The Air Transat Aftermath - Fines and Restrictions
NEWS RELEASE TRANSMITTED BY CCN NEWSWIRE

FOR: TRANSPORT CANADA AUGUST 30, 2001 - 16:46 EDT Transport Minister Collenette Announces New Measures Surrounding Air Transat Emergency Landing in the Azores OTTAWA, ONTARIO--Transport Minister David Collenette today announced measures to address the emerging maintenance and flight operation issues surrounding the emergency landing of the Air Transat Airbus A330 in the Azores. These measures are in advance of the final report of the Portuguese investigating authority.

Transport Canada has requested and Air Transat has agreed to immediately implement special training sessions on extended range operations for all Air Transat flight crew to review with them the proper procedures for the conduct of these flights. This will include fuel management procedures and the necessity to divert to the closest alternative airport at the first signs of an engine-related emergency.

Following discussion with Transport Canada, Air Transat has created a new senior director of safety position, reporting directly to the president and CEO, who will work closely with Transport Canada to implement a safety management system program.

In addition, Air Transat has voluntarily taken additional precautionary safety measures to prevent a reoccurrence of an incident of this type. Air Transat:

* has initiated a comprehensive review of the safety of their maintenance and operations program, and will report on the implementation of the review's recommendations to Transport Canada;

* has provided to Transport Canada a corrective action plan that will improve the performance of maintenance activity and includes the hiring of additional maintenance and quality assurance personnel; and

* will institute human factors training for all technical personnel, review their quality procedures and introduce a system for analyzing maintenance errors.

The above action does not preclude any potential separate regulatory action that Transport Canada may take following the conclusion of Transport Canada's special audit of Air Transat's maintenance and flight operations.

"Transport Canada takes occurrences of this nature very seriously, and will take whatever action is required to protect the traveling public," said Mr. Collenette. "We remain committed to maintaining Canada's already high level of aviation safety."

Transport Canada officials remain in ongoing communication with the Transportation Safety Board and the Portuguese authority, as well as the aircraft manufacturer (Airbus Industries), the engine manufacturer (Rolls Royce) and the responsible civil aviation authority for the Airbus aircraft (France).

The investigation by the Portuguese authority into the remaining components of the fuel system and the overall conduct of the flight is continuing. Transport Canada continues to monitor this investigation closely and will take prompt and appropriate corrective action should further safety deficiencies become known.

Transport Canada is online at www.tc.gc.ca. Keep up-to-date on the latest from Transport Canada by subscribing to news releases and speeches at www.tc.gc.ca/listserv/.

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FOR FURTHER INFORMATION PLEASE CONTACT:

Sue Ronald Office of the Minister, Ottawa (613) 991-0700 or Peter Coyles Communications, Ottaw AUGUST 30, 2001 - 17:30 EDT Transport Minister Announces Inspections of Airbus A330 Aircraft OTTAWA, ONTARIO--Transport Minister David Collenette tonight announced that Air Canada and Air Transat have inspected their Airbus A330 aircraft to ensure that they do not have the mechanical conditions that may have contributed to the Air Transat emergency landing in the Azores.

Air Canada and Air Transat are the only operators in Canada with Airbus A330s with the same engine as the aircraft involved in the emergency landing. Air Canada operates eight and Air Transat three Airbus A330 aircraft.

"I have been assured by both Air Canada and Air Transat that they have completed inspections on their Airbus A330," said Mr.

Collenette. "Safety remains a shared responsibility and I am pleased with the proactive spirit of cooperation in the Canadian aviation industry and its prompt attention to this safety issue."

Preliminary information received from the Portuguese authority indicates a problem with the fuel system, in which both engines failed as a result of fuel starvation. Initial inspection of the engines has determined that there was a crack on a pressure fuel line on the right engine.

"Transport Canada officials are in ongoing communication with the Transportation Safety Board and the Portuguese authority as well as the aircraft manufacturer (Airbus Industries), the engine manufacturer (Rolls Royce), the responsible civil aviation authority for the Airbus aircraft (France) and our affected air operators," added Mr. Collenette.

The investigation by the Portuguese authority into the remaining components of the fuel system and the overall conduct of the flight is continuing. Transport Canada continues to monitor this investigation closely and will take prompt and appropriate corrective action should other safety deficiencies become known.

To date, there have been no other reported cases of fuel line cracks on Canadian-operated Airbus A330 aircraft.

Transport Canada is online at www.tc.gc.ca. Keep up-to-date on the latest from Transport Canada by subscribing to news releases and speeches at www.tc.gc.ca/listserv/.

