越洋航空236班机.pdf

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1、All Engines-out Landing Due to Fuel Exhaustion, Air Transat, AirbusA330-243 marks C-GITS, Lajes, Azores, Portugal, 24 August 2001Micro-summary: Following an undetected fuel leak, this A330-243 had to dead-stickto a successful landing.Event Date: 2001-08-24 at 0613 UTCInvestigative Body: Aviation Acc

2、idents Prevention and Investigation Department,Portugal, with extensive cooperation by Canada TSBInvestigative Bodys Web Site: http:/www.gpiaa.gov.pt/Note: Reprinted by kind permission of the AAPID.Cautions:1. Accident reports can be and sometimes are revised. Be sure to consult the investigative ag

3、ency for thelatest version before basing anything significant on content (e.g., thesis, research, etc).2. Readers are advised that each report is a glimpse of events at specific points in time. While broadthemes permeate the causal events leading up to crashes, and we can learn from those, the speci

4、ficregulatory and technological environments can and do change. Your companys flight operationsmanual is the final authority as to the safe operation of your aircraft!3. Reports may or may not represent reality. Many many non-scientific factors go into an investigation,including the magnitude of the

5、 event, the experience of the investigator, the political climate, relationshipwith the regulatory authority, technological and recovery capabilities, etc. It is recommended that thereader review all reports analytically. Even a bad report can be a very useful launching point for learning.4. Contact

6、 us before reproducing or redistributing a report from this anthology. Individual countries havevery differing views on copyright! We can advise you on the steps to follow.Aircraft Accident Reports on DVD, Copyright 2006 by Flight Simulation Systems, LLCAll rights reserved.www.fss.aero Final Investi

7、gation Report 22 / ACCID / 2001 18 October 2004 S.R. COPY N Government of Portugal MINISTRIO DAS OBRAS PBLICAS, TRANSPORTES E COMUNICAES GABINETE DE PREVENO E INVESTIGAO DE ACIDENTES COM AERONAVES Aviation Accidents Prevention and Investigation Department Accident Investigation Final Report All Engi

8、nes-out Landing Due to Fuel Exhaustion Air Transat Airbus A330-243 marks C-GITS Lajes, Azores, Portugal 24 August 2001 22 / ACCID /GPIAA / 2001 Final Investigation Report 22 / ACCID / 2001 Pag 2 of 103 Occurrence Summary On August 24, 2001, Air Transat Flight TSC236, an Airbus 330-243 aircraft, was

9、on a scheduled flight from Toronto Lester B Pearson Airport, Ontario (CYYZ), Canada to Lisbon Airport (LPPT), Portugal with 13 crew and 293 passengers on board. At 05:33, the aircraft was at 4244N/2305W when the crew noted a fuel imbalance. At 05:45, the crew initiated a diversion from the flight-pl

10、anned route for a landing at the Lajes Airport (LPLA), Terceira Island in the Azores. At 05:48, the crew advised Santa Maria Oceanic Control that the flight was diverting due to a fuel shortage. At 06:13, the crew notified air traffic control that the right engine (Rolls-Royce RB211 Trent 772B) had

11、flamed out. At 06:26, when the aircraft was about 65 nautical miles from the Lajes airport and at an altitude of about FL 345, the crew reported that the left engine had also flamed out and that a ditching at sea was possible. Assisted by radar vectors from Lajes air traffic control, the crew carrie

12、d out an engines-out, vis-ual approach, at night and in good visual weather conditions. The aircraft landed on runway 33 at the Lajes Airport at 06:45. After the aircraft came to a stop, small fires started in the area of the left main-gear wheels, but these fires were immediately ex-tinguished by t

13、he crash rescue response vehicles that were in position for the landing. The Captain ordered an emergency evacuation; 16 passengers and 2 cabin-crew members re-ceived injuries during the emergency evacuation. The aircraft suffered structural damage to the fuselage and to the main landing gear. Final

14、 Investigation Report 22 / ACCID / 2001 Pag 3 of 103 Table of Contents 1.0 FACTUAL INFORMATION.7 1.1 HISTORY.7 1.1.1 History of the Flight.7 1.1.2 Passenger Cabin Events .9 1.1.3 Summary of Related Engine Maintenance Events .10 1.2 INJURIES TO PERSONS.11 1.3 DAMAGE TO AIRCRAFT.11 1.4 OTHER DAMAGE.12

