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ATSB Final Report Cites Communication Failures in Melbourne Runway Near Misses

Investigators say procedural controls left crews prone to missing critical runway changes.

Overview

  • The ATSB released its final findings on two takeoff incidents at Melbourne in September 2023 when a Malaysia Airlines A330 and a Bamboo Airways 787 lifted off beyond a temporarily shortened runway.
  • Runway 34 was reduced by about 1,568 metres to 2,089 metres for night resurfacing, and the aircraft passed roughly seven metres and 4.5 metres above workers and equipment.
  • Investigators found crews received NOTAM and ATIS updates yet did not integrate the changes into takeoff calculations, while dispatchers did not explicitly highlight the shorter runway.
  • No injuries were reported and both flights continued, but the ATSB warned that reliance on procedural controls leaves room for human error with serious potential consequences.
  • Both airlines have updated dispatcher procedures, ICAO has introduced highly visible signage standards, and Airservices Australia with CASA are developing proposed changes to air traffic control communications.