three torain alarm so great we are in an emergency [Music] on the night of the 24th of august 2001 a fully loaded Airbus a330 with 306 people on board ran out of fuel Midway over the Atlantic how could a state-of-the-art computerized airliners suffer such a catastrophic failure Mayday Mayday Mayday we have lost both engines due to fuel starvation we are gliding now while we're now 30,000 feet at the rate of descent of 2,000 feet per minute way off solution of water on your life jackets right now this film investigates what happened to air transat flight 236 this is it this is what it's over there's gonna die the next five to ten minutes it speeds increasing 203 knots now way too fast everybody [Music] [Music] august twenty-third 2001 Toronto's International Airport is busy air transat is a charter company that has grown rapidly to become one of the largest airlines in Canada mid summer brings fewer business travelers and a holiday atmosphere air transat flight 236 is bound for Lisbon most of the passengers are Canadians visiting europe or Portuguese immigrants heading home the plane a twin-engined Airbus a330 is being flown by a young copilot derp de jager and an experienced captain robear piche captain robert e che is somewhat out of the ordinary captain piche from the moment he gets his wing he gets to learn how to fly in the north of the province of Quebec where the conditions occasionally are very severe the flight deck of the a330 is ultra-modern banks of computers connected to over a hundred onboard sensors constantly monitor the operation of the plane this film reveals how serious problems can arise when the pilots get unusual readings from the computers and begin to distrust them on this night the computers assist the smooth takeoff a flight 236 or anything heavy Oh 8320 Air Canada turn left on Romeo and holy or Don who wore a Roger follow a320 air canada left on Romeo and hold short of 24 right with the crew of 13 flight 236 has 306 people on board [Music] transuranic heavy cleared for takeoff 240 at eight cleared for takeoff 24 right turns up to 36 heavy at ten minutes past eight the Airbus a330 loaded with over 47 tons of fuel left Toronto for Lisbon v1 rotate the weather forecast for the Atlantic crossing is good everything runs smoothly on the flight deck apart from a small adjustment to the route to avoid congestion air traffic control directs the flight 60 miles south of its original route it's a minor alteration but will play a crucial role later [Music] passengers settled down for the long crossing everything appeared quite normal and in fact my head traveled on air transat previously and found it not to be very good and was surprised by the quality of the flight that it was on time the plane was newer we thought generally with much better than we had expected it would be we're getting to our next checkpoint every 30 minutes across the Atlantic the crew checked their position and fuel consumption against their flight plan like two tons on the right 11.2 tons on the left despite the computerized systems some procedures like checking the fuel on board still need to be done by hand 20 tons by comparing the amount of fuel in the tanks with the amount the flight started with the pilots can keep an eye on their fuel consumption he'll check complete levels normal for the distance phone [Music] for the first five hours everything is routine the flight crew air transat and accident investigators have all declined to be interviewed about what happened next this film uses known facts about the flight standard emergency procedures and expert opinion to reconstruct what took place on flight 236 look we're getting a warning signal I templo and I pressure higher number two this warning is the first step in the crisis well pressure isn't within normal limits on number one number two is slightly high the computer display reveals that the oil temperature is low an engine number two but the oil pressure is high it is a very unusual reading the pilots are puzzled I can't see anything here or look in the f calm okay a low oil temperature indication is normally in indicative of bad readings bad sensor oil temperatures don't decrease normally they increase a low oil temperature would be of no concern the high oil pressure is is a very strange indication it's it's very rare in fact I've never actually heard of one it's only indicative of the contamination normally of the oil with fuel that's not something that's explained in the manuals call the company the crew contact air transat maintenance group in Montreal transat 236 to Mirabelle operations Maribel transit 2 3 pig hi hi we have a little problem we're getting the warding oil temp low and oil pressure high on the EKF Regin number two there's nothing in the QR age nor the F com can you help us out I'm looking in the manual the ground crew have no immediate solution the pilots must work it out themselves they may have been given some advice on troubleshooting to see if that would help but ultimately you know the pilots are up there on their own you know they can get advice