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-   -   The Atlantic Glider revisited - official report released (Merged) (https://www.pprune.org/rumours-news/71910-atlantic-glider-revisited-official-report-released-merged.html)

slice 28th Sep 2003 10:20

Heads up!
 
Just to put everyone in the picture, Winnie has been posting for some time over in the D&G forums, much to everyone's amusement. If you do a search for his posts in those forums you will get the picture pretty quickly.:=

HotDog 28th Sep 2003 13:22

Jesus Winstun, you are one brave hombre. What fantastic airmanship you must posses. Hopefully that same airmanship will keep you honest enough to tell us all about your next stuff up so we can all learn from it.:rolleyes:

Danny 28th Sep 2003 18:17

Just thought I'd fire this shot across the bows as a wake up call:

There are quite a few bona-fide, self absorbed, blowhards with a British, Australian or Kiwi accent lurking on PPRuNe mixed with the obligatory, awestruck wannabes. There are also quite few awestruck wannabes masquerading as self absorbed blowhards with a British, Australian or Kiwi accent.

The above observation was made by a visitor to PPRuNe and I thought it very pertinent. This thread is turning into one of those classical examples where we all need to sit back and analyse the posts and decide who knows what they are talking about and who only thinks they know what they are talking about. I may even make that the PPRuNe motto! :hmm:

Kaptin M 28th Sep 2003 20:01

Blasted colonials - not spiffing cricket, is it!
Eh what.

coopervane 30th Sep 2003 07:51

On lord is hard to be humble.....
 
Hey Witsun, only one joker on this forum.

It blokes like u that make aviation the ministry of self importance.

Factors like stress and fear do play a big part in emergencies but I guess a Mr. Perfect plonker like you would be imune to such human emotions.

We aint robots and even you must have have cocked up at some point in your perfect career.

Coop & human bear.

PS just looked at Witsun's profile. Under location. It says "planit"

But doesn't say which one he comes from.

Coop

Frangible 30th Sep 2003 22:45

Hauling thread sluggishly back on topic...

Have heard rumour that Airbus has now changed the A330 FMGS so that it does now calculate fuel remaining against what it's been burning and what was loaded and so can alert low fuel irrespective of manual checks.

If true, this is, no doubt, just another product improvement and unrelated to any incidents past present or future.

OzPax1 30th Sep 2003 23:24


If true, this is, no doubt, just another product improvement and unrelated to any incidents past present or future.
And do Pigs Fly! :mad: Like hell it wasn't related. Horse, bolt and stable door come to mind!

gumbi 30th Sep 2003 23:55

Well said Sooty!

it just goes to show what kind of solidarity pilots display...
no wonder our profession is in "dire straits"!

Frangible! that's a good one...;) like u say I'm sure it has no relation whatsoever to the incident at cause, or all others BTW

Lu Zuckerman 1st Oct 2003 01:55

Love is blind and so are some people.
 
To: Frangible


If true, this is, no doubt, just another product improvement and unrelated to any incidents past present or future.
This change is as a direct result of the Air Transat incident and closely follows an AD issued by Airbus changing the directions in the operating manual relative to managing a leak or suspected leak. It was in this AD that Airbus stated that it was the pilots’ fault.

Note to all: As for UK transmission of the Mayday program, we (Discovery Canada) know that three programs will be broadcast in
November and three in January at 8pm on Mondays on Channel Five. But,
unfortunately we do not yet know which order the programs are being
transmitted.

:E

Idle Thrust 1st Oct 2003 04:29

Not sure if I missed the schedule in the many posts here but just in case, the MAYDAY program "Flying on Empty" is planned to air on the Discovery Canada channel on

October 8 @ 2200
October 9 @ 1700
October 12 @ 2200

All times Eastern, and it will be in English.

India Four Two 1st Oct 2003 09:00

OzPax1 and Lu,

I think Frangible and Gumbi were being more than slightly sarcastic.

Frangible 1st Oct 2003 22:22

Thanks IFT. Irony can be dangerous...

