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| Date: | Thursday 28 February 2019 |
| Time: | 08:45 LT |
| Type: |  Embraer ERJ-195LR (ERJ-190-200 LR) |
| Owner/operator: | Flybe |
| Registration: | G-FBEJ |
| MSN: | 19000155 |
| Year of manufacture: | 2007 |
| Engine model: | General Electric CF34-10E7 |
| Fatalities: | Fatalities: 0 / Occupants: 105 |
| Aircraft damage: | None |
| Category: | Accident |
| Location: | Exeter Airport (EXT/EGTE) -
 United Kingdom
|
| Phase: | Take off |
| Nature: | Passenger - Scheduled |
| Departure airport: | Exeter Airport (EXT/EGTE) |
| Alicante Airport (ALC/LEAL) | |
| Investigating agency: | AAIB |
| Confidence Rating: |  Accident investigation report completed and information captured |
The Embraer ERJ-195LR aircraft was operating the first sector of the day and was scheduled to fly from Exeter Airport, UK to Alicante Airport, Spain as BE4321. While the aircraft was being prepared for flight, both pilots reported being aware of a sweet-smelling odour after the APU and APU bleed had been turned on to heat the cabin. They described the smell as being like caramel but considered that such odours were not unusual after the APU is started and the air conditioning is switched on at the beginning of the day.
Following completion of passenger boarding, the aircraft pushed back and taxied before being cleared to enter Runway 26, back-track and line up for take-off. It was daylight, the visibility was in excess of 10 km and the wind was from 210° at 5 knots.
The APU was shut down as the aircraft entered the runway and the air conditioning packs remained on with air supplied from the engines. A few seconds later, while back-tracking, both pilots became aware of fumes in the flight deck with a different odour, which the co‑pilot described as being like paint or white spirit. The wind was behind the aircraft at this point, so they initially thought the fumes were due to exhaust gas ingestion. Upon lining up at the runway threshold the flight crew had a brief discussion about whether the fumes were decreasing and decided that they were.
Upon receiving take-off clearance, the co-pilot advanced the thrust levers to 40% while holding the aircraft on the brakes and checked the engine indications, which were all normal. He then slowly advanced the thrust levers towards the take-off setting, while still holding the aircraft on the brakes. As the engines reached approximately 55% power, he saw something out of the corner of his eye which he believed to have been a puff of smoke coming from an air conditioning vent. He immediately stated that he was not happy with the situation and retarded the thrust levers to idle. By then the smell of fumes had grown worse and smoke was visibly entering the flight deck.
The commander set the park brake and asked the co-pilot to turn the engine bleeds and air conditioning packs to off and the flight deck windows were opened to ventilate the flight deck. There were no EICAS messages or warnings.
The commander established contact with the senior cabin crew member (SCCM), who had simultaneously been trying to contact the flight deck. The SCCM reported that there was smoke and fumes in the cabin, but that the cabin crew could not identify the source.
The commander decided to evacuate the aircraft. The co-pilot immediately selected flap 5, notified ATC of the intention to evacuate and requested assistance. Both pilots then carried out the Emergency Evacuation ‘vital actions’.
During the evacuation, passengers who evacuated via the over-wing exits reported being unsure of how to get down from the wing to the ground and several re-entered the cabin and exited via one of the escape slides.
The smoke and fumes were subsequently attributed to an incorrectly performed engine compressor wash procedure, which was carried out by maintenance personnel the night before the occurrence flight.
As a result of the findings of this investigation, the European Union Aviation Safety Agency (EASA) has undertaken two safety actions relating to the certification requirements for over-wing emergency exits. The operator has also undertaken several safety actions relating to passenger safety briefings, processes for maintenance planning, engineer training, competency and welfare and monitoring of ground equipment. Four Safety Recommendations are made relating to the certification requirements for over-wing exit markings and the height requirement for over-wing exits to be equipped with an assisted means of escape.
