The Atlantic Glider revisited - official report released (Merged)

[Tree]

I stand corrected. Thanks to all of you!

[Globaliser]

Not sure whether it's totally appropriate to post it on this thread, but an AD's apparently now been issued. Translation here - http://www.tc.gc.ca/aviation/ad/adfi...002-548(B).HTM.

[Getting URL to work properly.]

[Lu Zuckerman]

DGCA Blame the pilots and then CYA

Quote:

"Note: The procedures above have been incorporated into the manufacturer's Flight Manual by
TRs Nos. 4.02.00/13, 4.02.00/15, 4.02.00/16 and 4.02.0017 approved by the DGAC on September 05, 2002, and will be incorporated into the next general revisions of the flight manuals".

The AD blames the pilots for mismanagement of the fuel problem. This may be true if they were trained in accordance with the procedures outlined in the AD and did not follow the AD procedures. The AD however was written after the fact. My question is, did the pilots follow the instructions that were in place at the time of the incident?

[Globaliser]

Lu Zuckerman: The AD blames the pilots for mismanagement of the fuel problem.

Actually, no. What the AD (at least in this translation) says is:-

The inquiry revealed that fuel management by the crew directly contributed to the total loss of the fuel.

That much seems to be uncontroversial. Whether that "management" amounted to "mismanagement" or not, and according to what instructions or standards that should be decided, is something which the AD carefully avoids, as one would expect.

[Lu Zuckerman]

Tomato Vs Tomahto.

To: Globaliser

The inquiry revealed that fuel management by the crew directly contributed to the total loss of the fuel.

When the management of a situation ends in a failure then assuming there were instructions to follow then it results in "mismanagement".

What I stated several posts above was that when the pilots became aware of the fuel imbalance conditions they followed the checklist to the letter. In other words, everything they did was in direct accordance with Airbus published procedures. By following those procedures they ran out of fuel and had to dead stick into a landing field many miles away.

Knowing how the various certification authorities work (FAA has a tombstone mentality) and the DGCA accuses the pilots and then creates an AD that fully explains what a pilot should have done when faced with a severe loss of fuel. I would strongly suggest that you check the instructions that existed at the time of the incident and compare it with the instructions contained in the AD.

I am personally aware of a situation where the DGCA told the FAA that a major design fault had been corrected when it had not and that the aircraft in question still has that design defect. Believe me the certification authorities do not always get it right.

[Globaliser]

You could reach that view if you add in other information or assumptions.

The AD, though, does not itself contain any criticism of the crew. That's as I read it, and that's as I would expect. We may be seeing different things from the same words. But I would myself wait for the accident report for the necessary information.

[apfds]

Lu is not correct in his assumptions.

The fuel imbalance check list states that it should not be used unless a fuel leak has been completely ruled out. The previous page give step by step instructions on how to diagnose a fuel leak,which includes indications of fuel imbalance.

[Lu Zuckerman]

Four blind men touch an elephant and visualize four different things.

The inquiry revealed that fuel management by the crew directly contributed to the total loss of the fuel.

As I previously stated I did not read the AD. I was quoting from comments made by another poster who supposedly was quoting from the AD.

I also previously stated that by the time the crew were made aware of the problem they followed the check list to the letter.
I had also stated that on the A-330/340 the announcement of fuel imbalance comes well into the problem as opposed to the 757 which is announced when there is a difference of approximately 1700 pounds.

[aardvark2zz]

This is my timeline for Air Transat which lasted over 81 minutes. There is a time period of approximately 60 minutes between the first indications and the last engine out. (Of course some of the info is approximated). Merry Xmas.



In the following image the top of the triangle is where diversion occurred (42 20N 22 30W). Right corner is Lisbon. Left corner Lajes Island.

[Frangible]

Very interesting timeline that Aardvark. Been trying to work out something similar, but have not yet seen published quantities of fuel on board at take-off or rate of loss through the gash in the fuel line. Is this educated guesswork or reliable sources?