from somebody 2,500 miles away but they can't really fix the problems I can't you keep monitoring your oil no moment it would happen right but because the oil readings are so unusual the pilots believe they may indicate a computer error the crew keep monitoring the oil levels air transat 236 continues on track [Music] then 20 minutes later a new warning fuel imbalance worried haven't seen that before follow ali connection i have air traffic control in the airbus 330 most of the fuel is in large tanks in the wings the computer has now detected that the fuel level on the right is now significantly lower than the left the crew consults the airbus flight menu which recommends they transfer fuel through the special cross feed valve fuel then flow from one tank to the other [Music] but before opening the cross feed the pilots must be sure that the imbalance is not caused by a more serious problem such as a fuel leak last few check was only 15 minutes ago and it was okay no indication of a few leak keep going win crusty on on once you begin their cross feeding procedure to correct a fuel imbalance restorative action should commence quite quickly in other words the situation would not continue to to get worse it would do it either stabilized immediately and then begin to to correct itself but the situation is not correcting itself unknown to the pilots there is a major fuel leak in the number two engine on the right hand side of the plane flight 236 is some 300 kilometers from the nearest land in mid-atlantic [Music] 39,000 feet over the Atlantic some 300 kilometers from land air transat flight 236 is in trouble unknown to the pilots the right engine is leaking fuel the planes computer system has thrown up a series of warnings but the pilots believe these are computer errors have you ever seen something like this before nope doesn't make any sense hey even if there is a leak it doesn't explain the alarms on the oil system and everything was okay at the last few check at 30 west huh bet you it's a computer problem the task of finding out if there is a fuel leak is made harder by the design of the air bus systems the systems monitor hundreds and hundreds of sensors and you know they can be affected by you know such mundane things as a little bit of frost or ice on a sensor can can can cause it to present bad data there is no direct warning to show if the fuel level is falling faster than the engines are consuming it out if you so the pilots receive no immediate indication that there could be a fuel leak fuel quantity isn't rising in the tanks of the right wing check fuel quantity it's very low hold on when copilot de Jager carries out the fuel calculations he discovers something is seriously wrong it's much less fuel than we should have it looks like a fuel leak check again diagur finds a disturbing difference according to all the gauges all the tanks in the right wing are way below the level this should be according to the flight plan and it certainly anything in the other ones what about a trim tank it's nothing there either [Music] yes hello first officer here I think I'm took an archive man sure although captain piche still believes he is dealing with a computer problem he nevertheless decides to ask for a visual check just in case to see if there could be a fuel leak captain hi can you and Karen take some flashlights and go to the windows if you can see anything training back from the wings it'll look like a mere storystream and report back to me to see ok great I wanted to do another complete you check please [Music] in daylight the fuel pouring out the back of the wing would have been clearly visible but in the dead of night even with a torch the fuel leaking from the engine is impossible to see the crew evidently realized that the situation was not improving and at that point they realize that this that their circumstances were becoming more serious and I think that there were probably some discussions took place between the two pilots as to what the next course of action should be right if the computer is correct then with the amount of fuel remaining the Airbus will no longer be able to make it to Lisbon captain piche is forced to divert the flight we've got a direct get on to ocean take control where's the nearest airfield transat 236 ave santa maria control can you advise nearest airfield we have a possible fuel problem the nearest runway is over 300 kilometers away with the fuel remaining logis military airbase on the tiny island of Terceira in the Azores should be within reach anamaria control traffic heavy cross into 30 flight level 39 throw the red 350 miles the principle are you declaring an emergency standby side of Rio control not yet must be the computer transat 236 heavy santamaria control no assistance required yet [Music] flight 236 continues flying south for the next 25 minutes everything in the cabin seems normal but in the cockpit the fuel readings are getting worse must be the computer I've checked there's nothing in the trim or center tank and the gauges show only seven according to the fuel