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Serious incident to the Embraer EMB145 registered F-HYOG operated by Amelia International on 20/10/2022 at Paris-Orly

Non-stabilized approach, long landing, runway overrun

Responsible entity

France - BEA

Investigation progression Closed
Progress: 100%

After conducting an approach briefing in which the threats associated with the storms forecast in the ATIS were partially taken into account, the crew initiated the descent to Paris–Orly airport.

During the descent, the crew did not manage to agree on the storm cell avoidance strategy. The division of roles between the PF and the PM along with the decision making and the shared situational awareness progressively deteriorated. The PM's (captain) initiatives took precedence over the PF's requests and the decisions concerning management of the approach. Subsequently, he made inputs on certain controls without any prior coordination with the PF, thus impairing his own ability to effectively exercise his role as PM.

Shortly before the simultaneous interception of the ILS axis and slope, the aeroplane had a high approach speed, exceeding the recommended speed for intercepting the glideslope by more than 60 kt and was on a shortened path. These factors resulted in the aeroplane overshooting the ILS axis.

The PF quickly corrected the horizontal path to the detriment of the vertical path. The aeroplane was then above the approach slope. The selection of a heading by the PF, without a callout, resulted in a reversal of the guidance mode, which surprised the PM. The PM then improvised a procedure to intercept the glideslope from above, however, neither the selected vertical speed nor the selected altitude enabled him to join the nominal approach slope. During this phase, the aeroplane’s speed, which exceeded the VFE, meant that the flaps could not be extended to 22°, which is recommended prior to intercepting the glideslope. The landing gear was nevertheless extended, and the flap extension to 22° (request and action) was finally forgotten. It was only after a manual flying phase by the PF that the aeroplane joined the glideslope at an altitude of around 1,500 ft. This interception of the ILS axis and slope, which was rapid, unprepared and poorly coordinated, considerably increased the crew’s workload, which meant they no longer had good awareness of the situation, or of the aeroplane’s energy and its configuration.

Shortly before reaching the height of 1,000 ft AAL, the PM decided that they would land with the flaps 22° configuration, even if the flaps 45° configuration had been decided on during the approach briefing and confirmed 45 s earlier. The aeroplane’s speed exceeded the VFE for flaps 45° by more than 35 kt.

At 1,000 ft AAL, the stabilization was not mentioned although four of the nine stabilization criteria were not met: the speed exceeded the VAPP by 45 kt, the aeroplane was not configured, the engine thrust was not stabilized and the before-landing checklist had not been carried out. The PM no longer performed his monitoring role, busy with other tasks associated with the management of the flight and the changing of the strategy. The PF was very focused on flying in turbulence and rain showers. When given the clearance for landing, the crew did not assimilate the tailwind component of 8.5 kt.

No deviation was announced by the PM on short final. Moreover, the latter invited the PF to continue by offering encouragement. This may have prompted the PF to rule out the possibility of flying a missed approach. During the final approach, the wind direction changed from southerly to south-easterly, then to easterly, with a speed of around 25 kt. The crew did not detect this wind change. At a height of around 240 ft AAL, there was a visual and aural TAWS alert due to an incorrect flaps configuration. Both crew members indicated that they did not perceive this alert. However, two seconds later, the PM realised the oversight and extended the flaps to 22° calling it out to the PF. The PF did not hear the callout.

The aerodynamic effect associated with the extension of the flaps in ground effect, the speed of the aeroplane (exceeding the reference speed by 30 kt when passing over the threshold) and the tailwind of nearly 20 kt resulted in a long landing, 1,150 m from the runway threshold, beyond the wheel touchdown zone. Although he was aware that this landing was long, the PM did not order for the landing to be rejected. Given the latest runway condition information (wet and slippery, good braking), he considered that the runway length was sufficient. The crew had planned to vacate the runway at its end.

In fact, the zone located midway along the runway was contaminated by stagnant water 4 to 5 mm deep following the storm that had passed through the area several minutes earlier when the aeroplane was on final approach. The aeroplane hydroplaned upon landing. The crew had no element enabling them to know the actual runway condition. The crew were insufficiently prepared for the occurrence of a deterioration in landing conditions in the presence of storms. The aeroplane overran the runway 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 axis.