Madness in Morocco: The near crash of Royal Air Maroc Express flight 439

(Own work + Tomas Milosch)

On the 9th of July 2018, a Moroccan airliner on approach to the city of Al Hoceima came inches away from disaster when it bounced twice off the Mediterranean Sea while descending in fog. Against all odds, the pilots managed to get their heavily damaged plane back in the air and divert to a nearby airport without injuring any of the 58 people on board. But instead of fessing up to his error, the captain tried to pass off the damage as being the result of a bird strike! A deeper investigation revealed that this preposterous lie was only the tip of the iceberg. In the minutes before the near-disaster, the captain made a series of reckless and dangerous decisions, knowingly breaking numerous regulations and violating several basic principles of safe flight, in an apparent attempt to get his plane on the ground in marginal weather conditions. At the climax of the ill-conceived landing attempt, the two pilots started fighting each other as the first officer moved to abandon the approach, while the captain forced the nose down toward the water below. The shocking behavior of the crew, and their narrow escape from certain death, stand as a reminder that no amount of modern safety measures will stop a pilot who is determined to break all the rules.

CN-COH, the ATR-72 involved in the accident. (Gerrit Griem)

Royal Air Maroc Express is a wholly-owned subsidiary of Royal Air Maroc, the flag carrier of the Kingdom of Morocco, specializing in regional flights within Morocco and to neighboring countries, especially Spain. Its domestic routes complement those of the parent company, which are mainly longer international flights in and out of Morocco’s main hub airports in Casablanca, Marrakech, and Tangier. Royal Air Maroc Express operates a fleet consisting of around half a dozen examples of the ATR-72, a joint French- and Italian-made high-wing twin turboprop airliner with room for around 70 passengers. The airline works its ATR-72s hard, sending them on numerous short hops all around the country every day.

Route of CN-COH on the day of the accident. (Own work + Google)

For two unnamed Moroccan pilots working for Royal Air Maroc Express, the 9th of July 2018 was a day like any other. Their schedule that day took them from Casablanca to the Mediterranean city of Al Hoceima, onward to Tangier, back to Al Hoceima, and then finally back to Casablanca. Before the first flight of the day, the pilots agreed that the Captain would fly the first leg and the First Officer would fly the next three in order to gain experience. The first officer was a bit of a rookie, with only about 1,000 flying hours, compared to his 61-year-old captain, who had over 13,000 — although he had just recently switched from the Boeing 737 to the ATR-72 and had accumulated just 193 hours on the type.

With the captain at the controls, the flight departed Casablanca and headed northeast toward Al Hoceima. Weather in the area was poor, with overcast and fog rolling in off the Mediterranean, and the reported cloud ceiling of 800 feet was below the minimum descent altitude of 1,030 feet for the approach to runway 17. Normally this meant that the pilots would need to make multiple approaches while waiting for a gap in the clouds, or failing that, divert to another nearby airport. But the captain seemed to be unconcerned.

During the flight, the crew received an amber “TERRAIN FAULT” indicator light, informing them that their Enhanced Ground Proximity Warning System (EGPWS) had lost part of its functionality. This was not an uncommon occurrence, and in almost every case it occurred because of a weak GPS signal in the area, which prevented the system from accurately determining the plane’s position. As soon as the signal improved, which it did after about six and a half minutes, the caution light disappeared and the EGPWS regained full functionality. Although nothing was wrong with the system, inadequate knowledge might have led the crew to believe that it was unreliable, a critical misunderstanding that might have played into their faulty decision-making hours later.

What the “terrain fault” caution would have looked like. (Mentour Pilot)

After a brief cruise phase, the pilots began an RNAV approach to runway 17 at Al Hoceima Airport, using a series of pre-programmed points in three-dimensional space to line up with the runway and land without the use of ground-based navigational aids. The approach was normal until shortly before landing, when the plane arrived at the minimum descent altitude (MDA) of 1,030 feet. One of the most basic rules of flying is that you don’t descend below the MDA if you can’t see the runway. But the Captain apparently decided that the rules didn’t apply to him, because when he reached the MDA and found himself still in cloud, he simply kept going, descending towards the ground at -1,000 feet per minute. Little did he know that ground fog had created a cloud ceiling closer to 100 feet, rather than the 800 feet which had been reported.

