Coordinates: 42.733°N 23.

083°W

Air Transat Flight 236

Air Transat Flight 236 was a transatlantic flight bound for
Air Transat Flight 236
Lisbon, Portugal, from Toronto, Canada, that lost all engine
power while flying over the Atlantic Ocean on August 24,
2001. The Airbus A330 ran out of fuel due to a fuel leak
caused by improper maintenance. Captain Robert Piché, 48,
an experienced glider pilot, and First Officer Dirk de Jager,
28, flew the plane to a successful emergency landing in the
Azores, saving all 306 people (293 passengers and 13 crew) on
board.[1] Most of the passengers on the flight were Canadians
C-GITS, the Airbus A330
visiting Europe or Portuguese expatriates returning to visit involved in the incident, seen in
family in Portugal. 1999
Accident
Date August 24,
Contents 2001
Summary Fuel
Incident exhaustion
Investigation caused by
fuel leak due
Aftermath to improper
maintenance
Related studies
Site Lajes
In popular culture Airport/Air
See also Force Base,
Terceira
Notes Island,
Azores,
References
Portugal
External links 42.733°N
23.083°W
Aircraft
Incident Aircraft type Airbus A330-
243
Flight TS 236 took off from Toronto at 00:52 (UTC) on Friday,
August 24, 2001 (local time: 20:52 (ET) on Thursday, August Operator Air Transat
23), bound for Lisbon, Portugal. There were 293 passengers IATA flight No. TS236
and thirteen crew members on board. The aircraft was an ICAO flight No. TSC236
Airbus A330-243 registered as C-GITS[2] that first flew on Call sign TRANSAT
March 17, 1999,[3] configured with 362 seats and placed in 236 HEAVY
service by Air Transat on April 28, 1999.[3] It was powered by Registration C-GITS
two Rolls-Royce Trent 772B-60 engines capable of delivering Flight origin Toronto
Pearson Int'l
71,100 lbf (316 kN) thrust each. Leaving the gate in Toronto, Airport
the aircraft had 46.9 tonnes of fuel on board, 4.5 tonnes more Toronto,
than required by regulations.[4][Note 1] Ontario,
Canada
Unbeknownst to the pilots, at 04:38, the aircraft began to leak Destination Portela
fuel through a fracture which had developed in a fuel line to Airport
Lisbon,
the № 2 (right) engine.[4](p23) At 05:03 UTC, more than 4 Portugal
hours into the flight, the pilots noticed low oil temperature Passengers 293
and high oil pressure on engine № 2.[4](pp7,23) Although
Crew 13
these readings were an indirect result of the fuel leak, there
Fatalities 0
was no reason for the pilots to consider that as a cause.
Injuries 18 (16 minor;
Consequently, Captain Piché, who had 16,800 hours of flight
2 serious)
experience (with 796 of them on the Airbus A330),[4](p12)
Survivors 306 (all)
and First Officer Dirk DeJager, who had 4,800 flight hours
(including 386 hours on the Airbus A330),[4](p12) suspected they were false warnings and shared
that opinion with their maintenance control center, who advised them to monitor the
situation.[4](p56)

At 05:36 UTC, the pilots received a warning of fuel imbalance. Still unaware of the fuel leak, they
followed a standard procedure to remedy the imbalance by transferring fuel from the left wing
tank to the right wing tank. The transferred fuel was lost through the fractured fuel line, which was
leaking at about one gallon per second. This caused a higher than normal fuel flow through the
fuel-oil heat exchanger (FOHE), which in turn led to a drop in oil temperature and a rise in oil
pressure for the № 2 engine.[5]

