Crisis of Confidence: The crash of Air Algérie flight 6289
Tags: Aviation, Human Behavior, Algeria

Rescuers swarm the crash site of Air Algérie flight 6289 in search of survivors. (CNN)

On the 6th of March 2003, an Air Algérie Boeing 737 lifted off from the runway in the remote Saharan city of Tamanrasset, bound for Ghardaïa and Algiers. But within seconds of becoming airborne, the plane’s left engine failed, plunging the pilots into an emergency situation for which they were not prepared. Witnesses watched in horror as the plane climbed to 400 feet, stalled, and plunged into the desert, where it erupted in flames. As rescuers rushed to the scene, they found that an explosion had totally consumed the plane, along with everyone inside it. But it just so happened that one man wasn’t in the plane — a 28-year-old soldier, seated in the very last row, had been thrown from the aircraft on impact and emerged as the only survivor out of 103 passengers and crew. The clues explaining why they died lay strewn across the Sahara Desert, and it would be up to investigators to figure out what went wrong with the engine — and with the crew. But some aspects of the investigation were woefully incomplete, and an in-depth analysis suggests there may be more to the story of why 102 people died on Air Algérie flight 6289.

7T-VEZ, the Boeing 737–200 involved in the accident. (Ken Fielding)

Air Algérie is the state-owned flag carrier of the North African nation of Algeria. Algeria is known as a relatively stable country today, but in 2003, it had only just emerged from 11 years of civil war that resulted in numerous high-profile terrorist attacks and aircraft hijackings. Air Algérie’s fleet was outdated and in questionable condition; it would be another decade before it acquired the capital to upgrade to modern airliners. The workhorse of its domestic fleet was the Boeing 737–200, the earliest generation of the ubiquitous model, which was powered by two cigar-shaped Pratt & Whitney JT-8D engines.

View over Tamanrasset, 2016. (Habib Kaki)

It was one of these 737–200s that was scheduled to carry out a domestic flight from the city of Tamanrasset to the capital, Algiers, with a stopover in Ghardaïa on the 6th of March, 2003. Located near the geographical center of the Sahara Desert some 1,600 kilometers south of Algiers, Tamanrasset is among the most remote cities on earth. The city was originally a military outpost built to protect Trans-Sahara caravan routes, and only began to see permanent settlement under French rule in 1915. Despite its inhospitable location, the population of the city has grown to 76,000 today, making it the largest inhabited place in the Central Sahara, and it remains a key transportation hub — no longer serving traditional caravans, it instead serves as a major stop on the Trans-Sahara Highway, one of the only roads across the desert that is paved most of the way.

Route of Air Algérie flight 6289. (Google)

Just outside town alongside the Trans-Sahara highway is Tamanrasset’s Aguenar Airport, where Air Algérie flight 6289 prepared to depart for Ghardaïa and Algiers on the 6th of March. The plane was nearly full, with 97 passengers and six crew on board, including dozens of Algerians and a smaller number of Europeans. The captain’s name has not been released, but it is known that he had been flying since 1979 and had over 10,000 flying hours, of which about 1,000 were on the Boeing 737. Although the practice was banned under international rules, he had also been flying as a first officer on the Boeing 767 at the same time, despite the two planes not sharing a common type rating.

His first officer that day was Fatima Yousfi, who was notable for becoming the first woman ever to fly for an Algerian airline when she got her license in the late 1990s. By 2003 she had accumulated about 5,200 hours, including around 1,300 on the 737, which she had been flying for around six months longer than the captain had.

Undated photo of Fatima Yousfi. I was unable to find any pictures of the captain, or even his name. (Save Me organization, via Facebook)

As flight 6289 waited at the gate, First Officer Yousfi found herself alone on the flight deck, as the captain was running late. She ran through the pre-departure calculations herself, and was about ready to start the pre-flight briefing when the captain arrived in the cockpit with a flight attendant in tow. As he and Yousfi started up the engines, the captain kept talking to the flight attendant, in violation of the sterile cockpit rule, which prohibits non-essential conversation between engine start and 10,000 feet. The pre-flight briefing, which would have gone over emergency procedures (such as what to do if an engine fails after takeoff) fizzled out before getting to any of the most important items.

