Here is an example of how the cause of a mishap can be obscured by press coverage, a good pilot's union, and a public's need for a hero now and then.
The captain of this airplane did a magnificent job dead sticking a Boeing 767 to a landing on an abandoned air field. The first officer did a great job of computing glide ratios and keeping the captain informed. In fact, the performance of this crew in Crew Resource Management and Situational Awareness was superb from the moment they suspected they were out of fuel, all the way through the successful emergency landing, passenger evacuation, and aircraft fire fighting. Excellent.
The problem is that both pilots were instrumental to the fact the airplane took off without enough fuel.
The lessons here are obvious:
An interesting side note. I like watching the U.K. television series May Day for recreations of these mishaps. The captain and first officer granted the series interviews and were treated very kindly, with only a one sentence note that they "were partly blamed for their roles in the incident." In fact, the captain was demoted for six months and the first officer was suspended for two weeks. The Canadian Transportation Safety Board cited Air Canada for failing to train the pilots to make the proper fuel calculations while praising the crew for overcoming the problems caused by "corporate and equipment deficiencies. Two years later both were awarded the first ever Fédération Aéronautique Internationale Diploma for Outstanding Airmanship.
Outstanding airmanship? I would give them an award for outstanding stick and rudder skills but then I would take away their licenses for very poor airmanship. The primary ingredient in airmanship, after all, is judgement.
Everything here is from the references shown below, with a few comments in an alternate color.
Photo: Inspecting the damage after Flight 143's unorthodox landing, from Flight Safety Australia, pg. 22
Click photo for a larger image
The aircraft was then flown from Edmonton to Montreal via Ottawa. All three fuel gauges operated normally. The pilot of that trip briefed the new pilot about the MEL item, but the new pilot was under the impression the gauges were not working and the aircraft was flown that way. Meanwhile a technician in Montreal reset the circuit breaker to further trouble shoot and determined a new processor was needed. He tried to order one but was told none were available. He forgot to repull the circuit breaker. When the new captain showed up, the breaker was not pulled and his three fuel gauges, therefore, were blank.
Even if the conversation had taken place, pilots must understand their responsibility for the safety of the flight outweighs any "higher authority."
The ground crew dipped the tanks and determined there was 7,682 liters of fuel on the airplane. The crew then used the incorrect conversion factor of 1.77 kilograms per liter to determine the airplane had (7682)(1.77) = 13,597 kg of fuel on board. Since they needed 22,300 kg to fly the trip, they ordered (22,300 - 13,597) = 8,703 kg of fuel. They used the same factor to compute 8,703 / 1.77 = 4,916 liters of fuel to fly the trip.
The correct factor was 0.80 kg/liter, which meant they only had (7682)(0.803) = 6,669 kg of fuel on board. They needed 22,300 - 6,6169 - 16,121 kg to fly the trip and should have ordered 16,131 / 0.803 = 20,088 liters of fuel to fly the trip. They uploaded about a quarter of the fuel needed. Instead of having 22,300 kilograms of fuel, they had 22,300 pounds (10,100 kilograms). They had half the fuel they needed.
Final Report of the Board of Inquiry into Air Canada Boeing 767 C-GAUN Accident - Gimli, Manitoba, July 23, 1983, Government of Canada
Flight Safety Australia, The 156-tonne Gimli Glider, July-August 2003
May Day: Gimli Glider, Cineflix, Episode 37, Season 5, 14 May 2002 (Air Canada 143)
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