What happened
In September 2023, two distinct runway excursion events occurred at Melbourne Airport during take-off operations on runway 34. The first incident took place on the night of 7 September involving a Malaysia Airlines Airbus A330-300, registration 9M-MTL. Eleven days later, on 18 September, a Bamboo Airways Boeing 787-9, registration VN-A819, also overran the same runway.
At the time of both departures, the runway had been temporarily shortened by 1,568 meters at the northern end to accommodate resurfacing works. Both aircraft lifted off beyond the temporary runway end, entering a 450-meter safety zone. While the jet blast from the departures displaced construction equipment and lights, there were no injuries to passengers or ground personnel, and no damage was sustained by either aircraft.
The investigation
The investigation established that the flight crews of both aircraft utilized takeoff performance calculations based on the full-length runway rather than the reduced distance. This led to reduced-thrust engine settings that resulted in takeoff rolls extending past the temporary runway end.
Investigators found that while the necessary information was available via Notice to Airmen (NOTAM) and the Automatic Terminal Information Service (ATIS), the crews failed to identify the critical changes. Factors such as workload, expectations, and time pressures—including power outages experienced by the Bamboo Airways crew—contributed to insufficient reviews of flight information. Additionally, while flight dispatchers had accounted for the shorter runway in their calculations, they did not specifically highlight the restriction to the pilots. In one instance, a dispatcher provided a briefing note that incorrectly suggested no significant NOTAMs were active.
Findings
- The primary cause was the failure of flight crews to recognize the reduced runway length due to inadequate review of aeronautical information.
- Flight crews relied on takeoff performance data that assumed a full-length runway, leading to extended takeoff runs.
- Information dissemination was inconsistent; dispatchers did not emphasize the operational restriction, and one briefing note was misleading.
- The ATIS review was insufficient, as crews primarily recorded weather data but overlooked aerodrome changes.
- A lack of conspicuous visual aids or signage at the temporary runway end meant that the runway appeared visually identical to a normal, full-length runway to the approaching pilots.
Safety action
Following the incidents, both Malaysia Airlines and Bamboo Airways updated their dispatcher procedures to ensure that any changes to runway distances are explicitly communicated to flight crews. Furthermore, Airservices Australia and the Civil Aviation Safety Authority (CASA) are reviewing changes to Air Traffic Control procedures to provide better assurance that crews are aware of critical aerodrome information during runway works.