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Air Transat Flight 236

24 Aug 2001 · Lajes Airport/Air Force Base, Terceira Island, Azores, Portugal

Airbus A330-243 · Fuel exhaustion due to fuel leak and pilot error

From Toronto Pearson International Airport (YYZ) to Lisbon Humberto Delgado Airport (LIS)

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Event

NTSB case
DCA01WA062
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Unknown · led by another country; figures from NTSB notifications
Event fatalities
0 · all aircraft and ground
Ground fatalities
Unknown
Occupants
306
Survivors
306
InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
18
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Airline
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Not recorded

Airbus A330-243

Flight
TS236
Aircraft type
Airbus A330
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
C-GITS
Operator
Air Transat
Onboard fatalities
0
Route
From Toronto Pearson International Airport (YYZ)To Lisbon Humberto Delgado Airport (LIS)
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 129: Foreign
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Not recorded
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Not recorded
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Minor

Cause areas

  • Personnel issues › Task performance
  • Personnel issues › Psychological
  • Aircraft › Aircraft handling/service
  • Organizational issues › Management

From the investigation findings the Wikipedia article reports, sorted into the NTSB's cause areas with AI assistance.

Approximate · Coordinates from the Wikipedia article; not checked against an investigation report.

From the Wikipedia article

Air Transat Flight 236 was a transatlantic flight bound for Lisbon, Portugal, from Toronto, Canada, that lost all engine power while flying over the Atlantic Ocean in the dark on August 24, 2001. The Airbus A330 ran out of fuel because of a fuel leak caused by improper maintenance. Captain Robert Piché, 48, and First Officer Dirk DeJager, 28, glided the plane to a successful emergency landing in the Azores, saving the lives of all 306 people (293 passengers and 13 crew) on board. This was also the longest passenger aircraft glide without engines, gliding for nearly 65 nmi. Following this unusual aviation accident, this aircraft was nicknamed the "Azores Glider".

Accident

Flight 236 took off from Toronto at 00:52 (UTC) on Friday, August 24, 2001 (local time: 20:52 (ET) on Thursday, August 23), bound for Lisbon, Portugal, with 293 passengers and 13 crew on board. The flight was flown by Captain Robert Piché, who had 16,800 hours of flight experience (with 796 of them on the Airbus A330), and First Officer Dirk DeJager, who had 4,800 flight hours (including 386 hours on the Airbus A330).

The aircraft was a two-year-old Airbus A330-243 registered as C-GITS that had first flown on March 17, 1999, configured with 362 seats and placed in service by Air Transat on April 28, 1999.

It was powered by two Rolls-Royce Trent 772B-60 engines each capable of delivering 71100 lbf thrust. Leaving the gate in Toronto, the aircraft had 46.9 t of fuel on board, 4.5 t more than required by regulations.

At 04:38 UTC (almost four hours into the flight), the aircraft began to leak fuel through a fracture that had developed in a fuel line to the no. 2 (right) engine downstream of the fuel/oil heat exchanger. At 05:03 UTC, more than four hours into the flight, the pilots noticed low oil temperature and high oil pressure on engine no. 2.

Although these readings were an indirect result of the fuel leak, the pilots had no reason to consider that as a cause. Consequently, Captain Piché suspected they were false warnings and shared that opinion with Air Transat maintenance control centre in Montreal, which advised them to monitor the situation.

There were other potential indications of fuel problems:

The fuel on board was decreasing at an unusual rate which was displayed in the Fuel-On-Board (FOB) quantity on the Engine Warning Display.

The estimated fuel on board at destination would have been showing as decreasing indicating reduced fuel range.

The full forward transfer of the fuel in the trim tank was premature given the fuel load on departure from Toronto of 46900 kg. A prolonged, 19-minute TRIM TANK XFR memo between 05:11 and 05:30, and then the TRIM TANK XFRD memo between 05:30 and 05:33 would have displayed this information.

At 05:36 UTC, the pilots received a warning of fuel imbalance.

Rather than referring to the appropriate checklists, the crew performed procedures from memory, and this resulted in the cross-feeding of fuel into an already leaking engine.

The transferred fuel was lost through the fractured fuel line, which was leaking at about 13 tonnes per hour (more than 3.6 kg/s). This caused a higher-than-normal fuel flow through the fuel-oil heat exchanger, which in turn led to a drop in oil temperature and a rise in oil pressure for the no. 2 engine.

At 05:45 UTC, the pilots decided to divert to Lajes Air Base in the Azores. Initially there was a 14-degree heading deviation from their assigned heading of 230 degrees magnetic caused by the autopilot being in true heading mode. After 2 minutes Santa Maria Oceanic air traffic control radioed "Transat 236 heavy maintain 230 magnetic heading". This transmission was not acknowledged, but the aircraft turned to the correct heading. They declared a fuel emergency with Santa Maria Oceanic air traffic control three minutes after the heading was corrected.

At 06:13 UTC, while still 150 nmi from Lajes and at 39000 ft, engine no. 2 flamed out from fuel starvation. Piché then initiated a descent to 33000 ft, 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 traffic control.