At around 3:08 p.m., the crew finished up their calculations and taxied to the runway. The plane was almost at its maximum takeoff weight, the airfield elevation was over 1,300 meters, and the temperature was rather high — all factors that meant they would need to extract maximum performance to get the airplane off the ground. But both pilots had taken off from Tamanrasset many times before, and they were quite familiar with the unfavorable conditions often encountered in the Sahara.

At 3:12 p.m., the tower cleared flight 6289 to take off on runway 02, and the crew acknowledged. The captain delegated responsibility for the takeoff to First Officer Yousfi, who would be the pilot flying for the leg to Ghardaïa.

“Come on, let’s go. Let’s take off,” said the captain.

Yousfi pushed the throttles to takeoff power and the plane rumbled off down the runway.

“You have 90, 100 [knots],” the captain said, calling out their airspeed.

Seconds later, he called out, “V1, rotate.” They were now past the point at which the takeoff could be aborted. In response to the command to rotate, First Officer Yousfi pulled back on the controls, and the 737 lifted off the runway.

“Gear up,” she ordered.

But before the captain could reach for the landing gear lever, a series of loud bangs rang out from the left engine. Inside the engine, fatigue cracks in a blade of the stage 1 nozzle guide vane in the high pressure turbine had reached the breaking point. A large section of the guide vane broke away, causing a chain reaction failure of both the high pressure and low pressure turbines. As ground-up bits of the turbines spewed out onto the runway behind them, the engine began to lose power, and the plane started yawing to the left due to the sudden thrust imbalance. “Bismi allah, bismi allah, bismi allah!” First Officer Yousfi quickly exclaimed. “What’s this? What’s happening?”

Location and function of nozzle guide vanes on ajet engine (not a JT-8D). (Model Aircraft blog)

At this point she needed to immediately initiate the engine failure on takeoff procedure, which all pilots should have memorized: reduce the pitch angle to maintain V2 (rotation speed), raise the landing gear, increase thrust on the remaining engine, and use the rudder to counter the yaw. But before she could do any of these things — before either pilot had even identified the left engine as the source of the problem — the captain said, “Let go, let go!” Having realized that an emergency was occurring, it seemed that he wanted to take control of the airplane.

“I’ve let go, I’ve let go,” said Yousfi.

“Let go!” the captain repeated.

“Gear up, or….?” Yousfi began to ask.

But the captain didn’t reply. He seemed to be focused on trying to fly a normal climb profile, keeping the pitch attitude firmly at 18 degrees. With a failed engine, however, he needed to keep the pitch angle below 12 degrees in order to avoid losing speed. As the plane’s one remaining engine struggled to push the plane up at such a steep angle, their speed began to fall rapidly. At the same time, the right engine mysteriously began to lose power as well — not because there was anything wrong with it, but because someone in the cockpit was moving the throttle lever.

Data from a simulation of the flight run by Boeing shows the plane’s altitude, airspeed, engine thrust, and roll angle during its brief flight. (Boeing)

As flight 6289 soared toward its brief zenith, First Officer Yousfi keyed her mic and said to the tower, “We have a small problem, 6230 [sic]!”

The captain still seemed to think she was trying to fly the plane. “Let go, remove your hand!” he said.

“I’ve let go, I’ve let go!” Yousfi insisted again.

“Remove your hand!” the captain repeated.

“I’ve let go!” said Yousfi.

Suddenly, the speed of the airplane dropped low enough to trigger the stick shaker, warning the pilots of an impending stall. Seconds later, unable to continue climbing so steeply with only one engine at a low thrust setting, the plane stalled at a height of 400 feet and began to fall from the sky.

“DON’T SINK!” the ground proximity warning system called out.

“Please!” shouted First Officer Yousfi.

“Remove your hand!” the captain insisted.