At 05:45 UTC, the pilots decided to divert to Lajes Air Base in the
Azores. They declared a fuel emergency with Santa Maria
Oceanic air traffic control three minutes later. Toronto
Lisbon
At 06:13 UTC, while still 150 nautical miles (280 km; 170 mi)
from Lajes and at 39,000 feet (12,000 m), engine № 2 flamed Azores

out due to fuel starvation.[4] Captain Piché then initiated a

descent to 33,000 feet (10,000 m), which was the proper single-
engine altitude for the weight of the plane at that time. Ten
minutes later, the crew sent a Mayday to Santa Maria Oceanic air Flight 236's departure,
traffic control. original destination, and
ultimate destination
Three minutes later, at 06:26 UTC and approximately 65
nautical miles (120 km; 75 mi) from Lajes Air Base, engine № 1
also flamed out, requiring the plane to glide the remaining distance.[4](p8) Without engine power,
the plane lost its primary source of electrical power. The emergency ram air turbine deployed
automatically to provide essential power for critical sensors and instruments to fly the aircraft.
However, the aircraft lost its main hydraulic power, which operates the flaps, alternate brakes, and
spoilers. The slats would still be powered, however, when the flaps № 1 position was selected. Five
minutes later, at 6:31 UTC, the oxygen masks dropped down in the passenger cabin.[4](p9)
Military air traffic controllers guided the aircraft to the airport with their radar system. The
descent rate of the plane was about 2,000 feet (600 metres) per minute. They calculated they had
about 15 to 20 minutes left before they would be forced to ditch in the ocean. The air base was
sighted a few minutes later. Captain Piché had to execute one 360-degree turn, and then a series
of "S" turns, to dissipate excess altitude.

At 06:45 UTC, the plane touched down hard, approximately 1,030 feet (310 m) past the threshold
of Runway 33, at a speed of approximately 200 knots (370 km/h; 230 mph), bounced once and
then touched down again, approximately 2,800 feet (850 m) from the threshold. Maximum
emergency braking was applied and retained, and the plane came to a stop after a landing run that
consumed 7,600 feet (2,300 m) of the 10,000-foot (3,000 m) runway. Because the anti-skid and
brake modulation systems were inoperative, the eight main wheels locked up; the tires abraded
and fully deflated within 450 feet (140 m).[4](p11) Fourteen passengers and two crew members
suffered minor injuries, while two passengers suffered serious injuries during the evacuation of
the aircraft. The plane suffered structural damage to the main landing gear and the lower fuselage.

Investigation
The Portuguese Aviation Accidents Prevention and Investigation Department (GPIAA)
investigated the accident along with Canadian and French authorities.[6]

The investigation revealed that the cause of the accident was a fuel leak in the #2 engine, caused
by an incorrect part installed in the hydraulics system by Air Transat maintenance staff as part of
routine maintenance.[6] The engine had been replaced with a spare engine, lent by Rolls-Royce,
from an older model which did not include a hydraulic pump. Despite the lead mechanic's
concerns, Air Transat authorized the use of a part from a similar engine, an adaptation that did
not maintain adequate clearance between the hydraulic lines and the fuel line. This lack of
clearance, on the order of millimetres from the intended part,[6] allowed chafing between the lines
to rupture the fuel line, causing the leak. Air Transat accepted responsibility for the accident and
was fined 250,000 Canadian dollars by the Canadian government, which as of 2009 was the
largest fine in Canadian history.[6]

Pilot error was also listed as one of the lead causes of the accident (for failing to identify the fuel
leak). Nevertheless, the pilots returned to a heroes' welcome from the Canadian press as a result of
their successful unpowered landing. In 2002, Captain Piché was awarded the Superior
Airmanship Award by the Air Line Pilots' Association.[7]

Aftermath
The accident led to the French Directorate General for Civil Aviation (DGAC) and Federal Aviation
Administration (FAA) issuing an Airworthiness Directive (AD),[8] requiring all operators of
Airbus models A318, A319, A320 and A321 narrow body aircraft to revise the flight manual,
stressing that crews should check that any fuel imbalance is not caused by a fuel leak before
opening the cross-feed valve. The AD required all airlines operating these Airbus models to make
revisions to the Flight Manual before any further flights were allowed. The FAA gave a 15-day
grace period before enforcing the AD. Airbus also modified its computer systems; the on-board
computer now checks all fuel levels against the flight plan. It now gives a clear warning if fuel is
being expended beyond the specified fuel consumption rate of the engines. Rolls-Royce also issued
a bulletin advising of the incompatibility of the relevant engine parts.