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FOR FURTHER INFORMATION PLEASE CONTACT:

Transport Canada Art LaFlamme Director General, Civil Aviation (613) 990-6055 Investigation Communique Update - 29 August 2001 / Air Transat OTTAWA, ONTARIO--

/T/ MINISTERIO DO EQUIPAMENTO SOCIAL GABINETE DE PREVENCAO E INVESTIGACAO DE ACIDENTES COM AERONAVES PORTUGAL Investigation Communique Update - 29 August 2001 Air Transat Airbus A330-246, C-GITS Lajes Airport, Azores, Portugal, 100 nm North-East

24 August 2001 /T/ On august 24, 2001, Air Transat Flight TS236, an Airbus 330-200 aircraft was en route at Flight Level (FL 390 from Toronto Lester B Pearson Airport, Ontario (CYYZ), Canada to Lisbon Airport (LPPT), Portugal with 13 crew and 293 passengers on board.

The investigation into this aviation occurrence by Gabinete de Prevencao e Investigacao de Acidentes (GPIAA), the accident investigation authority of Portugal, continues. The following information has been determined from the flight data recorder and other information sources.

Air Transat Flight TS236 crossed the 30 degrees west longitude at

44 degrees north latitude (4400N/03000W) at 0458Z.

At 0536Z and at approximately 4230N/02230W, the crew became aware of a fuel imbalance between the left and right-wing main fuel tanks.

At approximately 0541Z and at 4225N/02200W, the crew concerned about the lower-that-expected fuel quantity indication, decided to divert to Lajes Airport (LPLA), Terceira Island in the Azores.

At 0548Z and approximately 4220N/02230W, when the crew ascertained that a fuel leak could be the reason for the possible fuel loss, an emergency was declared to Santa Maria Oceanic Control.

At 0613Z, when the aircraft was at FL390 and at a calculated distance of 135 miles from Lajes, the right engine (Rolls-Royce Trent 772B) flamed out.

At 0626Z, when the aircraft was about 85 nautical miles from the Lajes and at an altitude of about FL345, the left engine flamed out.

At 0639Z the aircraft was at 13,000 feet and 8 miles from the threshold of runway 33.

The engines-out, visual approach was carried to runway 33 at the Lajes Airport in the following weather conditions: wind 330 degrees at 8 knots, visibility unlimited, a few clouds at 2,500 feet, few at 5000 feet, temperature 19 degrees Celsius.

The investigation has determined that both engines flamed out as the result of fuel starvations.

As mentioned in an earlier communique the investigation has determined that a low-pressure fuel line on the right engine.

Rolls-Royce Trent 700 Serial number 41 055, had failed probably as the result of its coming into contact with an adjacent hydraulic line. The engine had been installed on the occurrence aircraft at the Air Transat maintenance facility at Mirabel, Quebec, Canada on

19 August 2001. The engine had accumulated 67.2 hours since installation. Further metallurgical analysis will be conducted on the failed fuel line to determine the cause of the failure.

Since the occurrence, on 29 August 2001, Rolls-Royce issued a World Wide Communication (DBY/CS/00697/2001). advising operators, in part, to check all engines to ensure that adequate clearance exists between the fuel and hydraulic line. A Non modification service bulletin is to be issued to formalise this inspection, and will be rendered mandatory by the Bristish Civil Aviation Authority.

On 29 August 2001, Airbus issued an All Operators Telex (AOT)

A330-73A3033 requiring a one-time visual inspection to verify that no interference exists between the fuel and hydraulic lines on all A330 aircraft equipped with Rolls-Royce 700 series engines. This inspection must be done at the earliest convenient opportunity within 72 hours elapsed time from the reception of the AOT.

This AOT will be rendered mandatory by the Direction Generale de l'Aviation Civile of France.

Although the field portion of the investigation is nearing completion, further fact gathering and analysis will continue.

Concerning the fuel system, all tests and inspections performed to date showed no anomalies.

This Investigation Communique is based on preliminary information and is subject to change as the investigation progresses.

The Investigator-in-charge would like to thank the Portuguese Air Force, Transportation Safety Board of Canada, Bureau Enquetes -

Accidents of France, Rolls-Royce, Airbus and Air Transat for their contributions to the field investigation.

Frederico JF Serra Investigator-in-charge Lajes 30 August 2001

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FOR FURTHER INFORMATION PLEASE CONTACT:

Transportation Safety Board of Canada

819-953-7812

-- *********

416 534 4008 fax 416 534 7617 http://www.jgoss.com ttu/ofl-clc
Conjectural

> > As I suspected, this has set off alarm bells among the ETOPS operators !

