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Last updated: 3 December 2021
Statuts:Enquête Officielle
Date:lundi 9 juillet 2018
Heure:20:05
Type/Sous-type:Silhouette image of generic AT76 model; specific model in this crash may look slightly different
ATR 72-600 (72-212A)
Compagnie:RAM Express
Immatriculation: CN-COH
Numéro de série: 1034
Année de Fabrication: 2012-07-03 (6 years )
Heures de vol:11563
Cycles:10665
Moteurs: 2 Pratt & Whitney Canada PW127M
Equipage:victimes: 0 / à bord: 4
Passagers:victimes: 0 / à bord: 54
Total:victimes: 0 / à bord: 58
Dégats de l'appareil: Substantiels
Conséquences: Repaired
Lieu de l'accident:2,6 km (1.6 milles) N de Al Hoceima-Charif Al Idrissi Airport (AHU) (   Maroc)
Phase de vol: A l'atterrissage (LDG)
Nature:Transport de Passagers Nat.
Aéroport de départ:Tangier-Ibn Battouta Airport (TNG/GMTT), Maroc
Aéroport de destination:Al Hoceima-Charif Al Idrissi Airport (AHU/GMTA), Maroc
Numéro de vol:AT439
Détails:
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 Cause:

Causes probables :
- L’événement survenu le 9 juillet 2018 à l’aéronef, immatriculé CN-COH, durant son approche sur l’aéroport d’Al-Hoceima Charif Alidrissi, serait dû au non-respect des procédures opérationnelles, notamment ; l’arrêt délibéré du GPWS, la poursuite de l’approche instable en dessous du plancher de stabilisation et la poursuite de l’approche au-delà de l’altitude minimale de descente (MDA) en l’absence de références visuelles.
- Par l’arrêt indu du GPWS et l’absence d’annonces Advisory Calls pendant l’approche, l’équipage s’est privé de toute possibilité de prendre conscience et de gérer la situation indésirable de Vol dirigé vers le sol « Controlled Flight Toward Terrain » dans laquelle se trouvait l’aéronef jusqu’au toucher.
- L’item (038-42-02-01) du DDM ne prévoyant pas de consigne opérationnelle (O) pour la panne totale du GPWS, serait de nature à avoir conforté la décision de l’équipage de conduite de l’arrêter sans précaution.
- La carence en CRM au sein de l’équipage de conduite, notamment en termes de communication, de coordination et de dosage adapté entre le gradient d’autorité du CDB et le niveau d’affirmation de soi de l’OPL, font que ce dernier a tardé à réagir contre les directives du CDB, incompatibles avec les limites du plancher de stabilisation et des minimas de l’approche.
Il n’en demeure pas moins que la réaction de l’OPL, quand bien même tardive, a permis de limiter la situation finale aux seuls dégâts matériels subis par l’aéronef.

Accident investigation:
cover
Investigating agency: 
Status: Investigation completed
Accident number: BEA09072018-01
Download report: Final report

METAR Weather report:
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=


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Plan
This map shows the airport of departure and the intended destination of the flight. The line is connecting ADS-B datapoints from Flightradar24.
La distance entre Tangier-Ibn Battouta Airport et Al Hoceima-Charif Al Idrissi Airport est de 197 km (123 miles).
Accident location: Approximate; accuracy within a few kilometers.

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.
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