Reference : Amelia ERJ145 Orly Runway Overrun
You are working for the Safety Department as a safety expert and must prepare for the next safety meeting a detailed incident report with the bow-tie methodology. The event is classified as an “accident” according to ICAO Annex 13.
Elements of context identified through the Pilot’s report and Flight Data Monitoring (FDM):
• Thorough briefing performed by the crew, including performance calculation
• Adverse weather (strong cross-wind + rain)
• Incorrect informations for landing reported by the Tower
• Unstabilized approach (excessive speed)
• Aircraft defect (one reverser inoperative on the logbook)
• Internal crew factors (fatigue, 4th sector of the day)
• Evacuation was initiated by flight crew and performed by cabin crew
• Minor injuries during evacuation (no fatalities)
• Airport emergency services arrived on the site very rapidly
The safety report shall contain:
• Facts (free to use an existing case)
• Extracts or detailed bow-ties used to identify preventive and recovery barriers, effective or not (use the bow-ties)
• The analysis (can be based on the bow-ties), including a reactive risk assessment of the event using the ERC matrix
• Proposal of corrective actions with an associated date of implementation