Air Transat A-330

golden hawk · Post by **golden hawk** » Mon Oct 18, 2004 6:36 am

Report blames pilots in Transat near-disaster

CTV.ca News Staff

Updated: Mon. Oct. 18 2004 7:28 AM ET

The official report is taking the shine off an Air Transat pilot's apparent feat of heroism, blaming Captain Robert Piche and his crew for needlessly jeopardizing their Portugal-bound airliner.

In August 2001, Capt. Piche was hailed as a hero after he glided his Airbus A-330 to an emergency landing in the Azores, 19 minutes after the plane ran out of fuel over the Atlantic Ocean.

According to the official report of the incident, obtained by The Globe and Mail ahead of its release on Monday, Portugal's Aviation Accidents Prevention and Investigation Department says the jet could have made a routine diversionary landing if pilots had followed proper procedure.

The report suggests that when the flight crew recognized a fuel leak -- more than an hour after it began -- they misdiagnosed the problem as an imbalance, rather than a leak.

Trying to correct the problem from memory, rather than following an established checklist, led to a miscalculation and the dumping of tonnes of fuel.

Despite their criticism, the Portuguese investigators were nevertheless impressed by Piche's ability as a pilot.

"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, singling out the final 360-degree turn Piche executed to lose sufficient height for landing at the Lajes air base in the Azores.

The report concludes the initial leak was caused by improper installation of the plane's right-side engine nearly a week before the emergency landing. Improperly attached fuel and hydraulic lines had chafed, creating a rupture.

In a statement released late Sunday night, Piche said the report brings the incident to an end.

"The report by Portuguese authorities on Air Transat Flight TS 236 confirms that the August 24, 2001, occurrence was the result of a chain of events, and identifies the risk factors involved," Piche said.

"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.''

Credited with saving the lives of more than 300 passengers and crew, details of Piche's past, including 19 months in a Georgia prison after he was caught flying marijuana runs, were brought to light in the subsequent public spotlight.

In a separate statement released Sunday, Air Transat president and CEO Allen Graham said his company supports the recommendations included in the report.

"Since the occurrence we have reviewed our training programs and enhanced our processes, in terms of both maintenance and flight operations. Passenger safety has always been and continues to be our top priority; this event is unique in our history,'' Graham said.

© Copyright 2004 Bell Globemedia Inc.

Report blames pilots in Transat near-disaster

CTV.ca News Staff

Disco Stu · Post by **Disco Stu** » Mon Oct 18, 2004 6:47 am

Are the captain and FO still employed at AT?

Snowgoose · Post by **Snowgoose** » Mon Oct 18, 2004 7:07 am

I am pretty sure that what they said in the Discovery channel movie about the flight. Both of them are still working there.

Tango01 · Post by **Tango01** » Mon Oct 18, 2004 12:57 pm

So he flew weed around and didn't follow the proper procedures. I'd like to know how many pilots out there can make a 360 turn dead stick on a 330 and land such beast with that precision . Media seems to point out all the flaws he had as a human, well did anyone die?

T01

pika · Post by **pika** » Mon Oct 18, 2004 1:17 pm

Wrong Tango01. As TC once said, "He did a great job from 34 000' down". How he ended up in that situation is where the problem is. Read the conclusions. THE WHOLE EVENT COULD HAVE BEEN AVOIDED!

TopperHarley · Post by **TopperHarley** » Mon Oct 18, 2004 1:18 pm

T01,

You're missing the point. The fact that is being pointed out now is that the pilots created a possible emergency situation. Sure they glided the plane down and did a great job at that, but that situation could have been prevented, had proper procedures been followed.

I'm not saying these guys should be fired... I just do not think they should have been portrayed as heroes. Just my opinion,

Chris.

golden hawk · Post by **golden hawk** » Mon Oct 18, 2004 1:23 pm

Exactly, C-HRIS

If someone sets fire to a building, then rushes in to save everyone including the cat and dog, does that make him a hero?

