Runway excursion Serious incident Embraer ERJ-145LR F-HYOG,
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ASN Wikibase Occurrence # 299539
 
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Date:Thursday 20 October 2022
Time:19:17 LT
Type:Silhouette image of generic E145 model; specific model in this crash may look slightly different    
Embraer ERJ-145LR
Owner/operator:Amelia International
Registration: F-HYOG
MSN: 145526
Fatalities:Fatalities: 0 / Occupants: 42
Aircraft damage: Minor
Category:Serious incident
Location:Paris-Orly International Airport (ORY) -   France
Phase: Landing
Nature:Passenger - Scheduled
Departure airport:Rodez-Marcillac Airport (RDZ/LFCR)
Destination airport:Paris-Orly Airport (ORY/LFPO)
Investigating agency: BEA
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Amelia International flight 8R1217, an Embraer ERJ-145LR, suffered a runway excursion after landing on runway 25 at Paris-Orly Airport (ORY).
No injuries reported.

After conducting an approach briefing with partial consideration of the threats linked to storms forecast in the ATIS, the crew began the descent towards Paris-Orly Airport.

During the descent, the crew was unable to agree on the storm cell avoidance strategy. The distribution of roles between the Pilot Flying (PF) and the Pilot Monitoring (PM) as well as decision-making and shared situational awareness have gradually deteriorated. The PM (captain) took the initiative on requests from the PF and decisions relating to the conduct of the approach. Subsequently, he acted on certain orders without prior coordination with the PF, leading to a degradation of his own ability to effectively exercise his role as PM.

Shortly before the ILS capture the aircraft's speed was exceeding the recommended speed by more than 60 kt, and the flight followed a shortened trajectory. These factors led to the crossing of the ILS axis.

The PF quickly corrected the horizontal trajectory to the detriment of the vertical trajectory. The plane found itself above the glide path. The selection of a heading by the PF without announcing it led to a reversion of the guidance mode which surprised the PM. The PM then improvised a procedure for catching the glide path from above; however, neither the chosen vertical speed nor the selected altitude allowed a return to the nominal descent plan. During this phase, the speed of the aircraft, greater than the VFE, did not allow the 22° flaps to be extended, recommended before capturing the glide path. The landing gear was nevertheless extended, and the extension of the 22° flaps (demand and action) was finally forgotten. It was only after a phase of manual piloting by the PF that the aircraft returned to the descent path towards an altitude of 1,500 ft. This phase of interception of the axis and glideslope of the ILS, rapid, unprepared and poorly coordinated, considerably increased the workload of the crew, no longer allowing them to have good situational awareness.

Shortly before reaching the height of 1,000 ft AAL, the PM decided that they would land with 22° flaps, even though 45° flaps had been decided during the approach briefing and confirmed 45 seconds earlier. The aircraft speed exceeded the 45° flap VFE by more than 35 kt.

At 1,000 ft AAL, stabilization was not mentioned while four of the nine stabilization criteria were not acquired: the speed was 45 kt higher than the VAPP, the aircraft was not configured, the thrust of the engines was not stabilized and the 'before landing' checklist had not been carried out. The PM no longer performed his surveillance function, busy with other tasks related to flight management and change of strategy. The PF was very focused on flying in turbulence and rain showers. During the landing clearance, the crew did not integrate the tailwind component of 8.5 kt.

No deviation was announced by the PM in the short final. The latter also invited the PF to continue, encouraging him. This may have prompted the PF to rule out the possibility of aborting the approach. During the final approach, the wind direction changed from south to south-east then east, with a force of around 25 kt. The crew did not detect this change in wind. At a height of approximately 240 ft AAL, a visual and audible TAWS alert was issued due to the incorrect flap configuration. The two crew members indicated that they had not noticed this alert. However, two seconds later, the PM noticed the oversight and pulled out the 22° flaps, announcing it to the PF, an announcement not heard by the latter.

The aerodynamic effect linked to the extension of the flaps in ground effect, the speed of the aircraft 30 kt higher than the reference speed when crossing the threshold and the tailwind of nearly 20 kt led to a landing long, 1,150 m from the runway threshold, beyond the touchdown zone. Although aware that this landing was long, the PM did not order the landing to be aborted. Taking into account the latest runway condition information (wet, slippery, braking good), he considered that the runway length was sufficient. The crew had planned to clear the runway at the end of the runway.

In fact, the area located mid-runway was contaminated by stagnant water 4 to 5 mm thick following the storm that passed a few minutes earlier, while the plane was on final approach. The aircraft experienced hydroplaning upon landing. There was no information allowing the crew to know the actual runway condition. The crew was insufficiently prepared for the occurrence of a deterioration in landing conditions, in the presence of storms. The plane left the runway longitudinally at high speed and came to a stop approximately 450 m from the end of runway 25, and 50 m to the right of the runway centerline.

Weather reported about the incident time (1717Z):
LFPO 201730Z 18005KT 130V280 8000 VCTS FEW011 SCT022 BKN060CB 16/13 Q1008 RESHRA TEMPO 4000 -TSRA BKN060CB
LFPO 201700Z 22008KT 180V250 8000 -TSRA FEW032 BKN060CB BKN090 20/17 Q1009 TEMPO 4000 -TSRA BKN060CB

Accident investigation:
cover
  
Investigating agency: BEA
Report number: BEA2022-0508
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report

Sources:

https://bea.aero/en/investigation-reports/notified-events/detail/serious-incident-to-the-embraer-emb145-registered-f-hyog-operated-by-amelia-on-20-10-2022-at-orly/
https://www.bfmtv.com/paris/aeroport-de-paris-orly-un-avion-fait-une-sortie-de-piste-aucun-blesse_AN-202210200840.html
Twitter

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https://www.airfleets.fr/ficheapp/plane-e145-526.htm
https://www.flightradar24.com/data/aircraft/f-hyog#2dea6927

Images:


Media:

Revision history:

Date/timeContributorUpdates
20-Oct-2022 18:59 Iceman 29 Added
20-Oct-2022 19:00 Iceman 29 Updated [Aircraft type, Embed code]
20-Oct-2022 19:04 Iceman 29 Updated [Cn, Phase, Departure airport, Destination airport, Source, Photo]
20-Oct-2022 19:19 harro Updated [Time, Cn, Operator, Location, Damage, Narrative]
20-Oct-2022 19:20 harro Updated [Cn]
20-Oct-2022 19:24 harro Updated [Total occupants, Source, Narrative]
20-Oct-2022 19:27 harro Updated [Embed code]
20-Oct-2022 20:43 Iceman 29 Updated [Embed code]
28-Oct-2022 18:38 harro Updated [Source, Embed code, Damage]
05-Dec-2023 13:50 harro Updated [Other fatalities, Embed code, Accident report]
08-Dec-2023 17:07 harro Updated [Other fatalities, Narrative]
26-Jan-2024 13:30 harro Updated [Other fatalities, Accident report]

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