Final Report Blames Pilot Error, Fuel Leak For Air Transat
Incident
It was a remarkable
feat. After his engines quit on a flight from Toronto to Lisbon,
Captain Robert Piche (below, right) glided for 19 minutes,
bringing his Airbus A-330 into Lajes Field (Azores) for a perfect
dead stick landing. He blew out some tires, but none of his 306
passengers and crew was hurt.
The question is, what forced the dead stick landing in the first
place?
Portugese authorities blame a combination of pilot error and an
improperly installed engine for the emergency landing of an Air
Transat flight in the Azores three years ago.
Issuing its final 103-page report, the Portuguese Aviation
Accidents Investigation Department ruled that a poorly installed
engine and the captain's errors in transferring fuel forced the
emergency landing.
The report, issued Monday, said the senior mechanic who
installed a replacement engine aboard the aircraft "relied on
verbal advice" and didn't refer to the manuals. As a result,
investigators said fuel and hydraulic lines were mismatched. They
came in contact, fractured, and caused a massive fuel leak in the
right engine.
But that's not how it
looked in the cockpit, according to the report. The flight crew got
what the report called a "low-level" fuel warning in the cockpit.
But instead of recognizing the problem for what it was,
investigators said Piche and his copilot thought the tanks were
merely imbalanced -- that fuel in the right wing was low -- so they
initiated a fuel transfer.
That caused Jet A to pour out of the fractured lines leading to
the right engine. The aircraft ran dry and both engines quit.
Investigator said the crew should have shut down the leaking
right engine or simply not transferred fuel from the left wing
tank.
"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 said, as quoted by the Canadian
Broadcasting Corporation.
But the report didn't exclusively blame the pilots. Although
investigators said they "did not correctly evaluate the situation
before taking action," they also said "the low-level nature of [the
fuel advisory], on its own, did neither clearly indicate the cause
of the imbalance nor the severity of the situation that existed.
There was not a clear, unambiguous indication or warning that a
critical fuel leak existed."
The report did have high praise for Captain Piche's landing.
Investigators said his skill in a dead stick landing averted a
catastrophic accident.