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Air Canada Flight 143

Air Canada Flight 143. Ken Duenwald. Overview. The Incident The Causes Damaged Fuel Gauge Processor Crew Assumptions Unit Conversion Error Summary Lessons Learned. The Incident. 23 July 1983 New Boeing 767 Scheduled Montreal to Edmonton Flight Fuel exhausted mid-flight

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Air Canada Flight 143

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  1. Air Canada Flight 143 Ken Duenwald

  2. Overview • The Incident • The Causes • Damaged Fuel Gauge Processor • Crew Assumptions • Unit Conversion Error • Summary • Lessons Learned

  3. The Incident • 23 July 1983 • New Boeing 767 • Scheduled Montreal to Edmonton Flight • Fuel exhausted mid-flight • Diverted to Gimli, Manitoba http://presurfer.blogspot.com/2007/11/gimli-glider.html http://www.wadenelson.com/gimli.html

  4. Damaged Fuel Gauge Processor • Dual Channel System • Faulty inductor coil in one channel, gauges blank • Damaged channel disabled, gauges restored • Damaged channel later reactivated http://www.isplc2006.org/b2b/crude_oil/1/

  5. Crew Assumptions • Malfunction and blank gauges noted • Manual Fuel Measurement • Flight crew assumptions vs. Minimum Equipment List http://users.telenet.be/dkaviation http://jetphotos.net

  6. Unit Conversion Error • Volume vs. Weight • 22,300 kg. of fuel required • 7,682 liters measured before refuel • Metric System new in Canada • Incorrect mass to volume conversion (lb vs. kg) Source: Flight Safety Australia

  7. Summary • Fuel Exhaustion Mid-flight • Causes • Mechanical Flaws • Human Error • Lessons Learned

  8. How the plane was landed • No fuel, power, hydraulics, or electronics • Ram air turbine provided basic systems • Side-slip (Crab) Configuration • Increased descent without increased speed http://blog.fagstein.com/wp-content/uploads/2008/07/

  9. Damaged Processor Details • Design Faults • Cold Solder Joint • Dual Channel Flaw • Malfunction Log Error http://workmanship.nasa.gov/lib/insp/2%20books/links/sections/601%20General%20Requirements.html

  10. Why volume vs. weight • Ground crew only considers how much fuel to add • Volume easier to measure • Pilots consider weight for various factors • Take-off • Cruise Speed • Landing • Adequate amount without excess weight

  11. Aftermath • Plane repaired and resumed service • Government Recommendations • Metric conversion training • More spare parts • Improved training with new aircraft • Aircraft design improvements • Ethical Improvements

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