The aircraft was repaired and returned to service with Air Transat in December 2001, with the
nickname "Azores glider". As of December 2019 the aircraft is still in service, still with Air Transat.

Related studies
Margaret McKinnon, a postdoctoral psychology student at Baycrest Health Sciences in Toronto at
the time, was a passenger on her honeymoon on Flight 236. She and colleagues recruited fifteen
other passengers in a study of posttraumatic stress disorder (PTSD), published in August 2014 in
the academic journal Clinical Psychological Science, which compared details recalled by
passengers suffering from PTSD with those recalled by passengers without PTSD and with a
control group.[9][10]

In popular culture
The events of Flight 236 were featured in "Flying on Empty", a Season 1 (2003) episode of the
Canadian TV series Mayday[11] (called Air Emergency and Air Disasters in the U.S. and Air
Crash Investigation in the UK and elsewhere around the world). The flight was also included in
a Mayday Season 6 (2007) Science of Disaster special titled "Who's Flying the Plane?"[12]
MSNBC produced a report on the incident with the title "On a Wing and a Prayer", which first
aired in the U.S. on August 7, 2005.[13]
The story of Robert Piché is depicted in the 2010 French Canadian biographical drama film
Piché: The Landing of a Man culminating with the events on Flight 236.[14] Captain Piché is
portrayed by both Genie Award-winning actor Michel Côté and his son Maxime LeFlaguais.

See also
US Airways Flight 1549
Air Canada Flight 143
TACA Flight 110
List of airline flights that required gliding

Notes
1. TSC236 was planned to depart CYYZ at 00:10 UTC1, with 47.9 metric tons of fuel, which
included 5.5 tons over and above the fuel required by regulations for the planned flight; the
actual take-off time was at 00:52 with a reported 46.9 tons of fuel on board.[4]
References
1. Crossette, Barbara (September 10, 2001). "Jet Pilot Who Saved 304 Finds Heroism Tainted" (
https://www.nytimes.com/2001/09/10/world/jet-pilot-who-saved-304-finds-heroism-
tainted.html). The New York Times. Retrieved August 21, 2007.
2. "Canadian Civil Aircraft Register (C-GITS)" (http://wwwapps.tc.gc.ca/Saf-Sec-Sur/2/CCARCS-
RIACC/RchHsRes.aspx?st=2&m=%7CGITS%7C&rfr2=RchHs.aspx). Transport Canada.
3. "Airbus A330 – MSN 271 – C-GITS: General information & flightlog" (http://www.airfleets.net/fi
cheapp/plane-a330-271.htm). airfleets.net. Retrieved June 16, 2018.
4. "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" (http://www
.fss.aero/accident-reports/dvdfiles/PT/2001-08-24-PT.pdf) (PDF). Portuguese Aviation
Accidents Prevention and Investigation Department. Retrieved December 26, 2016.
5. "Air Transat Flight 236: The Azores Glider" (http://www.rvs.uni-bielefeld.de/publications/compe
ndium/incidents_and_accidents/Ladkin-AirTransat.pdf) (PDF). Retrieved July 27, 2010.
6. Mayday – S01E03 – Flying On Empty Air Transat flight 236 (https://www.youtube.com/watch?v
=wPJaMfVQG9Q) on YouTube
7. "Robert Piché Given Award" (http://www.aero-news.net/index.cfm?do=main.textpost&id=8c64b
4a7-4084-4f96-be6d-d141966b95ba). Aero News Network. Aero News Network. August 26,
2002. Retrieved December 26, 2016.
8. Airbus Model A318-100, A319-100, A320- 200, A321-100 (http://www.airweb.faa.gov/Regulato
ry_and_Guidance_Library/rgad.nsf/0/3b2d4350048640a0862570e4006843e4!OpenDocument
)
9. "PTSD clues gleaned from passengers on terrifying flight" (https://www.cbc.ca/news/health/pts
d-clues-gleaned-from-passengers-on-terrifying-flight-1.2734768). CBC.ca. August 14, 2014.
10. McKinnon, Margaret C.; Palombo, Daniela J.; Nazarov, Anthony; Kumar, Namita; Khuu,
Wayne; Levine, Brian (July 1, 2015). "Threat of Death and Autobiographical Memory – A Study
of Passengers From Flight AT236" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495962).
Clinical Psychological Science. SAGE Publications. 3 (4): 487–502.
doi:10.1177/2167702614542280 (https://doi.org/10.1177%2F2167702614542280). ISSN 2167-
7026 (https://www.worldcat.org/issn/2167-7026). PMC 4495962 (https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC4495962). PMID 26167422 (https://pubmed.ncbi.nlm.nih.gov/26167422).
11. "Flying on Empty". Mayday. Season 1. Episode 6. 2003. Discovery Channel Canada / National
Geographic Channel.
12. "Who's Flying the Plane?". Mayday. Season 6. Episode 3. 2007. Discovery Channel Canada /
National Geographic Channel.
13. "On a Wing and a Prayer (download)" (http://www.tvguide.com/tvshows/msnbc-reports/episod
e-4853462/390086/). MSNBC Reports. Retrieved March 26, 2018.
14. "Entre ciel et terre review (in French)" (http://www.cinoche.com/films/piche-entre-ciel-et-terre/in
dex.html). cinoche.com. Archived (https://web.archive.org/web/20100722104525/http://www.ci
noche.com/films/piche-entre-ciel-et-terre/index.html) from the original on July 22, 2010.
Retrieved July 1, 2010.

