Cause of two near misses at Melbourne airport revealed
ATSB in question Although the warnings were delivered through an update known as NOTAM (notice to airmen) and broadcast over the radio by the automated terminal information service, neither Malaysia Airlines nor Bamboo Airways flight crews had noticed the changing conditions before takeoff.
The Malaysia Airlines plane was seven meters away from the work crew, while the Bamboo Airways plane passed 4.5 meters.
The near misses at Melbourne Airport in 2023.Credit: ATSB
Both times, the jet’s thrust covered areas where employees and equipment were located.
When the crew reached the takeoff point, “they knew they were passing close to the end lights and workers, but the full extent of this was not obvious to them at the time,” Mitchell said. “And it wasn’t until our conversations with them later that they realized how close they were.
“Despite the provision of the relevant NOTAM in flight briefing packages, neither flight crew detected a significant shortening of the runway.”
Commercial airliners routinely use the “reduced thrust takeoff” method, which takes advantage of runway length to use less fuel, increase efficiency and reduce wear on the aircraft. A shorter runway requires increased thrust.
Failure to adequately warn flight crews about take-off conditions will almost lead to two major crashes at Melbourne Airport in 2023, Australia’s transport safety inspector has said.Credit: Aaron Francis
The first event involving Malaysia Airlines took place on September 7, 2023. The second one took place on September 18, 2023, with the participation of Vietnam’s Bamboo Airways. The track works lasted from 22.30 at night until 04.30 in the morning.
While Malaysia Airlines crews did not confirm that they received the ATIS (Automatic Terminal Information Service) notification on the runway, Bamboo Airways crews had received an earlier version of the update on the runway.
Mitchell said office-based flight attendants at the two airlines took the reduced runway length into account in their calculations, but did not indicate the shortened runway to flight crews for entry into the plane’s flight management computers.
“Both flight crews assumed in their performance calculations that the entire runway length was available and that the respective takeoffs were performed with less thrust than required for the reduced runway.”
CCTV footage of one of the runway overflows.Credit: ATSB
The ATSB investigation found that the “risk controls” in place at the time to prevent such incidents were “procedural in nature”.
While pilots are responsible for reviewing and understanding all relevant information in preparation for flight, “this and previous incidents demonstrate that this process is prone to human error.”
“Given the potentially devastating consequences of a loaded and fully fueled aircraft crashing into a worksite during takeoff, additional layers of defense are necessary,” Mitchell said.
As a result of the events of 2023, Airservices Australia, in consultation with the Civil Aviation Safety Authority, is proposing changes to air traffic control procedures regarding how basic information about runway status will be communicated.
The ATSB is also calling on the International Civil Aviation Organization to review air traffic communication procedures with crews regarding “safety-critical airport conditions”. ICAO has already adopted rule changes for warnings about temporary changes in runway distances.
Immediately after the first incident, Melbourne Airport questioned Malaysia Airlines and subsequently issued a safety warning to all airlines.
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