gauges the plane is using fuel much faster than normal weather they believe the gauges are not the captain has no choice he must warn air traffic control we have to declare a fuel emergency [Music] transat 236 heavy Santa Maria control I memory on y'all grandpa let me go ahead transat 236 heavy declaring fuel emergency I really hope it's a computer bad because if we learn in the Azores have a Plane full of you crucify us but at six thirteen am less than an hour from the first fuel alarm the full gravity of their situation strikes home [Music] the right hand engine runs out of fuel and cuts out we're losing engine number two I don't believe this okay maximum throttle number one lights started flickering on and off which I thought was kind of odd strange on one engine the Airbus will not fly at 39,000 feet they must descend quickly all right to transfer fuel from center tank and the trim pain transferring fuel quantity is reaching zero this can't be I'm not gonna go completely dried this airplane alright we can't stay at 39,000 feet with just one engine of this M to 33,000 two controllers to 36 the largest power we have lost one engine engine flameout Roger gear and everything we can see on primary radar you are at 135 nautical miles from latchet view we are 135 nautical miles from lashes field for the next 10 minutes the stricken Airbus continues on its one remaining engine the pilots still believe that the computer may be partly faulty and that they can make it to Oz yes with fuel to spare at the end I'd be all right fuel gauge is falling fast though it's nearly hitting 0 [Music] but 13 minutes after the right hand engine cut out and with 157 km/h we're losing number one [Music] Mayday Mayday Mayday we have lost both engines due to fuel starvation we are gliding now [Music] one of the most sophisticated airliners of the modern era carrying 306 passengers and crew is now nothing more than a giant glider drifting steadily down towards the ocean excuse me um you can literally hear a pin drop the external is no sound in that plane in that cabin at all a lot of people were praying and screaming for God list of functions we've lost we have no more stabilizer and yellow hydraulic 80 are two and three no anti skill reversers leather trim radio hf 1 n 2 with a loss of both engines we have no electrical system as if the engines aren't running the generators aren't running so there's there's no power on the airplane there is a small device it's called a ram air turbine it will deploy from underneath the fuselage near the wing fairing and it's it's it's a small propeller that deploys at the bottom of the fuselage and it spins in the wind and that small propeller will provide very limited electrical and hydraulic systems to run the aircraft in other words although it's a glider at least its control of a glider calculate how far we can go with our triangle will you well we're now at 30,000 feet at the rate of descent of 2,000 feet per minute we can handle hang on for a 14 or 15 minutes I was just trying to calm her that like try and reassure her that everything would be okay it's a very big struggle to stay calm when you're considering your own death without power the plane loses 1,000 feet in height for every five kilometers it travels forward they can reach the Azores but if the pilots make a mistake they may face a forced landing on the water we have the ditch in the water [Music] air transat flight 236 is now drifting without fuel over the Atlantic although their initial calculations show that the plane should make it to lodge as captain piche must now follow standard emergency procedure in a passenger jet over water prepare to kevin the cab is slowly depressurizing we need to put her off engine on the loss of engine power means the cabin will soon depressurize [Music] everybody please I need your attention we are preparing to ditch the plane I need you to put on your life jackets right now within probably I'd say two minutes I saw flight attendants with life jackets in their hand running down the aisles obviously that was a sign of fear what you know what was happening was the first question that popped in my mind no you don't really know what to think but people did start to panic at that point when they were told to put on life jackets my best friend was talking to his father his father died three years ago but he's talking to him because he thought for sure he was gonna be joining us ditching a large passenger jet on the water presents a severe hazard if the airbus 330 has to make a forced landing the chances of survival are bleak in my personal opinion I don't think these airplanes would make very good boats typically an airplane with a low mounted tail like this as it enters the water one of the first things is going to hit the water is the tail and it's probably going to be rip right off and the fuselage is probably going to open right about there in 1996 a Boeing 767 ran out of fuel off the coast of East Africa its last moments were caught on amateur video and reveal what happens when an airliner attempts a controlled