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.

FMI: www.airtransat.com