15、 1.5 PERSONNEL INFORMATION.12 1.5.1 Flight Crew.12 1.5.1.1 Captain Information.12 1.5.1.2 First Officer Information .13 1.5.2 Cabin Crew.13 1.5.3 Technical Personnel .13 1.5.3.1 Engine Controller .13 1.5.3.2 Maintenance Technicians .14 1.5.4 In-house Rolls-Royce Representative.14 1.6 AIRCRAFT INFORM

16、ATION.14 1.6.1 Weight & Balance.15 1.6.2 Right Engine Information .15 1.6.2.1 Right Engine History.15 1.6.2.2 Rework Summary Sheet.16 1.6.2.3 Carry-forward Items.16 .6.2.4 Engine Log Book.16 1.6.3 Engine Fuel Tube Rupture.17 1.6.4 Oil parameters.18 1.6.5 Fuel System.18 1.6.5.1 Fuel System Descriptio

17、n .18 1.6.5.2 Fuel System Operation on the Occurrence Flight.20 1.6.5.3 Fuel System Examination.21 1.6.6 Electronic Centralized Aircraft Monitoring .22 1.6.6.1 Electronic Centralized Aircraft Monitoring System Description.22 1.6.6.2 ECAM Indications During the Occurrence Flight.23 1.6.7 Flight Manag

18、ement Guidance Computer .25 1.6.8 Electrical Systems.26 1.6.9 Flight Controls.26 1.6.10 Emergency Exit L3.27 1.6.11 Cabin Pressurization System.28 1.6.12 Passenger Cabin Oxygen System.29 1.6.12.1 Oxygen System Components .29 1.6.12.2 Oxygen System Requirements .29 1.6.12.3 Oxygen Container Examinati

19、on.30 1.6.12.4 Oxygen Flow to Passenger Masks .31 1.6.12.5 Oxygen Flow to L3 Masks.31 1.6.12.6 Oxygen Flow to R3 Masks .31 1.7 METEOROLOGICAL INFORMATION.32 1.8 AIDS TO NAVIGATION.32 1.9 COMMUNICATIONS.32 1.9.1 Communications Equipment.32 1.9.2 Cockpit Communications Activity.33 1.10 AIR TRAFFIC CON

20、TROL AND AIRPORT SERVICES.33 1.10.1 Air Traffic Control Units.33 1.10.2 Aerodrome Information.34 1.10.3 Lajes Approach and Tower Control Services.34 Final Investigation Report 22 / ACCID / 2001 Pag 4 of 103 1.11 FLIGHT RECORDERS.35 1.11.1 Recorders General.35 1.11.2 Solid State Cockpit Voice Recorde

21、r.35 1.11.3 Digital Flight Data Recorder.36 1.11.4 Digital Access Recorder.36 1.11.5 Recorders Power Source.36 1.12 WRECKAGE AND IMPACT INFORMATION.37 1.13 MEDICAL INFORMATION.37 1.14 CRASH FIRE RESCUE SERVICES.38 1.15 PASSENGER SAFETY AND SURVIVALS.38 1.15.1 Cabin Emergency Preparation .38 1.15.2 P

22、assenger Life Jackets.38 1.16 TESTS AND RESEARCH.40 1.16.1 Examination Reports.40 1.16.2 Hydraulic Line Installation Tests.40 1.17 ORGANIZATIONAL AND MANAGEMENT INFORMATION.41 1.17.1 Company Certificates.41 1.17.2 Extended Range Twin-engine Operations.41 1.17.3 Flight Crew Training.42 1.17.4 Air Tra

23、nsat Maintenance Organizations.42 1.17.4.1 Engineering.42 1.17.4.2 Engine Control.42 1.17.4.3 Quality Assurance.43 1.17.4.4 Quality Control.43 1.17.4.5 Maintenance Control Centre.43 1.18 MAINTENANCE AND TECHNICAL FACTORS.43 1.18.1 Illustrated Parts Catalogue.43 1.18.2 Scope of Service Bulletins.44 1

24、.18.3 SBs Addressing the Hydraulic Pump and Engine Dressing.45 1.18.4 Methods of Reviewing Service Bulletins .46 1.18.5 Company Review of Non-mandatory SBs.46 1.18.6 Receipt and Inventory of Engines .46 1.18.7 Engine Change Planning.47 1.18.8 Right Engine Replacement.48 1.18.9 Pressure Line Installa

25、tion.50 1.18.10 Documentation of Work Done.50 1.18.11 Quality Control.50 1.19 AIRCRAFT OPERATIONAL AND OPERATIONAL FACTORS.51 1.19.1 Cockpit Management .51 1.19.2 Fuel System Abnormal Procedures.51 1.19.2.1 Fuel Imbalance .52 1.19.2.2 Fuel Leak .53 1.19.2.3 Fuel Tank Low Quantity .54 1.19.3 Cockpit

