What happened
On 30 November 2022, a Boeing 737-800, operating flight VA324, began its take-off roll from the A3 intersection of runway 19L at Brisbane Airport. The aircraft was operating a service from Brisbane to Melbourne. During the departure, the crew was unaware that the available take-off distance had been significantly shortened because the upwind threshold was displaced. Because the crew used performance data based on a standard runway length, the aircraft had insufficient power applied at the start of the roll to safely complete the take-off within the actual distance available.
The investigation
The investigation focused on how the crew developed an incorrect mental model regarding runway 19L. During the preceding flight from Melbourne to Brisbane, a dispatcher's note indicated that while the threshold for runway 01R was displaced, there were no landing weight limitations. The captain misinterpreted this note to mean that the displacement had no impact on performance requirements for runway 19L.
Furthermore, the crew failed to identify critical Flight Operations Engineering (FOE) data contained within a NOTAM. While reviewing NOTAMs, the captain used headlines as a guide to save time during a short 40-minute turnaround. Because the headline for NOTAM YBBNC1174/22 only mentioned the displacement of runway 01R and did not explicitly reference 19L, the captain dismissed the information as irrelevant to their intended departure. The investigation also noted that the crew did not review the full NOTAM package or the ATIS notification regarding the reduced runway length.
Findings
- The captain's misinterpretation of the dispatcher's note created a false belief that runway 19L performance was unaffected by the displacement.
- Time pressures and the need to prioritize training requirements during the Brisbane turnaround contributed to the dismissal of relevant flight planning data.
- The crew relied on NOTAM headlines rather than reviewing the detailed free text, which contained the necessary performance adjustments.
- A lack of an independent check by the first officer meant the error in performance calculation went undetected.
- The movement area guidance sign at the A3/19L intersection presented a take-off distance that exceeded the actual available runway, which could mislead pilots.