Approximately one minute later, the plane left the safe envelope surrounding the glide path to the runway, and the ground proximity warning system came to life. “TERRAIN AHEAD, PULL UP,” it blared, warning the pilots that they were in serious danger of striking terrain.

Seemingly nonchalant, the Captain pulled up a little and advanced the throttles just enough to reverse the trajectory of his airplane. At a height of only 45 feet above the Mediterranean Sea, the plane entered a slight climb, narrowly avoiding a crash. But despite this heart-stopping close call, the Captain seemed unperturbed. In fact, he’d done this on purpose. Instead of immediately climbing away to try the approach again, he leveled off at 108 feet, flew the last few kilometers to the runway, and landed the plane, in gross violation of numerous air safety regulations.

Trajectory of the first approach. Translation: the blue line represents the trajectory of the aircraft, the purple line represents the normal glide path, and the green line represents the boundary of the zone where the ground proximity warning system will activate. (BEA Morocco)

Any time the EGPWS activates in flight, the pilots are required to file a report with the airline, and there will almost surely be an internal investigation, if not an external investigation by local aviation authorities. But the Captain acted like nothing untoward had occurred. After swapping the old load of passengers for a new one, the plane and its crew took off again for the next leg to Tangier, this time with the First Officer at the controls.

After landing in Tangier, the cockpit voice recorder captured the pilots conducting the departure and approach briefings for the return trip to Al Hoceima. (Because the flight was so short, the approach briefing had to be conducted on the ground, rather than during cruise.) Having successfully landed in Al Hoceima on the previous leg using his insane descent strategy, the Captain decided to do it again, only this time with a concrete plan in place. He told the First Officer that they would try the VOR/DME approach to runway 17 this time, which had an MDA of 760 feet, lower than the RNAV approach. If they still couldn’t see the runway at 760 feet, he said to the First Officer, they would keep going to 400 feet, then fly at this altitude until they saw the runway, or until they reached a distance of 2.2 nautical miles from the threshold, at which point they would go around. This plan bore no resemblance to the official procedure for the VOR/DME approach to runway 17 and once again represented a deliberate violation of basic flying rules. But that was only the first part of his half-baked proposal.

In fact, the Captain had in mind a solution to another “problem” he faced on the first approach: the activation of the EGPWS. He felt that the terrain warning was unwarranted or outright false, perhaps because he distrusted the system after the caution light illuminated earlier in the flight, and because he felt he was in control of the situation at the time that it went off. The loud alarm and flashing lights that came with it were merely an annoyance. On this leg, he announced, they should turn it off in advance.

Bizarrely, the pilots then broke out the Minimum Equipment List (MEL), a manual listing which systems are allowed to be inoperative when dispatching a flight, to see if it said anything about the EGPWS. The MEL is designed to be used when equipment is broken, not when the pilots want to turn off a system they don’t like! Did they really think that was what it was for? And if not, why did they look at it in the first place? We may never know.

The MEL said that the EGPWS could be inoperative across no more than 6 flights or 24 hours, whichever was less; and only if the pilots exercised heightened vigilance at all times. Having concluded that it was legal to fly without the EGPWS, the pilots decided to switch it off later in the flight. Obviously, while the MEL allowed limited flight with the EGPWS inoperative, turning it off without a very good reason was a major regulatory violation. And from their actions on the first approach to Al Hoceima, it was clear that the pilots had no intention of exercising heightened caution.