Tango01 · Post by **Tango01** » Mon Oct 18, 2004 1:33 pm

pika wrote: THE WHOLE EVENT COULD HAVE BEEN AVOIDED!

Yeah and so can more than 85% of accidents, but are they avoided? Go to the NTSB site and read the reports. You got enough to read for the rest of your life. People make mistakes guys, human error was certainly a factor here, but have we considered why the leak happened in the first place? The maintenance? I understand that the crew made the wrong decision, but there are two things to keep in mind.

1) None of us were there, nor do I think we're qualified to even make a comment on it (unless one of you guys fly a 330)

2) The Captain's flying skills were outstanding, and although the wrong decision was made, he was competent enough to avoid a disaster.

Give the guy some credit, and never quote any Civil Aviation Authorities, investigators, etc. It's too easy to judge and pass blame with your warm cup of coffee on the ground.

T01

paul972 · Post by **paul972** » Mon Oct 18, 2004 1:35 pm

Can I rephrase?

golden hawk wrote: If someone sets fire to a building, then rushes in to save everyone including the cat and dog, does that make him a hero?

I would say:

If someone makes a mistake and a building is set on fire, then rushes in to save everyone including the cat and dog, does that make him a hero?

I know that lots of pilots in this site don't make mistakes, but it sounded a bit unfair since the guy didn't "set the fire to a building" on purpose.

pika · Post by **pika** » Mon Oct 18, 2004 1:36 pm

I am indeed typed on the A330 and stand by my original comments that you are wrong. The wrong pump was only one link in the chain of errors. An empty tail tank (3200 kg in this case) and a gross imbalance says you have a serious problem. Time to land and figure it out on the ground.

CAL · Post by **CAL** » Mon Oct 18, 2004 1:47 pm

Oh and one more thing....lets not really take anything the portugese say seriously......

paq · Post by **paq** » Mon Oct 18, 2004 2:13 pm

I read another report saying that maintenance in Toronto had made a mistake while working on the right engine, causing the initial fuel leak.

Capt Piche probably did a mistake, but he saved the airplane and passengers. Only the tires were damaged.

"Ok guys, fill her up, change the tires, and she's good to go!"

PAQ

TopperHarley · Post by **TopperHarley** » Mon Oct 18, 2004 2:21 pm

Paul,

This may seem a little nit-picky, but I will post it anyway.

To elaborate on your scenario...

Imagine that the person who "accidentally" set-fire to the building had purchased some sort of electrical device. He decides to use it, but neglects to read the manual on how to properly use the special device and deal with any abnormal circumstances. He improperly uses the device, and because of his neglect, he a fire starts.

Although this person did not intend to start the fire (and I am certain that the crew never intended this incident to occur), a potentially dangerous situation resulted because of neglectful action.

I agree with someone's post that we should not be pointing fingers and trying the get these pilots fired. I am just trying to point out that we should not elevate these pilots to a heroic status.

Chris.

golden hawk · Post by **golden hawk** » Mon Oct 18, 2004 2:29 pm

Paul972

An interesting point. However, we need to ask "Did that pilot take the actions that another reasonable A-330 Captain would make". Obviously he did not intend to make that mistake, but that is not a defense, especially in a court of law re negligence.

Saving the aircraft and passengers does not mean everyone walked away happy - most of those pax suffered mental trauma and likely have long lasting issues to deal with. None of it would have happened if this Captain had acted properly from the start.

Mistakes will happen, no doubt - we are human. But recovering from mistakes does not make someone a "hero".

If the same AME who installed the pump incorrectly re-installs it correctly, is he also a hero?