Accident investigation:
 |
|
Sources:
1. AAIB Final Report: https://assets.publishing.service.gov.uk/media/5f5a01b18fa8f5106c6c425d/ERJ_190-200_LR_G-FBEJ_10-20.pdf
2. http://www.goklerdeyiz.net/kabin-dumanla-doldu-ucak-acil-tahliye-edildi/
3. https://www.itv.com/news/westcountry/2019-02-28/flybe-plane-evacuated-at-exeter-airport/
4. https://www.dailymail.co.uk/news/article-6755367/Flybe-plane-evacuated-runway-Exeter-Airport.html
5. https://www.devonlive.com/news/devon-news/live-flybe-exeter-airport-evacuation-2592792
6. https://www.planespotters.net/airframe/embraer-erj-195-g-fbej-falko-regional-aircraft/r6vzqk
7. https://www.aerotime.aero/pijus/25931-passengers-leave-re-enter-flybe-embraer-e195-during-evacuation
8. http://aerossurance.com/safety-management/flybe-fumes-maintenance-hf/
Media:
Smoke and fumes in cabin during takeoff, resulting in emergency evacuation, Exeter Airport, Devon, 28 February 2019.https://t.co/6zGO6wvgEv pic.twitter.com/IEDO5BT58k
— AAIB (@aaibgovuk) September 17, 2020
FLYBE STATEMENT – UPDATE #2
— Flybe ✈ (@flybe) February 28, 2019
BE4321
Exeter – Alicante pic.twitter.com/v0kzNOU3bd
FLYBE STATEMENT
— Flybe ✈ (@flybe) February 28, 2019
BE4321
Exeter – Alicante pic.twitter.com/iO4aGo1YMx
G-FBEJ - Embraer ERJ 195 (LR) - Flybe - with "Welcome To Yorkshire" sponsors livery, at Paris 13 May 2019:100 passengers had to evacuate a plane at Exeter Airport using the emergency slides after holidaymakers heard a 'loud bang' and smelt 'smoke' in the cabin. Read more: https://t.co/Q8NJy6gAIr pic.twitter.com/rzAUAknuFj
— ITV News WestCountry (@itvwestcountry) 28 februari 2019
_-_Flybe_(32897007237).jpg)
#OTD 2019: A series of systemic #aviationmaintenance #humanfactors issues emerge from the #AAIB investigation into cockpit/cabin fume event. https://t.co/jf3xG2of7y #flightsafety #aviationsafety pic.twitter.com/fu2WF2U0KB
— Aerossurance (@Aerossurance) February 28, 2021
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 28-Feb-2019 15:19 | Goklerdeyiz.net | Added |
| 28-Feb-2019 15:57 | harro | Updated [Country] |
| 28-Feb-2019 16:41 | Anon. | Updated [Location, Country, Phase] |
| 28-Feb-2019 16:43 | harro | Updated [Cn, Other fatalities, Departure airport, Destination airport, Narrative] |
| 28-Feb-2019 16:46 | harro | Updated [Total occupants, Location, Source, Embed code] |
| 28-Feb-2019 16:46 | harro | Updated [Departure airport, Embed code] |
| 28-Feb-2019 17:44 | Anon. | Updated [Source] |
| 01-Mar-2019 09:00 | Chieftain | Updated [Time] |
| 04-Mar-2019 23:42 | Dr. John Smith | Updated [Location, Departure airport, Source, Embed code, Narrative] |
| 08-Mar-2019 18:15 | harro | Updated [Time, Source, Embed code, Narrative] |
| 17-Sep-2020 09:22 | harro | Updated [Time, Phase, Narrative, Accident report, ] |
| 15-Oct-2020 22:53 | Dr. John Smith | Updated [Source, Embed code, Narrative, Accident report] |
| 15-Oct-2020 22:55 | Dr. John Smith | Updated [Embed code, Narrative] |
| 16-Feb-2021 19:56 | Aerossurance | Updated [Source, Accident report] |
| 28-Feb-2021 09:03 | Aerossurance | Updated [Location, Embed code] |
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