Why only twins? A common point failure in the fuel system should be a concern independent of the number of engines.

There is a good explanation of the A330 fuel system in an accompanying

article to Fiorino's by Mike Dornheim.

There are two major issues here (amongst four that the incident brought

up). First, an ECAM fuel-imbalance warning was generated. Second, it took

the crew 12 minutes from then to determine that the problem was a leak.

Dornheim proposes that the fuel-imbalance warning is likely the first

sign that anything is amiss. The A330 fuel system is completely

automatic (you set it on start-up and look at it again on shutdown).

Fuel is transferred between the trim tank and the inner wing tanks

automatically to correct the inevitable imbalances due to differential

burn between the two engines. There are outer tanks, which feed the

inners, and a center tank. The trim tank holds about 4.5 tonnes.

A fuel imbalance warning is generated with 3 tonnes difference.

Most A330 pilots have never seen one. That's as it should be.

Worst case is thus that you can lose 7.5 tonnes fuel before generating

a warning. The A330 uses about 5 tonnes in cruise (at high altitude;

not at the lower altitude of 15K-20K ft to which one has to descend to

allow the engines to gravity-feed without vapor lock, which is

part of the recommended QRH procedures in many fuel-problematic cases).

Dornheim doesn't mention about fuel quantity indications or sensor

fusion.

One standard alternative is manual fuel burn calculation at waypoints:

Ramp fuel = total fuel burn + fuel available in tanks.

You calculate the first pretty accurately before departure. The second

is provided by integrating the figures from the fuel flow sensors

(on the engines, downstream of the leak, in the case of the RB211s on

the aT incident aircraft). What about fuel available? Dornheim doesn't

say.

A simple arithmetic calculation, comparing the two methods, under

reasonable assumptions concerning fuel contingency planning, shows that

waiting for the fuel-imbalance page may not be all that bad an

alternative to standard manual procedures. And it has the added

advantage of not requiring anything from the crew. But it seems as if

the automation could do a lot better if it were wanted.

I suspect that, if the basics of ETOPS are questioned by this incident,

then it that question is valid for all ETOPS aircraft, not just for

the A330.

I have queries out to see if some of the uncertainties above can be

resolved.

PBL

--

Peter B. Ladkin PhD FBCS CW(hon)

Professor of Computer Networks and Distributed Systems,

Faculty of Technology, University of Bielefeld, 33594 Bielefeld, Germany

Tel (Vx/msg/Fax) +49 (0)521 880 7319 http://www.rvs.uni-bielefeld.de

 
Sept 7, 01

Troubled airline is fined $250,000 

Air Transat flew Airbus 14 times with faulty engine repairs 

Joseph Hall and Sonia Verma STAFF REPORTERS 

Air Transat has been hit with the largest fine in Canadian aviation history in the wake of its near disaster in the Azores two weeks ago.

The federal transport department also extended harsh route restrictions to cover the airline's entire fleet.

The $250,000 fine was slapped on the airline after federal inspectors discovered it had flown an Airbus A330 about 14 times with faulty engine repairs before an emergency landing on the remote Portuguese archipelago grounded the aircraft, department officials said yesterday.

Officials also revealed that route restrictions had been imposed last year on Air Transat - forcing a portion of its fleet to always fly within 90 minutes of an airport - after an accumulation of previous maintenance problems.

Adding to Air Transat's woes, a class-action lawsuit claiming $30 million in damages, was launched yesterday on behalf of passengers on the troubled Airbus flight.

However, Transport Minister David Collenette said that despite the fines and restrictions, it was still safe to fly Air Transat.

He stressed that he believed Air Transat was safe and that any problems it did have were being rectified. He said travellers should not hesitate to use the airline.

`Air Transat along with all Canadian carriers, especially with these measures, certainly offers a safe way to travel.'

- Transport Minister David Collenette ``Air Transat, along with all Canadian carriers, especially with these measures, certainly offers a safe way to travel,'' he said.

``And people should not in any way believe that because of this unfortunate occurrence, that they should not travel on Air Transat.'' The restrictions imposed yesterday require all of Air Transat's 23 planes to fly routes that keep them no more than 90 minutes away from the nearest airport. The department had earlier restricted only the Airbus A330s to flying within 60 minutes of an airport. That 60-minute restriction remains in effect for the A330s but it may be raised to 90 minutes if airline mechanics complete an engine maintenance course.

