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