26、and Fuel Management.55 1.19.3.1 Fuel & Systems Monitoring .55 1.19.3.2 Prior to Fuel Advisory .56 1.19.3.3 Fuel Imbalance Situation.56 1.19.3.4 Fuel Distribution.57 1.19.3.5 Crews Awareness of the Fuel Leak.58 1.19.4 Cockpit Workload .58 1.19.5 Cockpit Decision-Making .59 1.19.5.1 Framing Bias .59 1

27、.19.5.2 Confirmation Bias.59 1.19.5.3 Realignment of the Mental Model.60 1.19.6 Cockpit Automation Management.60 1.19.7 Impact of Display Type on Problem Solving.61 1.19.8 Engines-out Approach and Landing .61 Final Investigation Report 22 / ACCID / 2001 Pag 5 of 103 1.19.9 Aircraft Performance Scena

28、rios .63 1.20 OTHER FUEL LEAK OCCURRENCES.64 1.20.1 Previous Air France A320 Fuel Leak Occurrence.64 1.20.1.1 Occurrence Information.64 1.20.1.2 BEA Investigation .65 1.20.1.3 Actions Taken In Response to BEA Preliminary Recommendation .65 1.20.2 Previous Virgin A340 Fuel Leak Occurrence.66 1.20.3 H

29、istory of Other Fuel-leak Events .67 1.20.4 Fuel Leak Recognition and Training .67 1.20.5 Overwriting of CVR Recordings .68 1.21 USEFUL OR EFFECTIVE INVESTIGATION TECHNIQUES.68 2.0 ANALYSIS.69 2.1 GENERAL.69 2.2 TECHNICAL ISSUES.69 2.2.1 Engine Receipt.69 2.2.2 Engine Change Planning.70 2.2.2.1 Role

30、 of Service Bulletins.70 2.2.2.2 Engine Change Plan .71 2.2.3 Engine Installation.71 2.2.3.1 Initial Detection of the Configuration Problem.71 2.2.3.2 Fuel Tube Installation.72 2.2.4 Quality Control Issues.72 2.2.4.1 Maintenance Inspection.72 2.2.4.2 Quality Assurance Documentation Checks.73 2.2.5 C

31、onfiguration Control .73 2.3 AIRCRAFT OPERATIONAL FACTORS.73 2.3.1 Uncertain Engine Oil Parameters.73 2.3.2 Initial Recognition of the Fuel Loss (0438 0533) .74 2.3.3 Reaction to the Fuel Imbalance Advisory (0533 0545).75 2.3.4 Reaction to the Continued Fuel Loss (0545 0610).76 2.3.5 Reactions to th

32、e Engine Failures.77 2.3.6 Approach and Landing.78 2.4 AIRCRAFT FUEL ISSUES.78 2.4.1 Fuel Imbalance Procedure .78 2.4.2 Fuel Leak Warning and Procedures.79 2.4.3 Trim Tank Transfer.79 2.5 A330 ECAM SYSTEM.80 2.6 FUEL MALFUNCTION TRAINING.80 2.7 PASSENGER SAFETY ISSUES.81 2.7.1 Emergency Exit Door L3

33、 Failure .81 2.7.2 Oxygen Flow to Passenger Masks.81 2.7.2.1 Oxygen Container Doors.81 2.7.2.2 Chemical Oxygen Generator R3 Installation.82 2.7.2.3 Oxygen Flow at L3 Position.82 2.7.3 Language of Passenger Safety Briefings .82 2.7.4 Passenger Life Jackets.82 2.8 FLIGHT RECORDERS.83 2.8.1 Flight Reco

34、rder Power Supply.83 2.8.2 Erasure of CVR Recording.83 3.0 CONCLUSIONS.84 3.1 FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS.84 3.2 FINDINGS AS TO RISK.85 3.3 OTHER FINDINGS.86 Final Investigation Report 22 / ACCID / 2001 Pag 6 of 103 4.0 SAFETY ACTION.87 4.1 ACTION TAKEN.87 4.1.1 Action Taken By Tr

35、ansport Canada.87 4.1.2 Action Taken By Air Transat.88 4.1.3 Action Taken By Direction Genrale de lAviation Civile of France (DGAC) .88 4.1.4 Action Taken By Airbus.89 4.1.5 Action Taken By Rolls-Royce.89 4.1.6 Action Taken By CAA.89 4.2 ACTION REQUIRED.90 4.2.1 Fuel Leak Detection and Warning.90 4.

