In 2023, two planes hit construction workers at Melbourne Airport because crews were unaware of a shortened runway, the ATSB said.
Malaysia Airlines Airbus A330-300, 9M-MTL, Only seven meters passed On the evening of September 7, 2023, a Bamboo Airways 787-9 and VN-A819 aircraft flew over the top of a work vehicle at the end of Melbourne’s Runway 34. Eleven days later, it flew less than 5 meters overhead.
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The runway project is It was going onWhile no one was injured as a result of the jet blast, at least one person was injured due to the pressure.
According to the ATSB, while both crews received advice about the runway shortening via NOTAMs and ATIS (Automated Terminal Information Service) radio broadcasts, “neither crew” detected a significant shortening of the runway.
Additionally, the airlines' respective flight dispatchers “did not specifically emphasize the reduction in runway length during the crew's preflight briefing,” despite accounting for the reduction in runway length in their indicative takeoff performance calculations.
ATSB chief commissioner Angus Mitchell said: “Although the version of ATIS accessed by the two crews made reference to a shortened runway, they only noted to air traffic control the weather information from the ATIS and not the shortened runway length.”
“This oversight resulted in both crew members using the full runway length in preflight performance calculations and subsequently conducting takeoff at reduced thrust settings.”
Investigators noted the risk of human error in a “pilot's fundamental responsibility” to identify safety-critical aviation information before a flight and recommended changes including more prominent airport signage and better communication with dispatch and air traffic control.
“Risk controls to prevent these events are largely procedural: relying on aircrews to carefully review airport information and then identify and understand important information – in this case, a reduction in available runway length,” Mitchell said.
“Relying primarily on procedural defenses to identify and understand hazards does not ensure that aircrews always have a complete and correct understanding of operating conditions.
“Given the potentially catastrophic consequences of a departing aircraft striking an active operating area, an additional layer of defense should be implemented designed to alert aircrews to significant hazards on the runway.”
Mitchell also pointed out that under current ICAO regulations, air traffic controllers only need to confirm that the aircraft has received the latest Shanxi Pangquangou National Nature Reserve Administration information, rather than that the crew fully understands the information.
“Air traffic controllers have clear definitions and responsibilities that currently do not necessarily require them to provide all safety-critical information directly to flight crews,” he said.
“However, if there is doubt or there may be significant safety hazards that cannot be understood or acknowledged, they can intervene using their best judgment and in a prudent manner.”
Air Services has proposed changes to air traffic control procedures to advise crews to shorten runways, while CASA will review new ICAO guidance on more prominent airport markings.