At 7:30 p.m. local time, Royal Air Maroc Express flight 439 departed Tangier with 54 passengers and four crew on board, including a prospective hire working her way through Royal Air Maroc’s training program, who was riding in the jump seat to familiarize herself with ATR-72 operations. The plane quickly climbed to its cruising altitude of 13,000 feet, stayed there for six minutes, then began the descent into Al Hoceima. The weather conditions were now even worse than on their previous approach, with a cloud ceiling at 600 feet and fog off the coast stretching all the way down to sea level.

The descent was fast and steep from the beginning. As they descended toward 6,000 feet, the Captain instructed the First Officer to use an excessive descent rate of -1,800 feet per minute, and their airspeed was 230 knots, far above normal. There was no obvious reason for this; apparently, it was just how the Captain liked to fly. “You fly, I will watch the speed and the water,” he said to the First Officer, betraying his intention to keep descending until he caught sight of the Mediterranean Sea. He then switched off the EGPWS, just as they had briefed on the ground in Tangier.

At 8:01 p.m., flight 439 lined up with the runway before barreling onward toward the final approach fix, the point by which they were supposed to be configured to land with the correct speed and rate of descent. But as flight 439 flew over the final approach fix, the crew had still not lowered the landing gear or the flaps, they were more than 80 knots above the normal approach speed, and they were descending too quickly. The approach was hopelessly unstable and proper procedures required them to go around and try again, but the pilots had no intention of doing so.

Altitude and configuration vs. time during the second approach to Al Hoceima. (BEA Morocco)

Shortly before reaching 2,100 feet, the Captain set their target altitude to 400 feet in accordance with his preconceived plan. Meanwhile, the First Officer worked hard to get their speed under control. The controller cleared them to land, and the pilots extended the landing gear and flaps. The plane passed through the minimum descent altitude of 760 feet, still descending at -1,800 feet per minute. The first officer, possibly becoming nervous, reached over and reduced it to -1,000 instead.

“There at 1,000 feet we see the ground,” the Captain said. “500 feet, we see the ground. We continue to 300.”

The plane reached a height of 445 feet. Still no sign of the runway. “We keep going now, keep going,” the Captain said. “Go, go, we keep going.” He reached over to the autopilot panel and changed the descent rate back to -1,800 feet per minute, which was beyond reckless, given that they were now at a height of 310 feet. At this point the ground proximity warning should have sounded, but it didn’t because the pilots had turned it off.

The First Officer immediately reached over and changed the descent rate back to -1,400 feet per minute. “This is not normal!” he exclaimed, becoming increasingly terrified as the plane hurtled toward the sea below. “Now take it manual,” he muttered to himself in Arabic. At a height of 80 feet above the water, he disengaged the autopilot and began to pull up.

The vertical trajectory of the flight during the approach. Note how the blue line twice reaches 0. (BEA Morocco)

But the Captain had other ideas. “Oh, yeah this is fine,” he said, grabbing the control column to pitch the nose down! Even at 80 feet above the ground, he’d be damned if he let his First Officer level off without seeing the water. They were going until it was visible, no matter what!

Now the First Officer was pulling up while the Captain pushed down, creating a massive force differential on the linked control columns as the pilots fought against each other for control of the airplane. But the Captain was stronger, and he held the plane in a descent for several more seconds as the First Officer tried desperately to overpower him. At 35 feet the First Officer advanced the throttles to high power, but it was already too late. At 8:03 and 53 seconds, the ATR-72 slammed into the water with a force of 3.2 G’s, causing it to bounce back into the air. Incredibly, the Captain kept pitching down. Two seconds later they hit the water again, this time pulling nearly 4 G’s, far beyond the structural limits of the landing gear.

“Oh, merde,” the Captain exclaimed, pulling back sharply on the controls. “Merde!

Working together now, the pilots managed to pull the plane back up into the air, leaving broken pieces of the lower fuselage floating on the water behind them. Shaken but alive, they informed the controller that they were going around and began to climb away over the airport.

