ASN Wikibase Occurrence # 319614
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| Date: | Monday 9 July 2018 |
| Time: | 20:05 |
| Type: |  ATR 72-600 (72-212A) |
| Owner/operator: | RAM Express |
| Registration: | CN-COH |
| MSN: | 1034 |
| Year of manufacture: | 2012 |
| Total airframe hrs: | 11563 hours |
| Cycles: | 10665 flights |
| Engine model: | Pratt & Whitney Canada PW127M |
| Fatalities: | Fatalities: 0 / Occupants: 58 |
| Aircraft damage: | Substantial, repaired |
| Category: | Accident |
| Location: | 2,6 km N off Al Hoceima-Charif Al Idrissi Airport (AHU) -
 Morocco
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Tangier-Ibn Battouta Airport (TNG/GMTT) |
| Al Hoceima-Charif Al Idrissi Airport (AHU/GMTA) | |
| Investigating agency: | BEA Maroc |
| Confidence Rating: |  Accident investigation report completed and information captured |
The RAM Express ATR 72-600, registration CN-COH, contacted the water during an approach to Al Hoceima Airport, Morocco. The flight crew performed a go around and diverted to Nador Airport.
The aircraft operated on a flight from Casablanca to Al Hoceima and Tangier (AT438) and return (AT439).
During the first leg, the "TERRAIN" warning message was displayed and the amber "TERRAIN FAULT" light illuminated, probably related to a degradation of the GPS signal in the area crossed by CN-COH while at FL160. It disappeared after about 6 minutes and 38 seconds. The crew flew the RNAV approach for Al Hoceima runway 17. Once at MDA (1,030 ft), the captain did not see the runway due to the low cloud ceiling and decided to continue the descent with a descent rate of about 1000 ft/min. One minute later, the "TERRAIN AHEAD PULL UP" and "AVOID TERRAIN" TAWS alarms were triggered when the aircraft was 1760m from the runway threshold and 60ft radio altitude. The Pilot Flying (PF) then performed a pitch-up attitude change and restored power. The lowest point reached was 45ft radio altitude. The aircraft then climbed to a height of 108 feet, which it maintained until the runway was in sight, and then resumed a descent to land.
The third leg of the flight was from Tangier Airport back to Al Hoceima Airport. Due to the short flight time, the approach briefing at Al Hoceima was carried out on the ground in Tangier, at the same time as the departure briefing. This time, the crew prepared a VOR/DME approach, the minima of which were 760 ft. The captain (Pilot Monitoring) explained to the first officer (Pilot Flying) that if the runway was not in sight at the minima, he would descend to 400 ft and maintain this altitude until the runway was in sight, and that if the runway was still not in sight at 2NM from the VOR, the approach would have to be aborted and a go-around would have to be made. In addition, the captain accepted, after consulting the Dispatch Deviation Manual (DDM), the co-pilot's suggestion to stop the GPWS to avoid alarms during the descent and approach, because they believed that the alarms emitted by this system, during the first leg, were untimely.
The plane took off from Tangier Airport at 18:30 and reached its cruising level of FL130 at 18:46. Descent was begun 6 minutes later. Before starting the descent, the captain discussed with the first officer the execution of the approach and gave him advice/instructions. At 18:55, the crew contacted the Al Hoceima tower air traffic controller. The controller asked the crew to confirm that they wished to conduct a VOR DME approach for runway 17, to which the crew replied in the affirmative. The controller then cleared them to descend to FL60 and asked them to call back on the VOR ALM. The LNAV mode was active. The crew engaged the AP (autopilot) V/S mode with a vertical speed of -1500 ft/min and selected the 6000 ft altitude. The captain instructed the first officer in the procedure with a point "ALM01", not on the published procedures, located at "12.5 NM radial 336°". At 18:56, the crew carried out a descent checklist, on the initiative of the PM (captain) and during this descent they increased the vertical speed to -1600 ft/min then to -1800 ft/min with an indicated speed of 230Kt. The captain reminded the first officer of the manoeuvres to be carried out in the event of a go-around and announced to the first officer that during the approach, he (the captain) would take care of monitoring "speed and water" and he (first officer) would take care of piloting.
Shortly before reaching 6000ft, at 18:58, the Indicated Speed of 210kt and an altitude of 3000ft were selected.
The crew selected the 3000-foot altitude and cross-checked the altimeters at QNH 1016 as they passed 6100 feet. Then the approach checklist was completed. At 18:59:54, the aircraft was 11.5 NM from the threshold of runway 17, speed 220Kt and altitude about 4500 feet, the captain deactivated the GPWS and reminded the first officer twice "Gear and Flaps for a greater rate of descent" he explained. At 19:00:16, at 4000 feet altitude, the heading increased from 90° to 148°, the captain said to the first officer: "At two nautical miles you must be at seven hundred ... we take the decision at three nautical miles, then you will maintain 400 feet radio altimeter".
