Air Canada Flight 143 Ken Duenwald

Overview The Incident The Causes Summary 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 Diverted to Gimli, Manitoba http://presurfer.blogspot.com/2007/11/gimli-glider.html http://www.wadenelson.com/gimli.html

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/

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

Source: Flight Safety Australia 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) Fuel Quantity Correct value Calculated Value Conversion Factor 0.803 kg/liter 1.77 lb/liter Weight before refuel 6,169 kg 13,597 lb Weight required to refuel 16,131 kg 8,703 lb Volume required to refuel 20,088 liters 4,916 liters Total Fuel 22,300 kg 22,300 lb (10,116 kg) Source: Flight Safety Australia

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

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/

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

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

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