Air Transat Flight 236

Air Transat
Industry	Airline
Founded	1986
Headquarters	Montreal, Canada
Products	Passenger air transport
Website	www.airtransat.com

Air Transat Flight 236 was a transatlantic journey originating in Toronto, Canada, bound for Lisbon, Portugal, which experienced a complete loss of engine power over the Atlantic Ocean on August 24, 2001. The Airbus A330 exhausted its fuel supply due to a leak caused by faulty maintenance procedures. Captain Robert Piché (48) and First Officer Dirk DeJager (28) managed to glide the aircraft to a successful emergency touchdown on the Azores islands, ensuring the safety of all 306 individuals aboard (293 passengers and 13 crew members). This event marked the longest glide of a passenger aircraft without engine power, almost , leading to the aircraft being dubbed the "Azores Glider."

Aircraft

The airplane involved was an Airbus A330-243, bearing registration C-GITS. It was slightly more than two years old and powered by two Rolls-Royce Trent 772B-60 engines.

Incident

Flight 236 took off from Toronto at 00:52 UTC on August 24, 2001, carrying 293 passengers and 13 crew members. Captain Piché had accumulated 16,800 flight hours in total (with 796 hours on the A330), while First Officer DeJager had logged 4,800 hours overall (386 hours on the A330).

This Airbus A330-243 (C-GITS), just over two years old, first flew on March 17, 1999. It was configured with 362 seats and entered service with Air Transat on April 28, 1999. Equipped with two Rolls-Royce Trent 772B-60 engines producing each, it departed Toronto fully fueled—exceeding regulatory minimums.

At approximately 04:38 UTC, nearly four hours after departure, a fractured fuel line caused a leak in engine number two (the right engine). By 05:03 UTC, the flight crew noticed abnormal oil temperature and pressure readings for that engine. These indicators were indirect consequences of the fuel leak; however, the pilots did not identify this as the cause and dismissed the warnings as erroneous. Maintenance control in Montreal advised continuous monitoring.

Signs of fuel issues

Fuel consumption was unusually rapid, as reflected by the Fuel-On-Board (FOB) readings on the Engine Warning Display. The projected fuel remaining upon arrival was also decreasing, signaling a diminished range. Despite having departed Toronto with of fuel load, an early full forward transfer of fuel from the trim tank occurred. This was evidenced by a prolonged TRIM TANK XFR message lasting 19 minutes between 05:11 and 05:30, followed by a TRIM TANK XFRD message from 05:30 to 05:33.

At 05:36 UTC, a fuel imbalance alert was triggered. Instead of referring to procedural checklists, the crew relied on memory and initiated cross-feeding of fuel into the leaking engine. Consequently, fuel escaping through the ruptured line amounted to roughly 13 tonnes per hour (more than 3.6 kg/s), intensifying flow through the fuel-oil heat exchanger and causing oil temperature to fall while oil pressure rose in engine number two.

By 05:45 UTC, the pilots elected to divert to Lajes Air Base in the Azores. An initial heading deviation of fourteen degrees occurred due to autopilot settings but was corrected following air traffic control guidance. A fuel emergency was declared three minutes later.

At about 06:13 UTC—approximately from Lajes at —engine number two flamed out due to fuel starvation. The crew descended to , appropriate for single-engine operation weight. Ten minutes afterward, a mayday call was issued.

At roughly 06:26 UTC and about from Lajes, engine number one also experienced flameout, leaving the aircraft to glide without any engine thrust. The emergency ram air turbine deployed automatically to provide power for essential sensors, flight instruments, and primary flight controls.

Hydraulic power loss affected operation of flaps, alternate brakes, and spoilers; however, slats remained functional and primary brakes operated briefly using accumulator pressure. With engines offline, cabin pressurization ceased and oxygen masks deployed at 06:31 UTC.

Military controllers provided radar guidance throughout. Descending at approximately , pilots estimated having fifteen to twenty minutes before ditching in open water. The air base appeared shortly thereafter; Captain Piché executed one full 360° turn along with several "S" maneuvers to reduce altitude.

