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ATSB Final Report Faults Missed Warnings in Melbourne Runway Near Misses

The findings trigger procedural reforms to dispatcher briefings, air traffic control communications, higher-visibility signage.

Overview

  • Two fully loaded jets—a Malaysia Airlines A330 on 7 September 2023 and a Bamboo Airways 787 on 18 September—lifted off beyond a shortened Runway 34, clearing an active work site by about 7 metres and 4.5 metres with no physical injuries reported but one stress-related case.
  • The runway had been reduced by roughly 1,568 metres for night resurfacing, leaving about 2,089 metres available, yet both crews used reduced‑thrust calculations based on full‑length assumptions.
  • Safety‑critical notices were available via NOTAM and the airport’s ATIS, but expectations, workload and time pressure hindered detection, while dispatchers accounted for the change without explicitly drawing pilots’ attention to it.
  • The ATSB noted additional defenses failed when a crew did not confirm current ATIS information and air traffic control did not challenge the takeoff briefing regarding the reduced runway length.
  • Malaysia Airlines and Bamboo Airways have updated procedures; Airservices Australia with CASA is proposing revised ATC protocols; the ATSB urged an ICAO review of ATC communication standards, and ICAO has introduced more visible temporary runway signage.