India Four Two 2nd Oct 2003 02:35

Frangible,

You are quite right - irony in the wrong hands is extremely dangerous. In retrospect, I should have used 'ironic' rather than 'sarcastic' in my message (it had been a long day!).

I see that 'irony' is defined as being more subtle than 'sarcasm'. In this case it might have been too subtle;)

Plastique 2nd Oct 2003 13:48

FU/FOB Disagree
 
Just for info:
The Fuel Used/FOB disagree message is calculated by the FCMC and is contained in FCMC9.0 and above. A FWC change is required in parallel to 'activate' the warning.
This is active on all new deliveries and Service Bulletins are available to apply the change retrospectively.
The Fuel Used/FOB disagree occurs when there is over 5t mismatch between the departure fuel minus fuel used, and the FOB figure.

This warning was conceived about 6 years ago, as an A340 operator and an A320 operator both lost significant amounts of fuel from the engine HP fuel filter cover which came off due to the helicoil inserts in the housing giving away. The A340 lost about 20 tonnes of fuel (xfeed valves were not opened), the A320 lost a lot more because the pilot did exactly as per the Air Transat pilot and opened crossfeed. The A320 landed with something like 200kg FOB.

There was resistance in some of the operators contacted (including the two operators, A320 and A340 cases above). The resistance was due to the fact that the Flight Ops departments considered en-route fuel checks to be basic airmanship, and they were concerned that the existance of such a warning could cause complacency.

Airbus eventually decided to inplement the function, as it was considered that it was beneficial to alert crew as soon as the threshold is exceeded. In theory if the leak is from one wing tank or engine, the fuel imbalance message should come first (in most cases).
There was one case about 9 years ago when an A330 had an excessive transfer to the trim tank due to a leaking vent, a pipe disconnected in the trim and pushed about 5 tonnes overboard (trim transfer continued as the tank was not reaching the trim tank fuel quantity requried for the aft CG target). This problem was due to incorrect pipe installation.

I think the FU/FOB Disagree function is a good thing, but hopefully it will be the last defense.

G fiend 7th Oct 2003 18:07

Hers an interesting fact for you all,

Years ago my airline had to ground it's entire fleet of b757 a/c (only 19 a/c but hell, still *ucks your day in ops) for inspection, after a fault was found with one of the clips that 'restrain'(sic) the fuel line and an AD was issued.

Guess what engine our 757's our equipped with?

A clue?
can't say Derby 'cos GE engines are also made there. but you get the point!

Makes me wonder if the MX organisation was up to speed.

jettison valve 8th Oct 2003 03:49

Plastique,

my papers quote a discrepancy threshold of 3.5t for the FU/FOB warning.

Given the number of scenarios in which this warning is inhibited and the fact that monitoring fuel consumption is one of the primary duties of a flight crew en route, I somehow doubt whether this feature is really worth its money.

BTW: The modification consists of a pin programming between FCMCs (9 and on) and FWCs (8 and higher, if I remember right).

Happy Landings,
J.V.

India Four Two 9th Oct 2003 13:14

Well, I've just seen "Flying on Empty" on Discovery Canada. A fairly typical Discovery production - about 10 minutes of facts strung out to an hour's show by some speculative and not very well done re-construction of events on-board, although it looks like they borrowed a simulator. Whose, I wonder, since Air Transat declined to participate in the filming.

Nothing new in the facts that hasn't already been raised in this thread, but the highlight for me was seeing a real live Ppruner - Lu Zuckerman :D

Lu, were those your model aircraft in the background?

Lu Zuckerman 9th Oct 2003 20:55

I'm waiting for my Juno nomination.
 
To: India Four Two


Lu, were those your model aircraft in the background?
Yes but they represented less 1/20th of the total collection. If you are ever in the are in the area you are welcome to come for a visit and see all of the models.

:E

pigboat 9th Oct 2003 21:23

Hi Lu. That's a great model collection Are they all from from kits, or are they manufacturers models? :cool:

Couple of quick comments:
Why oh why didn't they get the f:mad: g radio terminology correct? If the producers cannot get that simple fact right, it doesn't say dick for the rest of the research that went into the program.
I didn't see that they'd closed the x-feed after the loss of the first engine. Loss of an engine is a pretty good indication that your fuel problem is something other than a computer glitch.