Touchdown occurred at 06:45 UTC about past the runway threshold at an estimated speed of . The aircraft bounced once before settling again approximately from threshold. Maximum emergency braking brought it to a halt after rolling for along the runway.

With antiskid and brake modulation systems disabled, all eight main wheels locked up; tires wore down rapidly and deflated within , causing wheels to grind down to axle journals during rollout.

Fourteen passengers and two crew members sustained minor injuries; two passengers suffered serious injuries during evacuation. Structural damage included deformation of main landing gear components and punctures in lower fuselage caused by debris impact during landing roll.

Investigation

The Portuguese Aviation Accidents Prevention and Investigation Department (GPIAA), in collaboration with Canadian and French officials, conducted the inquiry into the incident.

The investigation determined that the primary factor was improper handling by the crew of a fuel leak originating from the number two engine. This leak stemmed from an incorrect component installation within the hydraulics system, performed by Air Transat maintenance personnel during routine servicing. Specifically, an engine replacement using a Rolls-Royce spare lacking a hydraulic pump necessitated fitting a part from a similar engine model, which reduced clearance between the hydraulic and fuel lines. This minimal separation caused abrasion and ultimately led to the rupture of the fuel line.

Air Transat acknowledged its responsibility and was levied a fine of C$250,000—the largest penalty imposed in Canada up to 2009.

Notable conclusions included:

The flight crew did not recognize the fuel issue until warning indicators were triggered.
Their evaluation of the situation prior to taking action was inadequate.
The crew incorrectly executed the fuel imbalance procedure from memory, inadvertently supplying fuel to the leaking engine.
Omitting checklist warnings delayed detection of the fuel leak.
The failure to promptly identify and respond correctly to the leak resulted in complete fuel depletion.

Despite these procedural shortcomings, the pilots were commended for their adept execution of a powerless landing. In 2002, Captain Piché received the Superior Airmanship Award from the Air Line Pilots Association, International for his exemplary skill.

Aftermath

Subsequent to the investigation, the French DGAC issued directive F-2002-548B, requiring detailed fuel-leak procedures be incorporated into flight manuals and emphasized crew training on this matter. This directive was later superseded by F-2005-195. Meanwhile, the US Federal Aviation Administration (FAA) released AD 2006-02-01, effective February 3, 2006, mandating updated flight manual protocols addressing fuel leaks on Airbus A330 and A340 aircraft.

Both DGAC and FAA issued an airworthiness directive (AD) compelling all operators of Airbus models A318, A319, A320, and A321 to revise their flight manuals. Crews were instructed to verify that any detected fuel imbalance was not caused by a leak before opening the cross-feed valve. Airlines were given 15 days to comply before enforcement commenced. Additionally, Airbus improved its onboard computer systems to monitor fuel consumption relative to flight plans, triggering alerts if usage exceeded engine parameters. Rolls-Royce also issued a service bulletin addressing compatibility issues between certain engine components.

This event marked the longest recorded glide of a passenger aircraft without engine power.

Margaret McKinnon, then engaged as a postdoctoral psychology researcher at Baycrest Health Sciences and a passenger aboard Flight 236, led research involving 15 additional passengers examining post-traumatic stress disorder (PTSD). Published in Clinical Psychological Science in August 2014, this study compared memory recall among passengers with PTSD, those without it, and a control group, providing valuable insights into trauma-related memory processes.

In popular culture

The incident involving Flight 236 was dramatized in the 2003 Canadian television episode "Flying on Empty," part of the first season of Mayday—also known as Air Emergency in the United States and Air Crash Investigation in the United Kingdom. The episode highlighted that Airbus, Air Transat, and the flight crew did not participate, with the reenactment relying on expert analysis and established facts.
Additionally, the flight was featured in a special edition of Mayday during its sixth season in 2007, titled "Who's Flying the Plane?"
On August 7, 2005, MSNBC broadcast a segment named "On a Wing and a Prayer."
The narrative of Captain Robert Piché is portrayed in the 2010 French Canadian biographical drama film Piché: The Landing of a Man, which culminates with the events of Flight 236. Actor Michel Côté plays Piché, with his son Maxime LeFlaguais depicting him as well.

References

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