“DON’T SINK,” said the GPWS.

Suddenly, at a height of 335 feet above the ground, both black boxes mysteriously lost power and stopped recording. What the pilots said in the final moments of the flight will never be known. But by this point, there was nothing they could do anyway: just seconds later, with its nose pitched high and its right wing hanging low, flight 6289 slammed into the desert just past the end of the runway and burst into flames. The plane slid across the Trans-Sahara Highway and came to rest a few hundred meters further on, totally consumed in flames.

My sketch of the final seconds of flight 6289. (Own work)

Upon witnessing the accident, controllers activated the emergency alarm and firefighters rushed to the scene, arriving some three and a half minutes after the crash. They found that although the main fuselage was largely intact — only the cockpit, tail, and wings had broken away — the intense fire triggered by the plane’s full fuel load had already rendered survival impossible. Those passengers who might have survived the relatively low-speed impact most likely perished within seconds as the raging inferno consumed the plane. It was then that they found one man clinging to life — not inside the plane, but in the sand, well back from the place where the wreckage came to rest. The man was a 28-year-old Algerian soldier who was returning to his barracks after spending his leave in Tamanrasset; he had found himself seated in the very last row and was thrown from the plane when the tail section broke away on impact. Firefighters found him lying unconscious with weak signs of life, and ambulances rushed him to hospital in critical condition. Despite his dire state, however, within hours his condition stabilized and he began to recover. His luck cannot be overstated: he was the only survivor out of 103 passengers and crew, a death toll which made this Algeria’s worst ever air disaster at the time.

Rescuers swarm the crash site of Air Algérie flight 6289 in search of survivors. (CNN)

Responsibility for investigating the accident fell to a special Commission of Inquiry established by the Algerian Ministry of Transport and led by the sitting Transport Minister, as Algeria did not have a dedicated aircraft accident investigation agency. The Commission of Inquiry soon found that the plane’s left engine had failed due to fatigue cracks in one of the blades of the stage 1 nozzle guide vane, which directs the flow of air from the combustion chamber into the high pressure turbine. The fatigue cracks had been caused by thermal damage associated with age: the engine had accumulated over 20,000 flight cycles and hadn’t been overhauled since 1999. The failure of the blade resulted in severe damage to “downstream” components that rendered the engine unable to produce any appreciable amount of power. Investigators also found similar cracks on the nozzle guide vanes in the right engine, although these had not yet progressed to failure. But the investigation didn’t appear to dig any deeper than this: despite these findings raising serious questions about Air Algérie’s engine maintenance and inspection practices, the final report included nothing about these topics at all.

Another photo of rescuers at the crash site. (Bureau of Aircraft Accidents Archives)

However, an engine failure alone shouldn’t cause an accident. Like all airliners, the Boeing 737–200 is certified to climb on only one engine, even at max takeoff weight, so there wasn’t really any reason that this should have led to a loss of control. On the other hand, it was true that responding to this failure would have required very prompt action on the part of the pilots. This was a worst-case-scenario engine failure: right after liftoff while near the max takeoff weight with the gear extended on a high-altitude runway in hot weather (note that takeoff performance is inversely correlated with both altitude and temperature). Although the plane could climb, the performance margins were slim.

Nevertheless, a well-trained crew that was on top of its game could have easily handled the failure, climbed to a safe altitude, turned around, and put the plane on the ground without any great difficulty. The problem was that this crew was not at all well-prepared. The first officer’s abortive attempt at a pre-flight briefing was cut short, apparently because the captain preferred to spend his time chatting with the flight attendants. Perhaps the most important part of this briefing is the discussion of what to do in the event of an engine failure after decision speed (or V1). Normally, pilots would discuss the correct speed and angle of climb, the proper aircraft configuration, who will fly the airplane, and other aspects of safely handling an engine failure on takeoff. The purpose of this exercise is to prime the pilots so that they can react almost instinctively if such a failure occurs. The fact that this crew never finished the pre-flight briefing shows that they did not place much weight on the possibility that they could encounter an engine failure on takeoff — even though this is probably the most common out of all the serious failures that a pilot might encounter in his or her career. This lack of appreciation for the importance of the briefing most likely originated from the broader culture at Air Algérie, but once again, the Commission of Inquiry seemed to have nothing to say about this.

