09 AM »

yes.. no doubt amazing! lol

lol imagine the ride on that jet! specially when the engines died! haha I'd imagine most of them were doing nothing but searching for god.. hehe

ra · « **Reply #3 on:** October 22, 2004, 07:43:22 AM »

It sounds like they screwed up but recovered nicely. Pilots are human, just because a checklist was skipped doesn't mean the pilots were totally incompetent. I hope these guys get to continue flying.

OTOH, shouldn't a modern, computerized airliner be able to detect a fuel leak? When the fuel level in a tank is dropping faster than the rate at which it is being pumped through the fuel system the fuel monitoring computer should be able to set a warning light in the cockpit. Why would that be so hard?

ra

Jackal1 · « **Reply #4 on:** October 22, 2004, 08:06:28 AM »

In the end the problem boiled down to using a wrong fitting and parts trying to adapt for a change over. Maintenance had repeatedly expressed their concern over this and were finaly told by their supervisors to proceed anyway. Of course after the problem it turned into a session of "Pass The Buck" starting with the crew and maintenance.
Changes were made in the checklist procedure and instrumentation in an attempt to avoid the same prob in the future.

OIO · « **Reply #5 on:** October 22, 2004, 08:44:45 AM »

theres was a special on discovery about that incident. The pilots did nothing short of a miracle to glide and land the thing without any engines.

Martlet · « **Reply #6 on:** October 22, 2004, 08:46:59 AM »

I saw the documentary about this on A & E a few weeks ago. Incredible.

gofaster · « **Reply #7 on:** October 22, 2004, 10:46:02 AM »

It was on A&E? How did I miss it? I'll have to keep my eyes open for it to repeat. Would make a great episode, I would imagine!

gofaster · « **Reply #8 on:** October 22, 2004, 10:50:00 AM »

An Airbus A330

rpm · « **Reply #9 on:** October 22, 2004, 10:58:28 AM »

There are a couple reinactments of that flight that I've seen. I personally feel the Captain made some serious errors before and after going deadstick. He bullied his young Co-pilot who noticed early on there was a serious problem. He also kept insisting there was a computer error instead of trusting his gauges. It was a tremendous feat, but it could have been easily avoided.

Furball · « **Reply #10 on:** October 22, 2004, 11:18:43 AM »

Airbus = good = yay!

Boeing = bad = boo!

Golfer · « **Reply #11 on:** October 22, 2004, 12:42:29 PM »

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Originally posted by rpm
There are a couple reinactments of that flight that I've seen. I personally feel the Captain made some serious errors before and after going deadstick. He bullied his young Co-pilot who noticed early on there was a serious problem. He also kept insisting there was a computer error instead of trusting his gauges. It was a tremendous feat, but it could have been easily avoided.

Don't believe everything you see or hear on the tube. Just look at your loyalty to John Kerry and you'll see how warped it can make someone.

Oh...Furball. "If it ain't Boeing, I ain't going."

Doesn't matter what led up to it, they saved the day. You can bet your bottom dollar they won't do it again either.

Jackal1 · « **Reply #12 on:** October 22, 2004, 12:47:34 PM »

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Originally posted by Golfer
Doesn't matter what led up to it, they saved the day. You can bet your bottom dollar they won't do it again either. [/B]

Unless once again economics and profit are placed above safety as was this case.

Golfer · « **Reply #13 on:** October 22, 2004, 12:57:45 PM »

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Originally posted by Jackal1
Unless once again economics and profit are placed above safety as was this case.

How so? They didn't just put in enough fuel for it to run out.

As I recall, it was a hose clamp or fitting that they used on this airplane, it rubbed against the fuel line causing a leak (over a number of flight hours) and during this flight the line ruptured.

To be honest, theres a 99% chance its just a fuel imbalance and I'd be willing to bet that this crew has seen the exact situation in their Simulator sessions and could easily diagnose and treat it as a fuel imbalance issue. No pilot would knowingly pump fuel into a leaking tank, especially if that is what they felt was likely.

In all fairness, I've had not using a checklist come back to bite me (Because I felt real stupid when I discovered the issue) and since then I always do the tasks, then go over the checklist to make sure all the items are taken care of. In my instance, I left takeoff flaps (approx 10º) in while flying a Mooney M20J and spent a while trying to figure out why I needed a lot of nose down trim and wasn't getting any speed out of the airplane.

Jackal1 · « **Reply #14 on:** October 22, 2004, 01:03:50 PM »

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Originally posted by Golfer
How so? They didn't just put in enough fuel for it to run out.

As I recall, it was a hose clamp or fitting that they used on this airplane, it rubbed against the fuel line causing a leak (over a number of flight hours) and during this flight the line ruptured.

The wrong bracket and adapter were used after a change over. It was repeatedly brought up and contested by the head of maintenance, but was pushed through by those in higher positions to allow the plane to be put back in service sooner. Profit over safety.