landing on water [Music] of the 175 people on board the Ethiopian Airways Jed only 50 survived the chances of surviving my ditching and floating for very long are not very good if air transat flight 236 has to carry out a similar maneuver it faces an equally grave outcome [Music] with over 100 kilometres before they reach the Azores the pilots face a long and difficult maneuver they need to keep the plane gliding for more than 15 minutes to reach the Azores [Music] you turns out to 36 heavy lashes power Blanchette power receiving transit 236 heavy do you have us on radar transat 236 we have you on primary radar confirm you're at 80 miles out you're heading is good John's at two thirty six heavy lashes tower we are trying to make the runway please subscribe runway heading end length magic power joins up to 36 Evie runways 33 and ten thousand eight hundred and sixty five feet long airport get ahead on your present heading please advise when you have it in sight [Music] transat 236 heavy we cannot see the airport we will tell you when we can [Music] as the minutes tick by the long wait for those on board is agonizing that's it that's this is it this is it's over just going to die the next five to ten minutes I had contemplated the idea that we would die certainly and kind of you can I think in that moment you can accept it more than you think you would accept it the torture of the whole fact that you're gonna die which I totally thought it was going to is worse to me than dying I'm gonna die just kill me now just just get a gun and shoot me or just let this plane go down and nose dive into the ocean and then just die instantly on the ground emergency services prepare for the crash landing of a fully loaded airliner with 20 kilometers to go the crew now prepare for the most dangerous part of the operation getting their plane on the runway in one piece Elijah's power do you have our distance from threshold now and weather please Roger transit 367 you're eight miles out according the primary radar airspeed 280 knots according to our reading visibility unlimited you should have the airport in sight negative lashes power until now we cannot see the runway [Music] there is no room for error without power the pilots have only one chance at landing if they miss or overshoot the runway the results could be catastrophic [Music] I got it just to the right [Music] minimum rat speed is 140 knots maximum speed for gravity gear extension 200 knots not lowering the gear until the last minute gay okay the crew struggled to lose height and speed for landing Roger lashes six nautical miles let's open the slats it'll slow us down a bit slots out locked as they approach the runway their speed increases dangerously too fast and they could run off the end of the runway lower the gear hold on [Music] speed is about 200 alright i stabilized the speed can you give me a landings me please no engine no flaps ideal approach speed is 170 knots we're too fast yes under runways very long [Music] captain piche now performs a difficult series of swerving maneuvers to slow the plane down for landing [Music] the plane was almost on her like a 45 degree angle I thought it was just gonna just gonna flip over and just noise dive straight down the plane was circling around the island just slow down so then we thought land and then we saw water and when I saw water again I'd really struck me that you know our chance for survival has maybe was gone [Music] the runway is long yeah sure but at the end is a 400-foot cliff if we don't stop in enough time we're toast we're dead the crew line up the giant Airbus for the final approach money gear down and locked three green no flops only the emergency brakes no spoilers no reverse thrust 4,000 feet 190 five knots [Music] 3000 feet 190 7 knots [Music] 2000 feet 200 knots owner de cabin cabin crew one minute to landing vertical speed at 3,000 feet per minute or one way too fast and the speeds increasing 203 knots now it's way too fast 1,000 feet 201 knots tried to get it fills up well write fast but even if the crew can get the airbus on the runway they face a further problem without engines the normal procedures for breaking are severely restricted the danger is far from over [Music] the pilots must land the plane without power and somehow get it to start [Music] everybody [Music] dear bus hits hard at high speed the tires upload captain piche tries to hold the nose down [Music] [Music] after bursting eight tires the plane finally stops in the middle of the runway [Music] Oh [Music] everybody clapping right now [Music] Oh told you make it [Music] I just wanted to get out of this airplane quickly I jump they hit the ground hard it's might I don't think my my rear end actually even touched the shoot at all I didn't slide down the slide I ran down it and they're just get out get out get out so you're just running out of this aircraft what in God's name just happy and I die I fell down to the ground literally and I just started I started crying I mean once you're off the plane and you're evacuated you want to know what