The previous record fine handed down to an airline was $50,000, imposed on an unidentified carrier in 1998 for flying without a proper operating certificate.

Collenette said the Air Transat fine ``is so high because this plane flew 14 times with the equipment and the engines configured inappropriately.'' He was referring to an hydraulic pump that Air Transat admits it installed improperly in a Rolls-Royce engine that it had leased as a temporary replacement on the ill-fated Airbus - which was forced a few days later to glide without fuel during a transatlantic flight Aug. 24.

Both Rolls-Royce and Airbus officials say that pipes from the improperly placed pump created a gash in the plane's fuel lines, large enough to empty its massive tanks and send the aircraft powerless and crippled to the island runway.

Art LaFlamme, director-general of civil aviation for Transport Canada, revealed at a news conference yesterday that Air Transat had route restrictions placed on part of its fleet last year after a series of maintenance mistakes came to light.

One error saw airline mechanics install parts from an old Lockheed L1011 into one of its new Airbus A330s. While the parts are physically similar, they are not legally interchangeable and the company was fined $1,250 at the time.

Over the past two years, Air Transat has also received fines of $1,250 each for:

Performing repairs on an aircraft without ensuring they conformed to technical instructions.

Not properly logging repairs made on one of its Boeing 757s.

Operating an aircraft without flight authority.

Operating an aircraft without the required number of flight attendants on board.

The 90-minute restrictions resulting from these infractions were eased late last year after the airline had shown it was improving its performance, LaFlamme said. He did no know how long they had remained in place.

The latest route restriction rolls back Air Transat to the status of ``entry-level'' airline and will remain in effect until the company can prove to department inspectors it has cleaned up its maintenance act.

``We're rolling back Air Transat to that entry level because of the seriousness of the occurrence,'' said LaFlamme.

Air Transat president Denis Jacob - accepting limited responsibility for the mechanical error agreed to pay the $250,000 fine.

He said that, to restore public confidence in the airline, he would not contest the $250,000 fine.

``We were not happy about (the amount of the fine), that's for sure,'' he said. ``We won't argue with it and we will pay this fine. We just want to put everything behind us.'' Collenette said his department did not preclude further fines or restrictions against Air Transat should the current Portuguese investigation into the Azores incident indicate they were warranted.

The latest restrictions will not seriously affect Air Transat's North Atlantic routes, which feature adequate runways in Newfoundland, Greenland, Iceland and Ireland. But it may force the airline to fly far out of its way to reach its southern European destinations.

As well, poor weather conditions at any of the North Atlantic airstrips may affect the airline's ability to fly to Europe at all.

Jacob agreed the restrictions will mean the airline's transatlantic flights will take up to half an hour longer. But he downplayed the impact the changes will have on ticket sales or pricing, saying the demand for transatlantic air travel drops off in the winter and that, by next summer, Transport Canada would hopefully lift the restrictions.

``The impact will be minor,'' Jacob said. The company will absorb any increased cost in fuel, he added.

As a mature airline, Air Transat was typically permitted to fly within 150 minutes of the nearest airport.

Jacob defended the reputation of the airline, citing fines previously levied against its rivals, including Royal Airline. ``This is the first major incident for Air Transat. Air Transat's infractions have been no more serious than its competitors.'' He would not comment on the lawsuit, filed in Ontario Superior Court by Toronto lawyer Antonio Azevedo, but not yet certified by a judge.

``We don't know if it is really serious. We'll have to look at it and our lawyer will have to look at it,'' Jacob said.

Collenette would not comment on the airline's claim that the pump installation was not solely responsible for the crippling fuel leak.

He said the department would await the results of the Portuguese investigation - which Transport Canada investigators are supporting - before passing judgment on the cause of the incident.

Among the questions the investigation must answer is how the plane's pilots could fail to notice and shut down a mass fuel transfer which sends tonnes of aircraft fuel from one of the aircraft's wings to the other.

The Airbus A330 automatically shifts fuel between wings to balance the plane if one tank suddenly became heavier. But with tonnes of fuel to move, the transfer takes time and is usually recorded on flight instruments. Instruments available to the pilots would usually have indicated a heavy fuel loss long before it became critical, alerting them to stop the transfer.

``The investigation being conducted by the Portuguese is still under way and they have not reached a conclusion in that respect,'' LaFlamme said. ``However, we are concerned that, in theory, there should be the isolation of the fuel system on one side from the other and we are reviewing the information as it comes from the investigation.''

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