That being said, after their balls were in the crack they pulled off a pretty fine piece of airmanship.

India Four Two 9th Oct 2003 22:35

Lu,

I can see it now - "The Juno for the best aircraft model collection goes to ..... ":D

Thanks for the invitation - I'll have to see if I can manage a trip Down East some time.


PB,

I agree - the radio terminology made me cringe - they couldn't even get the calling and receiving callsigns in the correct order!

Lu Zuckerman 10th Oct 2003 00:42

Aw gee wiz. I'd like to honor my mother, my producer.........
 
To: Pigboat


Hi Lu. That's a great model collection Are they all from kits, or are they manufacturers models?
Almost all of ny helicopter models are manufacturers models and some are custom built. A good portion of my fixed wing models are manufactures models. I have quite a few that are custom built and and a lot were purchased from a local model store. I have several factory model amphibs but I'm sorry to say no PBY. My favorite is a 1:72 model of a Coast Guard HO3S in the livery of a helicopter I maintained and flew in when I was in the Guard. This was built from a kit.

I didn't build any of them. My hands are too shakey and my fingers would most likely get super glued together.

When they signed me for the interview they asked if there was some place with an aviation atmosphere where they could conduct the interview. I told them wait until you get in my basement office. They were very impressed. They took a lot of footage of the collection but it never got on the show. They spent almost 4 hours in the interview and 80% of it ended on the cutting room floor.

:E

B767300ER 13th Oct 2003 11:43

Danny Fine---"Capt.PPrune"...

I wholeheartedly agree with your post. I suspected as much from a few posters.

As far as the "Atlantic Glider", I was flying a trans-Atlantic sector that night to LGW in a 767 and heard the Air Transat flight at the beginning, before they got out of range on 123.45; I was VERY impressed with the coolness and the professionalism of this crew, trying to make Lajes. When I heard the next day that they made it, I was very relieved and even though this incident has human factors and obvious errors associated with it, I am VERY impressed with the airmanship of that crew in landing safely. ALPA awarded them the "Superior Airmanship Award" last year, which says alot.

I'm sure the investigation will highlight the original mistakes, but applaud the crew for their reaction to the potential loss of the aircraft and souls on board.

Man, I wish I could see that "Discovery Channel" program in the US.

keepin it in trim 14th Oct 2003 03:40

A lot of people are getting awful high and mighty about "computer glitches" and indications which the crew should have acted on and "how they should have known / noticed what was actually happening".

Well, I enjoy the luxury of operating a twin engine, full glass-cockpit, single pilot IFR helicopter built by a well known european corporation. It is a wonderful machine and tremendously capable, HOWEVER..... We have had a number of incidents recently, all of which led to MORs, of electrical glitches or failures. On each occasion the indications and warnings that the crew observed should not have been possible ( the manufacturers words ), the actions in the emergency procedures cards did not resolve the situation and the crew had to analyse the fault in the air and use their best judgement to resolve the situation.

Computer glitches ARE a reality in very electric aircraft, confusing indications with drills that do not resolve the problem ARE a reality. Manufacturers subsequently changing procedures given the benefit of someones often painful experience (and often denying this as the reason) ARE a reality.

The crew may have made errors, but if the manufacturer saw fit to change the drills or update the software as a result of this incident then things cannot have been entirely right when this crew found themselves in trouble.

One last thought, we all make mistakes or end up in situations we wouldn't choose, how you cope with those situations is what matters. On this occasion exceptional flying skill and airmanship averted disaster, big hand of respect to these guys for pulling it out of the fire - how many of us can be sure we would have handled the whole situation as well?

