Flight 236: A Story of Human Psychology and Critical Decision-Making

Confirmation bias plays a crucial role in the decision-making process, as the pilots cling to their initial hypothesis despite conflicting evidence.

The lack of warning systems for fuel leaks in aircraft can lead to delayed awareness and critical situations.

The high workload and stress of the situation contribute to the pilots' difficulty in reevaluating their understanding of the problem.

The incident showcases the importance of effective communication between pilots and maintenance control during critical situations.

The need for ongoing training on identifying and responding to fuel leaks is highlighted by the pilots' lack of preparation in dealing with this rare occurrence.

How did the pilots initially interpret the unusual engine oil and fuel level indications?

—The pilots initially believed that the engine oil indications were the result of faulty sensors and assumed that the low fuel level readings were also erroneous.

Why didn't the pilots consider the possibility of a fuel leak?

—The pilots were busy with their tasks and lacked training in identifying and dealing with fuel leaks. Their mental model of the situation was focused on faulty sensors rather than a fuel leak.

What steps did the pilots take to address the fuel shortage?

—The pilots tried to balance the fuel between the wings by opening the cross-feed valve. They also contacted maintenance control for guidance.

Why didn't the pilots carry out the fuel leak procedure?

—The fuel leak procedure required descending to a lower altitude, which the captain decided against due to the critical nature of the situation and the limited time available.

What lessons can be learned from this incident?

—The incident highlights the need for pilots to reevaluate their understanding of a situation, especially under pressure. It also emphasizes the importance of effective communication, training, and awareness of rare occurrences like fuel leaks.

00:00Introduction to the incident: Air Transat Flight 236, carrying 306 passengers and crew, faces a fuel shortage over the Atlantic Ocean due to a fuel leak. The pilots struggle to understand the conflicting indications and make sense of the situation.

09:40The pilots' initial interpretation and doubts: The pilots consider the unusual engine oil and fuel level indications as erroneous due to their mental model focused on faulty sensors. They overlook the possibility of a fuel leak.

19:03The critical decision-making process: The pilots contact maintenance control, but the fuel continues to rapidly decrease. The lack of warning systems for fuel leaks and the pilots' high workload and stress contribute to their difficulty in reevaluating their understanding of the situation.

29:15The pilots' limited options and actions: The pilots divert the aircraft to an alternative airport, but the fuel shortage poses a significant risk. They consider carrying out the fuel leak procedure but ultimately decide against it due to the critical nature of the situation.

38:44Lessons learned and takeaways: The incident highlights the power of confirmation bias and the challenges of decision-making under pressure. It emphasizes the need for effective communication, ongoing training on rare occurrences like fuel leaks, and the importance of reevaluating understanding and mental models.