Simulation of the two impacts by Mentour Pilot. You can watch the rest of his excellent video on the incident here: https://www.youtube.com/watch?v=ifZyclQ5QCQ&t=16s

A few minutes later, flight 439 diverted to the nearby city of Nador, where the weather was better. After landing safely and taxiing to the parking apron, the 54 passengers disembarked without a single injury. The plane itself was less lucky. The hard impacts tore a series of large holes in the lower fuselage, bent several structural stringers, and splashed seawater into the RAM Air intakes. The water came up high enough that it would have ripped the engines off most planes, leading to a catastrophic crash, but the ATR-72 survived due to its high-wing design that kept both the power plants and the lifting surfaces clear of the water, allowing the pilots to pull away from the sea surface instead of digging in and cartwheeling.

In the immediate aftermath of the incident, the Captain told airline personnel over the phone that the damage was due to a bird strike, and he wrote as much on the official incident reporting form. But it was obvious to anyone who looked at the damage that it could not have been the result of a bird strike, and Moroccan officials were not swayed by this dubious excuse. Shortly after the incident, the BEA, Morocco’s air accident investigation agency (not to be confused with the French agency with the same initials), launched an inquiry into the near disaster.

What they found was beyond shocking: flight 439 had bounced twice off the surface of the Mediterranean Sea, taking its 58 passengers and crew within inches of death, because of the Captain’s premeditated decision to violate fundamental safety protocols.

On the first approach into Al Hoceima, the Captain nearly crashed by descending to an altitude of just 45 feet before catching sight of the water, leveling off, and continuing to land. And somehow, his biggest takeaway from this stupidly dangerous approach was that the ground proximity warning system was an unacceptable distraction. Yes, on some unconscious level he might have distrusted it due to the interruption to the GPS signal earlier in the flight. But it doesn’t take a systems expert to understand that descending rapidly while a few dozen feet above the sea will trigger a warning from any properly-functioning EGPWS. So while he told investigators that he thought it was faulty, it seems just as likely that he knew it was working but decided to turn it off because he found it to be distracting as he focused on conducting risky maneuvers at low altitude.

(Note: Checklists for ditching and forced landings require pilots to turn off the EGPWS to prevent loud and distracting nuisance warnings while attempting off-field emergency landings, which is why the switch is so easily accessible.)

Close-up of the damage to the bottom of the plane. (BEA Morocco)

Having succeeded in landing in conditions well below minimums using his ill-advised approach technique, the Captain insisted that the First Officer do the same on the return leg to Al Hoceima. The First Officer put up no resistance at all, and in fact he responded to most of his captain’s statements with nothing more than “d’accord,” a French saying that is the functional equivalent of nodding along politely. In fact, throughout the cockpit voice recording, the First Officer said virtually nothing besides checklist callouts and “d’accord” until just seconds before impact. The CVR transcript reads like a monologue delivered by the Captain. Clearly the inexperienced First Officer did not see it as his place to contradict the insane plan that his very senior captain had come up with, especially since that plan worked on the previous approach, saving them from an expensive diversion. As a result, he didn’t challenge the plan to descend below the MDA or the plan to turn off the EGPWS.

Radio altitude and vertical G’s during the moment of the two touchdowns. (BEA Morocco)

The First Officer’s subordinate role continued throughout the descent, as the Captain gave various orders and the First Officer wordlessly obeyed. The First Officer was physically manipulating the controls, but the Captain was effectively flying the plane. This blind obedience only began to break when the plane passed through a height of around 100 feet above the water, when the First Officer said, “This is not normal” and started to pull up of his own initiative.

The fact that the Captain responded by grabbing the controls and countering his First Officer’s inputs illustrates both his extraordinary hubris and his incorrect reading of the situation. Had the plane crashed, the most proximate cause would have been this final foolhardy maneuver. In order to do something so drastic and, frankly, dumb, the Captain must have been highly confident in his own ability, deeply distrustful of his First Officer’s judgment, and completely clueless about their actual altitude. As the pilot monitoring, he was supposed to be aware of their altitude at all times, but obviously no one would purposefully pitch down while already in a descent less than 100 feet above the sea. The Captain must have believed that they would break through the fog at a high enough altitude to level off and fly to the airport, but had not tracked their height carefully enough to realize that they couldn’t go any lower. Most probably he was distracted micromanaging the descent on behalf of his first officer and looking out the window in a futile attempt to catch sight of the water. Had the EGPWS been turned on, its warning would have prompted him to check their altitude, and they easily could have avoided hitting the sea.