[aardvark2zz]

Mostly research and a spread sheet. I reversed engineered the fuel backwards from Lisbon and Lajes back to the fuel line break point. Assuming 1 hr reserve. The hardest estimation was the time at which the break occured. I read an article on the web (I believe from aviationsafety.com) that they were losing 550 lbs/min. I was able to get reasonable agreement with that.

You can also calculate fuel from start up to near break but is more error prone since they were closer to the destination.

It's interesting how so much can be calculated using fundamental physics and aerodynamics.

Last November I met the Captain at his biography signing. I won't go into certain details here but it was a very interesting conversation about how so much of his instrumentation was lost during his night-time gliding phase over a dark ocean. I got the impression that a worldly barn door pilot with a lot of "bush" flying as compared to "urban" flying is wonderful experience in a stressful situation. We talked, amougst other things, about what technique he used to fly and estimate his glide. I was polite and did not ask him about the closure of the cross-feed fuel valve.

Previous postings of mine on other sites:
----------------------------------------------------

I just read a good chunk of his biography. It didn't take much time as it is in 18 point font. He seems to have paid his dues, especially in prison with the tough guys, the gay guys, the racist guys, and some of the guards. Many of these didn't like the fact that he ended up leading kitchen duties with over 70 men under him in the kitchen. He held quite a few of the blue collar jobs before jail and just after jail. He was a bar man in Montreal in between jail and Air Transat. He had a few ****ups as a teenager while doing his pilot training in college and almost lost his student position several times. Many college flying instructors hated his guts except for 1 particular instructor. He eventally moved to top of class even after half of the 30 students failed. What got him a job on big planes was letters of reference from earlier profs and co-students.

The Air transat glider story and its pilot's biography may be on TV in the future.
Captain Piché Makes a Perfect Landing at Pixcom

MONTREAL, Dec. 2 /CNW Telbec/ - Airline captain Robert Piché is about to have his story dramatized on the small screen. Pixcom, the Montreal-based television production firm, announced today that it had signed agreements with
Piché, his biographer, Pierre Cayouette, and the publishing house "Libre Expression" to proceed with a drama production inspired by the larger-than-life story of the now-famous pilot. The French book, "ROBERT PICHE, Aux commandes du destin", is already a best-seller just two weeks after its
release.
In August 2001, Robert Piché was at the controls of Air Transat flight TS-236 when his Airbus A-330 encountered serious technical difficulties. He made a spectacular and successful emergency landing in the Azores, saving the lives
of the 304 people on board.
Following the signing, Piché said he was very moved by the remarkable interest in his story and the positive things people had to say about him. "This dramatization will allow me to share with as many people as possible
those moments that marked my life forever."
Pixcom will be counting on development and broadcasting support from Canadian Broadcasting Corporation and the Société Radio-Canada. ... are confident that "the incredible story of Robert Piché will attract large audiences and be an important milestone for
Pixcom."
.... Pixcom ... is an integrated corporation involved in the development, production, postproduction
and distribution of hundreds of television programs every year. Pixcom exports its products around the world and also provides television engineering services to ensure the coverage of large-scale events in international
markets.

Met Robert Piché the Captain himself last November and I finally bought his autographed biography. Of course it was an awkward meeting considering all the things that have happened to him and all the attacks from the media. It was cute and funny to see all the non-aviation "little ladies" praise him for his heroics and putting him up there as if he was Jesus. I'm sure he was Jesus to most of his passengers. It seemed to me that every friend, and stranger in his life and his past lives came to see him and shake his hand.