Tango01 · Post by **Tango01** » Mon Oct 18, 2004 2:56 pm

I guess we can all agree that the guy is not a hero. He did, however saved everyone's ass (due to his mistake). Pika, what is the protocol for this situation?

pika · Post by **pika** » Mon Oct 18, 2004 3:08 pm

Without being completely familiar with the report... 6 tonnes of fuel are unaccounted for and you have to ask what the protocol is!? I believe the Fuel Imbalance ECAM was flashing which would (I believe and without me pulling books out) lead you to the Fuel Imbalance Checklist. On that checklist you will find a caution that advises to make sure it is not a fuel leak before opening the crossfeed. Nowhere do any FCOMs say perform the "Fuel Problem From Memory Drill" which opens the crossfeed. Guilty.

Always ask yourself, "What would I tell the board?"

Paq, the whole airframe was damaged dude, not just the tires. With no electrics to power the FDR nobody knows how many G's the airplane was subject to. Yet it still flies. Who's to blame in the future when the tail falls off this one?

(edited to make CVR into FDR)

Cat Driver · Post by **Cat Driver** » Mon Oct 18, 2004 3:12 pm

Hey G.H. , the main thing is you made sure they saved me, and my dog.

wrc · Post by **wrc** » Mon Oct 18, 2004 3:30 pm

The heros are all the guys who never make the critical errors and fly day in, day out, A to B in a safe manner.

The Transat skipper made a critial error obvious to most if not all A330 drivers.

He followed that up with a great bit of flying to save his sorry butt.

This reminds one of the Gimli f%#k-up a few years back. That other Montreal airline made their guy into a "hero" as well, after he also put himself in a rough spot. All part of the PR deflecting blame game (involving baffling with bs).

Cat Driver · Post by **Cat Driver** » Mon Oct 18, 2004 3:38 pm

O.K....O.K.

I was going to stay out of this one, but what happened to CRM is there not two pilots involved?

Why put all the blame on the Captain?

Cat

golden hawk · Post by **golden hawk** » Mon Oct 18, 2004 3:45 pm

Absolutely, Cat. Part of good CRM is Inquiry, advocacy, and assertion by both crew members.

P.S. I overlooked your title with the "cat and dog" being saved! Happy you made it.

Cat Driver · Post by **Cat Driver** » Mon Oct 18, 2004 4:17 pm

G.H. :

I mentioned the two crew issue because the industry sometimes focuses on just giving lip service to crew coordination and once finished with the PDM / CRM courses( sometimes taught by people with no first hand experience ) they then get in airplanes and do not carry through with the concept.

One of the biggest compliments I ever received was from a pilot who had flown several seasons with me in a water bomber.

He was flying as F.O. on a DC8 and they were in Gatwick ready to depart. The Captain was about to start a flight with a serious safety issue that he was going to just ignore.

My friend said that he expressed his concerns to the Captain and was told to shut up. He said he sat in the right seat and closed his eyes and asked himself " what would . do?" he then undid his seat belt and walked off the airplane.

Crew co ordination is manditory and in that your very life depends on making the right decisions both pilots are equal when it comes to speaking up and pointing out errors.

Cat

pika · Post by **pika** » Mon Oct 18, 2004 4:38 pm

Hey Cat, apparently the good Captain was not entertaining any ideas from the FO. The FO was reportedly (from the post RCMP interviews) SCREAMING at the good Captain to turn around. Even after both flamed out he wanted to press on. I'm sure there is some truth to this story so it seems the FO saved this from becoming a ditching exercise.

The Dude · Post by **The Dude** » Mon Oct 18, 2004 5:18 pm

This is why there will never be a UAV passenger airliner. Design flaw, retarded ground crew, terrorist, who cares when you can blame the pilot for not dealing with it. The best part is you will never have a shortage of pilots ready to rip into the accused.

reportedly (from the post RCMP interviews) SCREAMING at the good Captain to turn around. Even after both flamed out he wanted to press on.

Is this in the report?

Rebel · Post by **Rebel** » Mon Oct 18, 2004 6:08 pm

What are the chances that AT will survive long term the lawsuits that are going to occur as the result of the findings in the accident report? Me thinks they have a problem…

golden hawk · Post by **golden hawk** » Mon Oct 18, 2004 8:09 pm

I guess that's why they buy insurance........