The Air Transport Safety Bureau has welcomed air traffic control changes made by Airservices Australia in response to a pair of serious runway excursions involving large passenger airliners at Melbourne Airport.
The ATSB concluded its investigation into the September 2023 event in December last year, finding flight crews were not aware that Melbourne’s main runway was shortened due to resurfacing works when they took off using engine thrust appropriate for the full runway length in two separate incidents in September 2023.
In each case, the aircraft – a Malaysian Airlines Airbus A330-300 and then a Bamboo Airways Boeing 787-9 – left the ground beyond the temporary runway end, passing within metres of an active worksite.
This was despite the information about the shortened runway being available to each flight crew in the relevant notice to airmen (NOTAM) listing, and automatic terminal information service (ATIS) broadcast.
In each instance, flight crews partially recorded a version of the ATIS but had missed the included reduced runway length information.
But Carter Capner Law director Peter Carter said the findings show that “a catastrophic event was avoided only by good luck”.
“It could have resulted in a 350-person fireball. We are very fortunate to have escaped that outcome and the indelible scar that our aviation safety record would have sustained.
“Pilots are responsible for reading NOTAMs and listening to the ATIS – these are basic requirements even for day one students. The incident also shows that company procedures were lacking.”
Safety-critical changes
Although a procedure existed for flight crews to confirm the ATIS version with air traffic control, the ATSB concluded this did not provide positive assurance that those crews had received the information in full. This was particularly concerning when the ATIS detailed safety-critical changes to aerodrome conditions, such as a significant reduction to runway length.
“The ATSB exists to identify safety issues such as this one,” Chief Commissioner Angus Mitchell said. “But for safety to actually improve, we rely on actions to be taken by relevant stakeholders to address the issues we identify.”
Mitchell therefore welcomed the recent move by Airservices Australia to amend the Manual of Air Traffic Services (MATS), and the Aeronautical Information Package (AIP), in response to this finding.
Under recent changes, during temporary reductions in runway declared distances:
- ATIS phraseology has been amended to include the runway number and a reference to the associated NOTAM in effect. It will now state ‘REDUCED RUNWAY LENGTH(S) IN OPERATION [RUNWAY (number)], SEE NOTAM (number)’.
- In addition to the existing procedure for flight crews who have not notified receipt of the current ATIS, ATC will also advise pilots that reduced take-off or landing distances are in operation.
- In addition to information promulgated by NOTAM or ATIS, ATC will provide directed advice of a reduced runway length to flight crews, either with the taxi instruction to the holding point (for departures), or on the tower frequency on first contact (for arrivals).
“These positive changes undertaken by Airservices will improve the dissemination of critical information to pilots, specifically when there’s a reduced runway length in operation,” Mitchell said.
“These changes now provide a layer of protection which was not there when these incidents occurred – two incidents that were metres and seconds away from a potentially catastrophic outcome.”