After intercepting the final approach, the speed was reduced to 170Kts. At 19:01:51, the Tower controller reported the latest weather information: "Wind calm, visibility four kilos presence of mist, Overcast at 006, temperature 23, dew point 23, QNH 1016". The captain replied, "Roger, continue approach and call back."
The captain then selected an altitude of 400 ft, while the aircraft was 6.4NM from the runway threshold. Subsequently the crew re-engaged the V/S mode with a vertical speed of -1,200 ft/min when the aircraft was 6.2 NM from the runway threshold.
At 19:02:14, the captain selected flaps to the 15° position and radioed Al Hoceima Tower "Did you copy. We are fully established", after which ATC acknowledged receipt and issued landing clearance.
The captain then acknowledged "Roger". At the request of the first officer, the captain selected the landing gear down, followed by flaps to the 30° position at a threshold distance of 3.3 NM.
At 19:03:33, the aircraft was 2 NM from the runway threshold at an altitude of approximately 400 ft. Descent continued at a selected rate of -1800 ft/min, which was later reduced to -1400 ft/min.
After descending through 135 ft over the water, the PF said "this is not normal" and at a height of 80 feet and a speed of 130 knots, he disengaged the autopilot (AP).
For 9 seconds, the PF applies nose-up control column forces while the PM applied nose-down control column forces. The maximum opposite force on the two control columns reached 3 times 68 daN. At 19:03:51, the PF advanced the thrust levers to the 74° position reached in 4 seconds. At 19:03:53, the landing gear was compressed; the aircraft struck the surface of the water twice because the nose-down forces applied to the control column by the PM were greater than the PF's nose-up forces. On the second impact, the aircraft had a nose-down attitude of -3° and experienced a vertical acceleration of 3.92G and a deceleration of 0.42G.
This occurred at 2630 meters from the threshold of runway 17. At this time, the PM applied a 40 daN nose-down force while the PF applied a 28 daN nose-up force.
Subsequently, the PM's nose-down force decreased while the PF's nose-up force increased and the aircraft regained altitude. The Master Warning, associated with a TO config PWR MGT (PWR MGT in CRZ position during the approach), was activated for one second. The thrust levers were moved back to 67° and the attitude gradually increased to reach 17° to pitch up 10 seconds later.
At 19:03:59, when the aircraft was 1.08 NM from the threshold of runway 17, the captain told the first officer to turn and set the flap selector from 30° to 0°. The flaps were retracted to the 0° position about 14 seconds later at 19:04:05. The landing gear was then retracted, and the captain radioed toe Al Hoceima Tower that they were carrying out a go-around, and requested to proceed to Nador Airport. The crew continued their flight, and landed safely at Nador at 19:30
Probable causes:
- The event that occurred on 9 July 2018 to the aircraft, registration CN-COH, during its approach to Al-Hoceima Charif Al Idrissi Airport, would have been due to failure to comply with operational procedures, in particular; the deliberate stopping of the GPWS, the continuation of the unstable approach below the stabilization level and the continuation of the approach beyond the minimum descent altitude (MDA) in the absence of visual references.
- The undue shutdown of the GPWS and the absence of Advisory Calls during the approach deprived the crew of any opportunity to recognize and manage the undesired Controlled Flight Toward Terrain situation in which the aircraft was until touchdown.
- Item (038-42-02-01) of the Dispatch Deviation Manual, which does not provide an operational instruction (O) for the total GPWS failure, would have supported the flight crew's decision to stop the aircraft without precaution.
- The lack of CRM among the flight crew, particularly in terms of communication, coordination, and appropriate dosage between the captain authority gradient and the first officer's level of assertiveness, resulted in the first officer's delay in reacting against the captain's directives, which were incompatible with the limits of the stabilization level and approach minima.
The fact remains that the first officer's reaction, even if late, limited the final situation to the material damage to the aircraft.
METAR:
18:00 UTC / 19:00 local time:
GMTA 091800Z 36004KT 4000 BR OVC006 23/23 Q1016 NOSIG=
19:00 UTC / 20:00 local time:
GMTA 091900Z 02002KT 4000 BR OVC006 23/23 Q1016 NOSIG=
20:00 UTC / 21:00 local time:
GMTA 092000Z 08002KT 4000 BR OVC006 23/23 Q1017 NOSIG=
Accident investigation:
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Sources:
History of this aircraft
Other occurrences involving this aircraft
| 25 April 2018 | CN-COH | RAM Express | 0 | Al Hoceima-Charif Al Idrissi Airport (AHU/GMTA) | |
min |
| Heavy landing | ||||||
Location
Revision history:
| Date/time | Contributor | Updates |
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