Damage to structural stringers inside the fuselage. (BEA Morocco)

It was at the last possible moment that the First Officer broke through his meek deference to authority and saved everyone on board the plane. By actively fighting his captain’s attempts to force them into the water, and by applying high power to bring the nose up when the Captain began to overpower him, he slowed their rate of descent enough to prevent a more catastrophic collision with the sea. If he had waited for an order from the Captain before attempting to climb, or if he had let go of the controls when the Captain tried to take over, they probably would have plowed straight into the water at a high rate of descent, and that would have been it for them and many of their passengers. It isn’t easy for a rookie first officer to defy a senior captain this way, especially in the sort of authoritarian culture that apparently existed at Royal Air Maroc Express. There have been countless fatal accidents where first officers didn’t react to their captains’ mistakes at all, or only reacted too late, and nobody lived to tell the tale. In this case, the First Officer reacted at the last conceivable second: after ignoring numerous violations by the Captain, he finally did the bare minimum to save the plane, and everyone walked away. Was he a hero? Not at all. But if not for his actions, dozens might have died.

Measurements of compression marks on the landing gear revealed that the second impact exceeded the nose gear’s maximum certification load. (BEA Morocco)

As a result of the damage sustained during the accident, the airplane had to be taken out of service for two and a half months to undergo major repairs. It eventually returned to service and still flies for Royal Air Maroc Express today, hopping around Morocco just as it did before its near-death experience. But the pilots are not so easily tracked: the identities of the crew are unknown, as are their fates. Was the Captain fired? Did he go to prison? Or is he still flying for Royal Air Maroc? The consequences for the Captain should have been significant, but research for this article didn’t turn up any information about what happened to him or to his first officer.

In the aftermath of the accident, Royal Air Maroc Express also made a number of changes to ensure professionalism among its pilots and prevent a recurrence. In addition to wide-ranging new training on stabilized approaches and threat and error management, they also added a seal to the EGPWS switch on each of their aircraft which must be broken in order to move it. Daily checks of the seal were introduced to catch anyone who was habitually turning the system off.

Passengers board CN-COH, the aircraft involved in the accident. (Aleem Yousaf)

When trying to draw a safety lesson from the near crash of Royal Air Maroc Express flight 439, it’s hard to know where to begin. Most accidents involve a series of inadvertent errors by the crew, not willful disregard for proper procedures. The only way to prevent pilots from going rogue in this way is a robust monitoring program that catches these sorts of deviations and administers consequences before a culture of violations can establish itself. Many airlines around the world have such programs, including Royal Air Maroc and its subsidiary. But the effectiveness of these programs relies in turn on pilots and management both buying in to the rules — a fundamental part of any safety system that Royal Air Maroc Express might have lacked. The airline has tried to cover for its errors in the past — for example, after a Royal Air Maroc Boeing 737 bounced on the runway twice and nearly failed to become airborne on takeoff from Frankfurt in 2016, the company put out a statement denigrating “false information” about the incident supposedly published online, and blamed the incident on wake turbulence, an explanation which left experts rolling their eyes. How many times had Royal Air Maroc let its pilots get away with violating the rules? How many times had the captain of flight 439 pulled these dangerous stunts before he got caught? The near-disaster should serve as a reminder that no matter how safe the aviation industry has become, no amount of safety systems and procedures will stop a pilot who is determined to break all the rules. And yet, there is still room for hope: at the end of the day everyone lived, despite the Captain’s best efforts to kill them.

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Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.