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A runway excrusion is taken place at an airport while an aircraft is landing. Pa

A runway excrusion is taken place at an airport while an aircraft is landing. Passengers and crew member used slides to evacuate and had only minor injuries. The aircraft suffered substantial damages, which made this event classified as an “accident” according to ICAO Annex 13
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.
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 i.e. Amelia ERJ145 Orly Runway Overrun)
– Extracts or detailed bow-ties used to identify preventive and recovery barriers, effective or not
– 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

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