All Engines-out Landing Due to Fuel Exhaustion, Air Transat, Airbus A330-243 marks C-GITS, Lajes, Azores, Portugal, 24 August 2001 Micro-summary: Following an undetected fuel leak, this A330-243 had to dead-stick to a successful landing. Event Date: 2001-08-24 at 0613 UTC Investigative Body: Aviation Accidents Prevention and Investigation Department, Portugal, with extensive cooperation by Canada TSB Investigative Body's Web Site: http://www.gpiaa.gov.pt/ Note: Reprinted by kind permission of the AAPID. Cautions: 1. Accident reports can be and sometimes are revised. Be sure to consult the investigative agency for the latest version before basing anything significant on content (e.g., thesis, research, etc). 2. Readers are advised that each report is a glimpse of events at specific points in time. While broad themes permeate the causal events leading up to crashes, and we can learn from those, the specific regulatory and technological environments can and do change. 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Government of Portugal MINISTÉRIO DAS OBRAS PÚBLICAS, TRANSPORTES E COMUNICAÇÕES GABINETE DE PREVENÇÃO E INVESTIGAÇÃO DE ACIDENTES COM AERONAVES Aviation Accidents Prevention and Investigation Department Accident Investigation Final Report All Engines-out Landing Due to Fuel Exhaustion Air Transat Airbus A330-243 marks C-GITS Lajes, Azores, Portugal 24 August 2001 22 / ACCID /GPIAA / 2001 Final Investigation Report 22 / ACCID / 2001 18 October 2004 Occurrence Summary On August 24, 2001, Air Transat Flight TSC236, an Airbus 330-243 aircraft, was on a scheduled flight from Toronto Lester B Pearson Airport, Ontario (CYYZ), Canada to Lisbon Airport (LPPT), Portugal with 13 crew and 293 passengers on board. At 05:33, the aircraft was at 4244N/2305W when the crew noted a fuel imbalance. At 05:45, the crew initiated a diversion from the flight-planned route for a landing at the Lajes Airport (LPLA), Terceira Island in the Azores. At 05:48, the crew advised Santa Maria Oceanic Control that the flight was diverting due to a fuel shortage. At 06:13, the crew notified air traffic control that the right engine (Rolls-Royce RB211 Trent 772B) had flamed out. At 06:26, when the aircraft was about 65 nautical miles from the Lajes airport and at an altitude of about FL 345, the crew reported that the left engine had also flamed out and that a ditching at sea was possible. Assisted by radar vectors from Lajes air traffic control, the crew carried out an engines-out, vis- ual approach, at night and in good visual weather conditions. The aircraft landed on runway 33 at the Lajes Airport at 06:45. After the aircraft came to a stop, small fires started in the area of the left main-gear wheels, but these fires were immediately ex- tinguished by the crash rescue response vehicles that were in position for the landing. The Captain ordered an emergency evacuation; 16 passengers and 2 cabin-crew members re- ceived injuries during the emergency evacuation. The aircraft suffered structural damage to the fuselage and to the main landing gear. Final Investigation Report 22 / ACCID / 2001 Pag 2 of 103 Table of Contents 1.0 FACTUAL INFORMATION.......................................................................................................................7 1.1 HISTORY......................................................................................................................................................7 1.1.1 History of the Flight...............................................................................................................................7 1.1.2 Passenger Cabin Events ........................................................................................................................9 1.1.3 Summary of Related Engine Maintenance Events ...............................................................................10 1.2 INJURIES TO PERSONS................................................................................................................................11 1.3 DAMAGE TO AIRCRAFT .............................................................................................................................11 1.4 OTHER DAMAGE .......................................................................................................................................12 1.5 PERSONNEL INFORMATION........................................................................................................................12 1.5.1 Flight Crew..........................................................................................................................................12 1.5.1.1 Captain Information........................................................................................................................12 1.5.1.2 First Officer Information ................................................................................................................13 1.5.2 Cabin Crew..........................................................................................................................................13 1.5.3 Technical Personnel ............................................................................................................................13 1.5.3.1 Engine Controller ...........................................................................................................................13 1.5.3.2 Maintenance Technicians ...............................................................................................................14 1.5.4 In-house Rolls-Royce Representative...................................................................................................14 1.6 AIRCRAFT INFORMATION ..........................................................................................................................14 1.6.1 Weight & Balance................................................................................................................................15 1.6.2 Right Engine Information ....................................................................................................................15 1.6.2.1 Right Engine History.......................................................................................................................15 1.6.2.2 Rework Summary Sheet...................................................................................................................16 1.6.2.3 Carry-forward Items .......................................................................................................................16 .6.2.4 Engine Log Book..................................................................................................................................16 1.6.3 Engine Fuel Tube Rupture...................................................................................................................17 1.6.4 Oil parameters.....................................................................................................................................18 1.6.5 Fuel System..........................................................................................................................................18 1.6.5.1 Fuel System Description .................................................................................................................18 1.6.5.2 Fuel System Operation on the Occurrence Flight...........................................................................20 1.6.5.3 Fuel System Examination................................................................................................................21 1.6.6 Electronic Centralized Aircraft Monitoring ........................................................................................22 1.6.6.1 Electronic Centralized Aircraft Monitoring System Description....................................................22 1.6.6.2 ECAM Indications During the Occurrence Flight..........................................................................23 1.6.7 Flight Management Guidance Computer ............................................................................................25 1.6.8 Electrical Systems................................................................................................................................26 1.6.9 Flight Controls.....................................................................................................................................26 1.6.10 Emergency Exit L3..........................................................................................................................27 1.6.11 Cabin Pressurization System...........................................................................................................28 1.6.12