Winstun 14th Oct 2003 11:04


"how they should have known / noticed what was actually happening".
..What they did or did not know of what was actually happening is mute point....you don't open the crossfeed valve in this situation...:rolleyes: ..pretty basic really.

we all make mistakes or end up in situations we wouldn't choose, how you cope with those situations is what matters.
..:ooh: ..pretty BIG mistake...you make these kinda mistakes, you have no business being in a cockpit.
Same deal for crews of UA DC-8, LM DC-9, AC 767, HF A310.

exceptional flying skill and airmanship averted disaster, big hand of respect to these guys for pulling it out of the fire
....my friggin gawd!!.. :rolleyes: Try "pure arse". Really don't know where some here are coming from... In my dictionary, airmanship includes not running outta gas..:hmm:

scanscanscan 15th Oct 2003 02:48

I think these guys really needed a good old flight engineer to look after their fuel system problem in the first place.

keepin it in trim 15th Oct 2003 06:12

scanscanscan

I have always felt that a good flight engineer is worth his weight in gold, especially when life starts to get interesting.

Only thing is, given some of the flight engineers I've worked with that could be an awful lot of gold!

arcniz 15th Oct 2003 17:18

Agree that a good Flight Engineer might have made it all go away, but what can you do when the company doesn't want to pay the freight for a third set of eyes, ears, and lobes?

Answer has to be: Make the G**#% aircraft tell you what it knows whenever the heck you want to find out.

The aircraft either knew or could have quickly reckoned what was happening in regard to fuel ....problem was the crew evidently had no procedure available to depart from the SOP menus and ask the airframe the pointy kind of questions that would have quickly illuminated the bolix. Cost to add this class of function is not big, but it is a departure from the "we'll tell you what you know when you need to know it" philosophy -- a banality suffisant to offend the highly artistic senses of the designers.

Give it another hundred years and the surviving airframe companies are sure to have this sort of thing figured out.

innuendo 18th Oct 2004 05:16

Azores deadstick landing report released
 
As posted on AEF, the report on this incident can be found at:

http://www.GPIAA-portugal-report.com

rotornut 18th Oct 2004 10:29

Transat report blames pilots

By PAUL KORING
Associated Press


POSTED AT 5:58 AM EDT Monday, Oct 18, 2004

The harrowing, engines-out, emergency landing of a Canadian airliner that ran out of fuel over the Atlantic Ocean three years ago could have been avoided if the Air Transat pilots had followed established fuel-leak procedures, the official report into the accident concludes.

Instead of a near-disaster, a routine diversionary landing with plenty of fuel remaining would have resulted if proper produces were followed, Portugal's Aviation Accidents Prevention and Investigation Department says.

Passengers aboard Air Transat's Airbus A-330 cheered and applauded Captain Robert Piché as a hero after he slammed the unpowered jet onto the runway at Lajes air base in the Azores after gliding for 19 minutes after the second engine failed.

But accident investigators determined that the pilots turned a fuel leak into a near-disaster by failing to recognize it and trying to correct from memory -- rather than by following a checklist -- what they believed was a weight imbalance, during which time they pumped tonnes of fuel overboard.

The Globe and Mail obtained a copy of the Portuguese final report into the Aug. 24, 2001, accident. The report is expected to be released today.

Efforts to contact Air Transat yesterday for comment about the findings were unsuccessful.

Capt. Piché's extraordinary airmanship, including making a steep, 360-degree turn only a few kilometres from the threshold of the Lajes runway to lose sufficient height, then gliding to a landing, impressed the Portuguese investigators.

"The captain's skill in conducting the engines-out glide to a successful landing averted a catastrophic accident and saved the lives of the passengers and crew," the report says.

However, the report makes clear that such heroics would not have been needed had the pilots shut down the right-side engine (where the fuel was leaking) or had not pumped tonnes of fuel from the undamaged left wing into the right-wing tanks, from where it was poured overboard at more than three kilograms a second.

"Either of these actions would have conserved the fuel in the left-wing tanks and allowed for a landing at Lajes with the left engine operating," the report says.

Instead, "opening the crossfeed valve put the fuel in the left tank at risk, and initiated a worsening of the serious fuel-leak situation."

The crew failed to comprehend that the aircraft had a major fuel leak, even after the second engine died.