happened piche and de jager had flown there Airbus without power further than any passenger jet in history as news of their remarkable achievement spread around the world they found themselves reluctant heroes you don't have time really to think about anything else than taking care of their of the safety of your passenger you know that's your main goal and since we didn't have any engine the other main goal was to me the landing safely so at that time I guess the experience came in you know with the help of my colleague that's what that's why we made a successful landing you trying for the worst but you never know how you'll be deal with situations like this and reflecting afterwards I feel we dealt in the most professional and complete what matter we could a feeling of being grateful to see all the passengers how we're okay you know something like this happened you never know what what is gonna happen really I mean you don't you stop not to believe it I mean it's no ascended a big jet with two engine has no more power with 300 people on board you know but although the public story was of success disturbing questions remained why had a highly sophisticated airliner run out of fuel what exactly had happened to flight 236 away from the cameras an accident investigation began immediately by the Portuguese Canadian and French transport authorities initial checks quickly confirmed that all the fuel tanks of the Airbus were indeed empty but to lose more than 17 tons of fuel in such a short space of time meant they had a major leak the question was where engineers examined the fuel system searching for faults in the tanks and the fuel lines it wasn't long before they found what they were looking for just by the right engine in this particular case you had a hydraulic tube that's relatively small by comparison to the larger fuel tube and the hydraulic tube do possibly two pulsations in a hydraulic system were abrading against the larger tube and eventually the larger tube had a leak in it and the leak or not the leak itself but the the whole eventually possibly led into a fracture of the tube allowing this massive fuel flow outside the engine the investigators began checking air transat maintenance records they discovered that on the 19th of august five days before the flight air transat had removed the right hand engine for maintenance and installed a replacement unit sent by rolls-royce but as they analyzed the repair logs for the engine they uncovered a shocking mistake this was not a case of faulty design but of faulty maintenance rolls-royce had supplied the engine without a hydraulic pump assembly to overcome this transat mechanics had used the parts from an older engine but they didn't fit properly and the pipes had been rubbing together for five days until midway over the Atlantic one finally broke the engine was delivered minus these two tubes and a bracket that the purpose of that bracket was to maintain adequate clearance so if they took the bracket off the old engine and put it on the new engine is that the pipes would be locked together so that they could possibly abrade as investigators questioned air transat mechanics they found more disturbing evidence of malpractice the chief mechanic testified that he had been concerned about the substitution of another hydraulic assembly five days before the accident he raised his concerns with his superior the company decided that the aircraft must go back into service and could not wait for the missing parts he should go ahead with the substitution the replacement parts only differed from the correct ones by a few millimeters but it was a difference that nearly cost 306 lives [Music] [Music] a few days after the accident air transat publicly accepted responsibility for the faulty maintenance we have to realize that there was a small as a mistake made in terms of changing the pump we installed it but then some some some pipes so to speak were needed to be connected to the pump but there was a mismatch the immediate consequences for airtran zapped in that event was that they got to pay a fine of a quarter of a million dollar which was the highest ever in Canada for an error that could have been prevented how someone that is supposed to be qualified in their job can put the wrong part onto an engine and risk 300 people's lives is is beyond me this incident is a very strong reminder that regulations important and safety is important and lives will be lost in the absence of that in their real lives it's not just you know this imaginary figure in your head of 300 people it's real people who suffer and continue to suffer with all if it hadn't have enough suffering it would have been our families this was by no means the end of the story investigators now turned their attention to the cockpit itself [Music] and what role had the crew played in the events of August twenty-fourth [Applause] could they have done more to avert the crisis key questions remained unanswered questions about what happened on the flight deck the Transport Canada investigation into air transat flight 236 