Thirteen minutes later, at 06:26 UTC and about 65 nmi from Lajes Air Base, engine no. 1 also flamed out, requiring the plane to glide the remaining distance. 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 flight instruments to fly the aircraft as well as enough hydraulic pressure to operate the primary flight controls (without which the aircraft would be uncontrollable).

The aircraft lost hydraulic power for the flaps, alternate brakes, and spoilers. The slats would still be powered, while the primary brakes would be able to operate a limited number of times using pressure stored in the brake accumulator. With neither engine running, there was no source of bleed air to maintain cabin pressurization. Five minutes later, at 06:31 UTC, the oxygen masks dropped down in the passenger cabin.

Military air traffic controllers guided the aircraft to the airport with their radar system. The descent rate of the plane was about 2000 ft/min. 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. Piché executed one 360° turn, and then a series of "S" turns, to dissipate excess altitude.

At 06:45 UTC, the plane touched down hard, around 1030 ft past the threshold of runway 33, at a speed around 200 kn, bounced once, and then touched down again, roughly 2800 ft from the threshold. Maximum emergency braking was applied and retained, and the plane came to a stop after a landing run that consumed 7600 ft of the 10000 ft runway.

Because the antiskid and brake modulation systems were inoperative, the eight main wheels locked up, the tires abraded and fully deflated within 450 ft, and the wheels themselves were worn down to the axle journals during rollout.

Fourteen passengers and two crew members had minor injuries, while two passengers had serious injuries during the evacuation of the aircraft. The plane suffered structural damage to the main landing gear (from the hard touchdown and the abrasion of the locked wheels against the runway surface during the landing roll) and the lower fuselage (both structural deformation from the hard touchdown and various punctures from impact by pieces of debris shed from the main landing gear).

Investigation and cause

Investigation

The Portuguese Aviation Accidents Prevention and Investigation Department (GPIAAF) investigated the accident with extensive cooperation with the Transportation Safety Board of Canada.

The investigation revealed that the primary causal factors of the accident were crew actions in mishandling a fuel leak in the number two engine.

The fuel leak resulted from fitment of an incorrect part to the hydraulics system by Air Transat maintenance staff as part of routine maintenance. 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 a few millimetres from the intended part, allowed chafing between the lines to rupture the fuel line, causing the leak.

Air Transat accepted responsibility for the accident and was fined C$250,000 by the Canadian government, which As of 2009 was the largest fine in Canadian history.

The conclusions reached in the accident report revealed that:

The flight crew did not detect that a fuel problem existed until the Fuel ADV advisory was displayed and the fuel imbalance was noted on the Fuel ECAM page.

The crew did not correctly evaluate the situation before taking action.

The flight crew did not recognize that a fuel leak situation existed and carried out the fuel imbalance procedure from memory, which resulted in the fuel from the left tanks being fed to the leak in the right engine.

Conducting the fuel imbalance procedure by memory meant that the crew did not read the Caution note in the relevant checklist. Doing so might have caused the crew to consider timely actioning of the fuel leak procedure.

Although there were a number of other indications that a significant fuel loss was occurring, the crew did not conclude that a fuel leak situation existed – failure to perform the fuel leak procedure correctly was the key factor that led to the fuel exhaustion.

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.

Text from the Wikipedia article “Air Transat Flight 236” (revision 1374489118, retrieved 2026-09-18) by its authors, under CC BY-SA 4.0. Extracted as plain text: references, tables, images and some sections are left out. Read the article

Sources

Wikipedia article: Air Transat Flight 236
Article
Air Transat Flight 236
Revision
1374489118 · 2026-09-12 · retrieved 2026-09-18
Wikidata
Q406609
Licence
Text CC BY-SA 4.0, by the article's authors; Wikidata CC0; town positions GeoNames (CC BY 4.0)
NTSB record DCA01WA062
Event ID
20020111X00061
Case number
DCA01WA062
Dataset
historical-pre2008
Source SHA-256
89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Where each value comes from
Record
Wikipedia article "Air Transat Flight 236" (page 1311876, revision 1374489118); merged with NTSB case DCA01WA062 (events / aircraft)
Date
Wikipedia infobox: date
Place and country
Wikipedia infobox: site
Map position
Wikipedia: Wikipedia article coordinates
Aircraft, operator and route
Wikipedia infobox: aircraft type, registration, operator, origin and destination; route airports from the linked airport articles' Wikidata codes (OurAirports); gaps and aircraft details from NTSB record DCA01WA062
Operation
airline flight number in the infobox
Fatalities
Wikipedia: Wikipedia infobox: aircraft fatalities
Ground fatalities
Wikipedia: not stated in the Wikipedia infobox
Summary
Wikipedia infobox: summary
Source notes (2)
  • One occurrence in two sources, merged: the Wikipedia article "Air Transat Flight 236" and NTSB case DCA01WA062, matched by the same aircraft registration and date. For this event outside the United States Wikipedia's values are used where the two differ; each value names its source.
  • No bulk values were replaced by the NTSB case API.