The wreckage came to rest at the end of a long trail of blackened sand and scattered debris. (BEA)

After the plane took off, the engine failed right as the first officer called for “gear up.” This was an extremely critical juncture that the crew — especially the captain — botched badly. Instead of scanning the instruments to figure out what had gone wrong, which was his duty as pilot not flying, the captain’s first instinct was to demand that First Officer Yousfi relinquish control of the airplane. This was quite possibly the worst decision he could have made, short of flying the plane straight into the ground. In such a critical situation, the last thing a crew should do is execute a control handover. Yousfi was hand-flying the plane at that moment, and she was the one with the instinctive “feel” for what it was doing; her role was clearly defined, and so was the captain’s. He should have looked at his instruments and announced “failure, left engine,” which would prompt First Officer Yousfi to follow the engine failure procedures that she had presumably committed to memory. Instead, he created a fog of confusion from which neither pilot ever recovered, losing precious seconds trying to build up an awareness of the airplane’s energy state that Yousfi probably was well on her way to acquiring already.

After taking control of the plane, the captain did almost nothing to handle its dire energy state. He didn’t attempt to achieve the proper single-engine climb speed or pitch attitude and he didn’t respond to Yousfi’s suggestion that they retract the landing gear (an action which would have decreased drag and increased the plane’s performance). In fact, the captain and the first officer never discussed the warnings and instrument indications they were receiving and never tried to determine the nature of the problem. Instead, the captain spent the rest of the brief flight trying to get Yousfi to give up control, even though she insisted she had already done so. By the time the plane began to stall, it was already too late; the only way to recover was to sacrifice altitude for speed by pitching down, and they were only at 400 feet, too low to avoid striking the ground during a stall recovery maneuver. The captain went to his grave holding the pitch attitude at a firm 18 degrees nose up while yelling at Yousfi to “let go” of the controls.

The Commission of Inquiry did not expend much time trying to explain this ridiculous behavior, but there is enough evidence to do a little bit more speculation ourselves. First of all, why did the captain want to take over control in the first place? The commission wrote that he might have observed the first officer struggling to control the plane, or he might have felt it was his duty as captain to take over during an emergency. To this I would add a third contributing factor: he might not have trusted the first officer to handle the failure. His very first priority as soon as something went wrong was not to determine the source of the problem, but to make sure that First Officer Yousfi was not the one flying the plane. This reaction only makes sense if he believed Yousfi was incapable of handling the situation, and that she, not the failure, was the most immediate source of danger. There was no evidence to suggest that this belief was accurate: Yousfi actually had more hours on the 737 than he did, and she had done her best to stick to procedures up to that point; it was the captain who broke protocol and interrupted the pre-flight briefing. Instead, it seems likely that the captain was distrusting of first officers on principle — especially if that first officer was a woman, given that Algeria is a highly patriarchal society.

Over the seconds which followed the initial control handover, the captain continued to ask Yousfi to let go of the controls, while she repeatedly stated that she had already done so. This confusion is difficult to understand, but there are some plausible explanations. If we assume that the captain took over control because he distrusted the first officer’s ability, it’s possible that when he immediately experienced difficulty controlling the plane, he thought it was because Yousfi was still trying to make control inputs. Evidently he did not actually look at what she was doing (this seems more likely than the alternative, which is that Yousfi was lying about having let go), perhaps because he was struggling to maintain the normal climb profile.