"Notwithstanding indications that there had been a massive loss of fuel, the crew did not believe that there was an actual fuel leak," the report says. Instead, the crew believed they were dealing with a computer malfunction.

Details of the flight-crew conversations were lost to investigators because the pilots inadvertently recorded over the 90-minute cockpit voice tape after the landing.

Investigators established that fuel began leaking from the twin-engined, wide-bodied jet more than an hour before the pilots noticed anything amiss. When they did, they treated the problem as a fuel imbalance and failed to heed the checklist warning of fuel-leak possibility.

They did not call up the checklist on the computer screen, relying instead on memory for their actions. Fifteen minutes later, with the fuel level dropping alarmingly and below the minimum needed to reach Lisbon, the crew elected to divert to the Azores. But they continued to transfer the dwindling fuel from the left wing to the leaking right side.

At 6:13 a.m., with the aircraft more than 240 kilometres from Lajes, the right-side engine flamed out for lack of fuel. At 6:23, the crew radioed a full-scale mayday. Flight attendants were told to prepare the passengers for a ditching. Three minutes later, more than 100 kilometres from the nearest land, the left engine flamed out. During the next 19 minutes, in darkness and with only limited instruments, Capt. Piché nursed the unpowered aircraft to a landing.

Investigators determined that the fuel leak was caused by improper installation of the right-side engine nearly a week earlier. Air Transat technicians, dealing with a slightly different model of Rolls-Royce engine than they were familiar with, had improperly attached fuel and hydraulic lines to the engine. The lines chafed, eventually fracturing the fuel line.

The report says that the Air Transat flight crew were inadequately prepared to recognize and deal with fuel leaks.

"The flight crew members had never experienced a fuel leak situation during operations or training," the report says, adding the "lack of training in the symptoms of fuel-leak situations resulted in this crew not being adequately prepared."

Chutney 18th Oct 2004 10:37

Wonder if anyone will want to swing handbags at the report above. Or have we found a mainstream media journo who meets aviators' hopes and expectations?

Pip Pip!!

rotornut 18th Oct 2004 10:51


Details of the flight-crew conversations were lost to investigators because the pilots inadvertently recorded over the 90-minute cockpit voice tape after the landing.
Inadvertently?

M.Mouse 18th Oct 2004 11:11

Yes, inadvertently.

It's all there in the report.

Budgie69 18th Oct 2004 12:33

Rotornut

I know it's an awful drag to actually read the report, but why don't you give it a try. It doesn't have any joined up writing and doesn't use many terribly long words.

If you do read the relevant section you will see that deletion of the CVR data was inadvertent. However it is obviously much more fun to make sly insinuations.

Frangible 18th Oct 2004 12:50

Inadvertently recorded over CVR?
Two engines out, no power except through the RAT in flight.
How is that possible?

M.Mouse 18th Oct 2004 12:54

When you have read the report, ask the question again.

Assuming of course the answer isn't there.

Frangible 18th Oct 2004 12:54

Pardon me, I'll answer my own qustion. It was overwritten following application of ground power later on.

rotornut 18th Oct 2004 15:18

OK (deep breath) to be fair I'll read the report :(

EDDNHopper 18th Oct 2004 16:42

rotornut,
:ok:

Miserlou 18th Oct 2004 16:48

Our SOP says to pull the c/b's on the recorders after an incident. Shame their's didn't.

So, apart from the convenience, it may well have been inadvertant .

mac_scott 18th Oct 2004 17:04

Read the report
 
Interesting read. As with all accidents there is a chain of events that leads to the incident taking place. Blaming the Captain/FO for doing the checklist from memory misses any number of factors. Interesting ones for me were:

1) Training at the time did not seem to cover fuel leaks - so the crew were not trained to look for this.

2) Fuel leaks only appeared as a caution note on the fuel imbalance proceedure!

Overall sounds like the crew did an amazing job on getting this one down and putting all the blame on their doing a "check list from memory" is a gross oversimplification of the man steps that led to this incident.

Mac

Report says that the procedures on pulling CBs were not clear and the crew pulled 2 out of 3 - hence the data got zapped.

Mac


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