He seemed to be distracted by a whole bunch of details behind him. But, I did get to talk to him about flying but I did not dare ask him THE question "Why wasn't the cross-feed valve not closed?" for which all my friends were asking me to ask. But he did mention to me some things that I won't discuss here. We both did laugh when I reminded him about what he wrote in his book about it being a surreal moment when pieces of the wheels continued rolling on down the runway just after the plane stopped. He told me he lost ALL navigation except for the altimeter, artificial horizon, airspeed, compass, VHF. He lost GPS, VOR, etc .... But he was easily able to see the lights of the island from over 20000 feet since the sky was clear. The airport was flashing its lights. He did not have any flaps but only had some slats. The emergency break system only had one shot.
I really got the impression that his experience of thousands of hours flying barn doors all over the world helped him keep his calm. And that a pilot who did not fly barn doors all over the world may be too squeaky clean.

There is a 1:30 minute video clip of the televised biographical interview with Air Transat's Captain Piché yesterday where he talks about his financial woes which led him to Jamaica, many women, and 500 Kg of marijuana in a twin in the states. On the complete televised interview he talks about the continuous crisis you feel months after the Transat incident. It took him the 3rd therapist to understand his continuous state of "crisis" and he's been sober for 8.5 months (congrats). I believe he's also had some extremely serious crisis with his son (and I believe it may have been death related) but I missed most of that part. He's quite open. Too bad I don't have the transcript. His biography is coming out this week. The video clip is in french.

http://emission.tva.ca/medias-31/robertpiche.ram
http://emission.tva.ca/31-emission.shtml

Air Transat's ocean-glider-pilot's great biography in print. Over Newfoundland he asked Air Traffic for a higher altitude and got it but with one condition, that he flies parallel to the same air highway but 60 miles south. If he would of stayed on the originally planed route he would of glided 15 miles short of the airport and would of had to ditch in the ocean.
I read some of Robert Piché's bio that came out this week and it's a simple read. They could of written a book just about the details of the Air Transat Flight 236 incident but they kept it short but talked quite a bit about his life. He was interviewed on TV this week and he seems to have had quite a life: drug smuggling, jail, sons death??, airline, alcohol, etc... He was born very close to where my father was born.

If there would of been a complete layer of clouds like the day before and after then he would of not seen the airport (it was before dawn); he asked the airport to flash the runway lights. I don't know what radio navigation instruments were working to help him find the runway alignment. In the book they barely cover the "early" alarms that were hinting at engine # 2 problems and the plane's prior maintenance woes.

During the debugging phase he seemed to be convinced that it was a software problem and couldn't believe that he was running out of fuel. His "stewardesses" took flashlights to try to see if an engine was leaking fuel but they saw nothing. When he landed he was still convinced that he had plenty of fuel on board but found out that he had almost nothing when they powered up his plane with an external electrical generator.

When his plane came to a screeching halt (literally) on the runway, after doing a 230 mph touchdown without flaps nor slats (normally it's less than 150), with the dead silence around him he saw part of his wheels continue rolling ahead and beyond the airplane, which game him an eerie feeling. Because he locked his wheel brakes the tires blew causing the metal rims to scrape on the runway. One of his first comments after getting out of the plane and after doing the obligatory swearing in french was that his " #$%#$ wheels were square".

Air Transat Pilot's R. Piche web page at http://www.io-ms.com/piche/en/index.asp He's now doing conferences. Maybe he can do one on this Forum :-)

Keep the blue side up; wherever up is ?
Practice random acts of kindness and senseless beauty.

[aardvark2zz]

Tan when gliding when looking for max range one looks for an optimum IAS (Indicated Airspeed). But in actual fact a better number is the angle of attack to maximize the CL to CD (Coefficient of Lift to Drag) to approximately 17 with flaps and slats in.

In training they emphasize IAS, especially in small planes, but I was wondering if the angle of attack was used instead for max glide range.

[Frangible]

Thanks for that. And I had read your earlier postings. Very restrained of you not to ask the Xfeed question.

The only thing I'd add is that I understood that they were carrying a much higher reserve so as not to have to buy so much fuel in Lisbon, where it's more expensive. How much I don't know. No doubt the report will have the correct figure. It's expected next month.

[GotTheTshirt]

Lu,

One thing I dont understand about the fuel pump.