From this angle, it can be seen that the cockpit was largely intact, and the cabin and tail came to rest nearby, but were consumed by fire. (Algerie 360)

A key element of this scenario is the possibility that the pilots never figured out that an engine had failed. At no point on the cockpit voice recording does either pilot ever mention the engines. No one calls for engine-out emergency procedures or follows the engine-failure-on-takeoff memory items. No one tries to shut down the failed engine. In fact, there is no evidence whatsoever that either pilot knew an engine had failed. Such a situation could have arisen due to the botched control handover, which left both crewmembers unsure who was supposed to be monitoring the instruments — the captain might have thought this would be the first officer’s duty as pilot-not-flying, while the first officer might have thought the captain already knew what to do because he volunteered to take control so quickly. If no one ever looked at the engine gauges, the source of the problem might well have remained unclear right up until the end.

Another possibility is that they knew an engine had failed, but one of the pilots reduced power to the wrong engine by accident. The reduction in thrust on the right engine after the failure of the left engine makes no sense given the circumstances, but the Commission of Inquiry didn’t try to explain this bizarre occurrence. There have been a number of cases where a pilot rolled back or entirely shut off the wrong engine during an engine failure after failing to take sufficient time to examine the instruments. This could well have happened here, as the captain quickly took over without first assessing the situation, potentially causing him to make an incorrect snap judgment about which engine had failed. This would potentially explain the failure of both flight recorders before the plane hit the ground — on the 737, if both engines stop generating electrical power and the auxiliary power unit is not brought online, the black boxes will lose power and stop recording. However, proving this theory would be difficult; the plane had a very outdated flight data recorder that only tracked six parameters, so details like control column forces and throttle positions were not recorded. Had this information been available, it might have been easier to determine whether the pilots misidentified which engine was malfunctioning or whether they were both trying to control the plane simultaneously.

Another view of the cockpit. Although the cockpit is deceptively intact, this doesn’t mean that impact forces didn’t kill both pilots instantly. (Algerie Presse Service)

Regardless of the details of how they lost control, one thing is clear: neither pilot was prepared for the engine failure. And responsibility for that lack of preparation must fall on Air Algérie, which should have instilled crews with a healthy respect for the various ways in which things can go wrong. Indeed, for pilots around the world, the crash of flight 6289 should serve as a reminder that the worst case scenario really can happen, and every pilot must be ready at all times. The pre-flight briefing requires repeating the engine-failure-on-takeoff procedures before every single flight precisely because you only have a few seconds to react should you find yourself in the situation faced by the crew of flight 6289.

In its final report, the Commission of Inquiry issued four recommendations: that Air Algérie provide better training on when and how to perform handovers of control; that all Algerian flight crews be subject to a one-time assessment of their compliance with procedures; that Air Algérie put in place a safety analysis program that can make use of anonymous reports and flight recorder data to identify unsafe trends; and perhaps most critically, that the Ministry of Transport create an independent agency to investigate plane crashes.

A memorial to the 102 victims now stands at the site of the crash, on the shoulder of the Trans-Sahara highway. (Mechri Omar)

While these recommendations were on point, it is unfortunately true that the Commission of Inquiry could have done a lot more to understand the causes of the accident. Asking why the pilots failed to follow the procedures is critical to preventing other pilots from making the same mistakes, but this investigation failed to do that. I have offered some informed speculation about potential thought processes that could explain their actions, but this cannot replace the more scientific analysis performed by trained investigators that should have been carried out by the commission. Many other areas also could have been explored. Was Air Algérie inspecting its engines properly? Why was the captain flying two different aircraft types at once? Answering these questions would have done much to improve aviation safety in Algeria. In the absence of reforms, it’s unclear that safety in Algeria is improving. In 2014, a Swiftair MD-83 operating on behalf of Air Algérie crashed in Mali with the loss of all 116 passengers and crew. And in 2018, in what is probably Africa’s worst air disaster, 257 soldiers and crewmembers died when an Algerian military transport plane crashed shortly after takeoff in the town of Boufarik. Despite these accidents, it does not appear that Algeria has heeded the commission’s recommendation to set up an independent accident investigation agency, a step that has led to significantly better investigation outcomes in dozens of countries all over the world. It is clear that if a repeat of the crash of Air Algérie flight 6289 is to be avoided, more work will need to be done.

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