External links
Accident Investigation Final Report (http://www.fss.aero/accident-reports/dvdfiles/PT/2001-08-
24-PT.pdf) from the Portuguese Aviation Accidents Prevention and Investigation Department
 (Archive (https://www.webcitation.org/63xIYGyfW?url=http://www.moptc.pt/tempfiles/20060608
181643moptc.pdf), Archive #2 (https://web.archive.org/web/20120426052219/http://www.gpiaa
.gov.pt/tempfiles/20060608181643moptc.pdf), Alternate Link (http://www.gpiaa.gov.pt/wwwbas
e/wwwinclude/ficheiro.aspx?tipo=0&id=9627&ambiente=WebSiteMenu))
Report profile (http://www.gpiaa.gov.pt?cr=9627) (in Portuguese)
"Air Transat Flight TS 236 of August 24, 2001 – Air Transat welcomes investigation findings
and recommendations (http://www.transat.com/en/media_centre/2.0.media.centre.asp?id=827
)" (Archive (https://www.webcitation.org/6SLPzW8Lf?url=http://web.archive.org/web/20041029
232429/http://www.transat.com/en/media_centre/2.0.media.centre.asp?id%3D827) Archive #2
(https://web.archive.org/web/20041029232429/http://www.transat.com/en/media_centre/2.0.m
edia.centre.asp?id=827)). Air Transat. October 17, 2004.
Accident description (https://aviation-safety.net/database/record.php?id=20010824-1) at the
Aviation Safety Network
News report on logistical issues after the incident (http://www.prnewswire.co.uk/cgi/news/relea
se?id=72317)
"Grateful passengers praise Air Transat pilot (http://www.cbc.ca/news/world/story/2001/08/25/
airtransat_010825.html)." CBC News. Sunday August 26, 2001.
Captain Robert Piché's Official Website (http://www.robertpiche.com) (in French)
PTSD clues gleaned from passengers on terrifying flight (http://www.cbc.ca/news/health/ptsd-c
lues-gleaned-from-passengers-on-terrifying-flight-1.2734768)

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