36、2.2 Fuel Leak Training.91 4.2.3 Automated Fuel Transfers .92 4.2.4 Significant Fuel Imbalances .92 4.2.5 Safeguarding Recorders .93 4.2.6 Recorder Power Sources .94 4.2.7 Major Component Change Planning.94 APPENDIX A CALCULATION OF CABIN PRESSURE ALTITUDES.96 APPENDIX B OVERVIEW OF COCKPIT ACTIVITY

37、LEVEL.97 APPENDIX C TERCEIRA, AZORES (LAJES AB) CHARTS .98 APPENDIX D CALCULATIONS OF FUEL DISTRIBUTION.99 APPENDIX E - GLOSSARY.101 Final Investigation Report 22 / ACCID / 2001 Pag 7 of 103 Released copy1.0 Factual Information 1.1 History 1.1.1 History of the Flight On August 24, 2001, Air Transat

38、Flight TSC236, an Airbus 330-243 aircraft, was on a scheduled flight from Toronto Lester B Pearson Airport, Ontario (CYYZ), Canada to Lisbon Airport (LPPT), Portugal with 13 crew and 293 passengers on board. The Captain was carrying out the pilot flying (PF) duties for this flight. TSC236 was planne

39、d to depart CYYZ at 00:10 UTC1, with 47.9 metric tons of fuel2, which included a 5.5 tons over and above the fuel required by regula-tions for the planned flight; the actual take-off time was at 00:52 with a reported 46.9 tons of fuel on board. According to the crew, the flight progressed normally u

40、ntil after crossing 30 West and at 05:03 when they observed unusual engine oil indications on the Number 2 (right) engine (Rolls-Royce RB211 Trent 772B)3. The ENGINE Electronic Centralized Aircraft Monitoring System (ECAM) page was manually selected by the crew, and the oil indications were commu-ni

41、cated by high-frequency (HF) radio to the dispatcher at the companys Maintenance Control Centre (MCC)4 at Mirabel Quebec, Canada. At approximately 05:33, an advisory ADV message was displayed on the Engine/Warning Dis-play (EW/D). The crew noticed the ADV and deselected the ENGINE ECAM page. This ac

42、tion resulted in the Fuel ECAM page being displayed and the crew becoming aware of a fuel imbal-ance between the left and right inner-wing tanks. To correct the imbalance, the crew selected the cross feed valve OPEN and the right-wing fuel pumps OFF in order to feed the right engine from the left-wi

43、ng tanks. At 05:45, the fuel on board had reduced to below the minimum required fuel on board to reach Lisbon, and the crew initiated the diversion to Lajes Airport (LPLA) on Terceira Island in the Azores. By 05:48, the crew advised Santa Maria Oceanic air traffic control5 that the flight was divert

44、ing due to a fuel shortage; the fuel on board had reduced to 7.0 tons. In attempts to resolve the sudden and unexplained reduction in the fuel quantity readings, the crew asked the cabin crew to visually check the wings and engines for a possible fuel leak: the visual check did not reveal any eviden

45、ce of a fuel leak. At 05:54, in reaction to the continued abnormally high rate of reduction in the fuel-on-board quantity reading, the crew selected the right-wing fuel pumps to ON and the left-wing pumps to OFF. These selections established cross feed of the fuel in the right wing tanks to both eng

46、ines. According to the crew, the cross feed from the right tank was established to use up the fuel from the right wing and to counter the possibility that the fuel loss was the result of a leak in the right wing tanks. 1 All times are Coordinated Universal Time unless otherwise noted. 2 All fuel qua

47、ntities are in metric tons, unless otherwise noted. 3 Analysis of the DFDR data indicates that a higher-than-normal rate of reduction in aircraft gross weight started at 04:38, the time that the fuel leak started. 4 Air Transats MCC is manned by the companys dispatcher and maintenance manager. 5 The

48、 cabin preparations for the possible ditching and eventual engines-out landing are detailed in section “1.15 Passenger Safety and Survival” of the report. Final Investigation Report 22 / ACCID / 2001 Pag 8 of 103 Released copyThe crew then contacted MCC on HF, advising the dispatcher of the inexplic

49、able low fuel quan-tity readings. At this time, fuel on board was 4.8 tons, or 12 tons below the planned quantity. The crew reported that they could not determine what the problem was, that the fuel indication was continuing to reduce, and that the apparent fuel leak was happening in the right-wing

50、inner tanks. At 05:59, during the dialog with MCC, the crew reported that the fuel quantity had further re-duced to 1.0 tons in the right tanks and 3.2 tons in the left tanks. MCC asked whether the fuel loss might be a leak in the left engine. In reaction to this suggestion, the Captain momentarily