What happened
During separate operations at Melbourne Airport, two aircraft—an Airbus and a Boeag—both experienced runway excursions during take-off. While the flight crews were aware of ongoing works in progress at the airport, they did not realise that the usable runway length had been shortened.
Expecting a standard departure, the crews entered performance data into their flight management tools using the full-length runway 34 option. This selection utilised reduced-thrust settings that were insufficient for the actual available distance. Consequently, both aircraft reached their rotation speeds just as they approached the temporary end of the runway, causing both to enter the runway end safety area (RESA) before liftoff.
The investigation
The investigation examined several communication and procedural layers, including NOTAMs, ATIS, and dispatcher briefings. While the relevant 'REDUCED RUNWAY LENGTH' NOTAM was included in the flight briefing packages, both crews failed to identify its significance. In the case of the Bamboo Airways flight, the crew experienced increased workload and time pressure due to power outages, which prevented a secondary review of the NOTAMs after boarding.
Furthermore, the investigation found that while the flight dispatchers for both flights had correctly calculated performance for the shortened runway, they failed to highlight this critical change to the pilots. For the flight involving VN-A819, the dispatcher even provided a briefing note suggesting no significant NOTAMs were active.
Findings
- The flight crews did not recognise that reduced runway length operations were in effect, leading to reduced-thrust take-offs based on incorrect runway length assumptions.
- The ATIS information was not fully processed; crews recorded standard take-off performance data but overlooked aerodrome condition updates.
- The NOTAM presentation lacked emphasis, failing to prioritise safety-critical runway length changes over less significant information like taxiway closures.
- There was a lack of visual aids or standardised signage at the aerodrome to alert departing pilots to the temporary change in runway length.
- Dispatcher communications were insufficient, as critical safety information regarding the runway reduction was not explicitly highlighted to the pilots.