What happened
On July 4, 2009, a Royal Air Maroc Boeing 737-80 and registration CN-ROK was performing an international scheduled passenger flight from Casablanca to Paris Orly. During the approach, the air traffic controller proposed a change in landing runway to alleviate congestion on runway 24. The crew was instructed to perform an ILS approach for runway 24, followed by a visual circling maneuver (MVL) to land on runway 20.
As the aircraft descended, the crew was flying an approach that had not been fully prepared, as the updated ATIS information had been received 40 minutes prior to the approach change. At approximately 1,400 ft, the pilot flying disengaged the autopilot. During the transition to the runway 20 final, the aircraft became unstable. At 400 ft, the crew began a left turn to intercept the runway 20 centerline. The aircraft drifted past the runway centerline, reaching a heading of 184° at only 85 ft altitude.
In an attempt to correct the flight path, the crew applied power at approximately 20 ft altitude. However, the aircraft's right main gear struck the ground to the left of the runway at a heading of 210°. The impact caused the aircraft to bounce briefly before rolling approximately 200 meters. The aircraft subsequently landed on runway 24 without further incident. The incident resulted in two damaged wheels.
The investigation
The investigation focused on the sequence of events leading to the unstable approach and the lack of established procedures for the maneuver. Investigators examined flight parameters, air traffic control communications, and ground observations. It was noted that the PAPI lights for runway 20 were extinguished at the time of the approach. The investigation also reviewed the airport's operational configuration, which was under temporary changes due to construction on runway 08/26.
Findings
- The air traffic controller's late proposal to switch to runway 20 left the crew with insufficient time to prepare for the complex circling maneuver.
- The crew's decision to follow the improvised instruction resulted in an approach that was incompatible with the operator's stabilization criteria.
- There was an absence of a specific, published approach procedure for runway 20 at that time.
- The use of runway 20 for landings was not part of the standard operating instructions for that period, and the lack of visual aids (PAPI) contributed to the difficulty of the maneuver.