It is not unusual to get engines for change with bits missing. It often happens where you get a Bare Engine, a Non handed QEC or a Handed QEC.
To remove parts of the original engine is normal provided those parts are not lifed or within life and the previous engine did not suffer a failure that renders the parts unusable.
So having removed the pump from the old engine why did they not just take the duct and bracket at the same time ??

I was not aware that they had changed an engine , the original story I heard was that they were carrying out a mod kit that had bits missing ( which to me makes more sense)

[Lu Zuckerman]

I think, I believe therefore it is true.

To: Got The T Shirt

I believe they did use the duct from the removed engine however this duct did not incorporate the change that would prevent abrasion on adjacent parts. Air Transat felt that the use of the old parts would not cause a problem in the relatively short period (flight hours) that would transpire before receiving the correct parts from Rolls Royce. (I THINK)

[Lu Zuckerman]

Discover the facts.

The English, Canadian, German and I believe the Italian Discovery channel will be running a program in the near future covering the Air Transat A 330 Glider incident. The program is in the Mayday series.

All of the facts were not available for the program so they may be included in a voice over at the end of the program. These facts will raise a lot of eyebrows and they will silence a lot of the commentary on these threads.

Here are some facts that the readers of these threads may not be aware of: Very shortly after the incident Airbus Industrie published an AD outlining the changes to the pilots manual governing management of fuel leakage. In the first page of the AD Airbus said it was the pilots fault. I have been involved in the aviation industry since 1949 and I have never seen an AD that assigned blame. The AD went into every conceivable scenario relative to the management of a major fuel leak.

And just about everyone required the physical observation of the leak to ascertain where the leak was located which in turn would generate the counter effort by the pilot(s). This involved the flight crew or cabin crew making the observation. No consideration was given to the fact that if the leak occurred at night the observation could not be made. This is what happened on the Air Transat A330. Even if the information in the AD were available at the time the pilots could not respond correctly because it happened in the dark of night. Nothing was mentioned in the AD about the fact that the A 330 system provides a warning well into the leak as opposed the 757 which requires a very small differential in order to generate a warning.

The AD was a cover your ass effort and it was not very well thought out.

Here is another fact. An AD was issued to cover abrasion of lines on P&W and GE engines used on the A-330, which would result in loss of fuel. This AD was issued long before the Air Transat incident, which means that both Airbus Industrie and Rolls Royce, were well aware of the potential for the problem to manifest itself on the Trent-700. There is more and hopefully it will be covered in the Mayday program. If it isn’t, I will publish it on these threads.

[411A]

Lu,

Ah....the L1011 was not fitted with Trent engines.

[Lu Zuckerman]

I goofed.

To: 411A

I made corrections to my post which moots your post. Sorry about that.

[quarefellah]

Hindsight is ALWAYS 20/20 but I'm curious about the info. provided to the crew by the FMGS during all of this.

On a Honeywell fit I can think of at least two pages that show EFOB at dest. (FLT PLAN & FUEL PRED). On a typical 7 hour flight that number might vary by a couple of hundred kilos (depending on the accuracy of forecast winds, amongst other things). If fuel was leaking at a rate of 550 lbs/min (250 kgs/min) as mentioned earlier then I would have thought that the EFOB would be reducing at an alarming rate whilst ETA would remain the same. If it's going to take the same time to get somewhere and fuel=time then something's not right.

To confirm what has been mentioned earlier fuel imbalance ECAMs are at hopelessly high levels thus only telling you that you've HAD a fuel leak. Also the Trim Tank Transfer System for CG management can obscure any imbalance by transferring fuel forward from the trim tank asymmetrically!!

As has been said so many times before let's see the final report.

[Lu Zuckerman]

Reports are like statistics. They can be bent to make a point.

To: quarefellah

As has been said so many times before let's see the final report.

The report is finished however it has not been released due to some of the principals taking exception to the findings. The faults as identified have very little to do with the actions of the pilots.

Hopefully these points of contention will be discussed in the Discovery Mayday program that is supposed to be aired this month.