discovered that basic maintenance errors had led to the fuel leak air transat had accepted responsibility and were heavily fine but the focus now turned on the flight deck and the performance of the crew what part did they play in the fuel loss wing cross feed on oh when the crew opened the cross feed valve to transfer fuel from the left wing tank to the right they lost 17 tons of fuel in less than 30 minutes yet they failed to close the cross feed valve and prevent further loss we have lost both engines due to fuel starvation we are gliding now in the days after the incident captain robear piche and dirk de Jager were called before the inquiry and asked in detail about their actions more than two years later these findings have still not been published what follows are possible explanations for the course of events that night based on known facts and expert opinion I templo and I pressure higher number two the warnings of high oil pressure and low oil temperature from the number two engine on the right wing would not have led the pilots to suspect there was already a major fuel leak the indications that were being presented with respect to the oil system would probably not give the crew any indications they may have questioned what was causing the the erroneous or strange indications but there's nothing certainly in in my mind or their training I think they would have triggered them to suspect that you know a fuel system might be involved bet you it's a computer problem but although the pilots thought they had a computer error the oil warnings were actually correct and were the first indication of a much more serious problem fuel imbalance warning haven't seen that before when the fuel imbalance warning came up 20 minutes later showing less fuel in the right wing than the left it seemed unconnected with the oil alarms this could have reinforced captain pjs idea that he was facing a series of computer errors do not apply this procedure if a fuel leak is suspected despite his doubts captain piche was obliged to follow Airbus procedure to correct the imbalance he opened the cross feed valve when cross feed on [Music] but was following the checklist enough you just can't idly flip switches in response to commands from the computers and anticipate that all will be well at the end of it you know that once the checklist is complete we can sit there fat dumb and happy that's not the case at all you know you you gotta keep second-guessing it you know is that right did we do the right checklist have we got the results that we need once the pilots calculated the high rate of fuel loss they should have suspected a fuel leak transat 236 heavy declaring fuel emergency by the time they had confirmed the leak their options were severely limited now they had a choice do i close the cross feed and and see what happens or do I leave the cross feed open as that as the feeling balanced checklist as as dictated and maybe the situation will correct it's often the crew wasn't really sure captain piche believed for a long time that he was facing a computer error it was only when the engine stopped that he had to accept the fuel leak was genuine the technological complexity of modern aircraft can help to make them safer and more reliable but it can also lead to problems that nearly brought catastrophe to air transat 236 discrepancies in replacement parts led to a fuel leak distrust of computers led the crew to miss read the situation these errors have huge implications only because air traffic control initially sent the plane 60 miles south to avoid congestion was it close enough to the Azores when the crisis struck otherwise it would have had to ditch in the ocean the portuguese investigation remains unpublished Airbus blames the pilots firm is handling the fuel leak robear piche and dirk de jager continue to fly with air transat in august 2002 they received one of the highest honors of the airline pilots association for the longest glide ever accomplished in a passenger airliner after the accident Airbus modified its checklist in the event of fuel imbalance from now on the computer checks all fuel levels on board against the flight plan it now gives a clear warning if more fuel is being lost than the engines can consume [Music] rolls-royce has reissued a service bulletin alerting all its clients of the incompatibility of two almost similar parts [Music] whatever the circumstances are the pressure that he was under is tremendous he he got that plane down safely only blow out eight of the twelve tires and saved three hundred people he saved three hundred people's lives [Music] captain piche saved our lives and whether or not he made an error or if there was a failure of a computer it doesn't really matter because we're alive [Music] do I think he's a hero no do I think he's a hell of a pilot yes thank God the islands of the Azores were there and basically saved our lives but if that fuel pump broke 25 minutes beforehand weed we would have ended up into into the water and I probably wouldn't be here to tell the story [Music] [Music] you [Music]
