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ATSB: Melbourne Near‑Miss Takeoffs Stemmed From Unnoticed Shortened Runway

The safety watchdog faults missed recognition of a temporary reduction in available runway length that has prompted changes to controller briefings.

Overview

  • Two widebody departures in September 2023 — a Malaysia Airlines A330 and a Bamboo Airways 787 — passed over an active works area by about seven metres and less than five metres, with jet blast affecting personnel and equipment.
  • No physical injuries were reported in either incident, though one worker sustained a stress-related injury during the second event.
  • Investigators found both crews had NOTAMs and accessed an ATIS that mentioned the reduced runway length but did not identify it, and their ATIS read-backs to controllers included weather only.
  • Airline dispatchers had accounted for the shorter runway in performance calculations but did not specifically highlight the reduction in the crews’ briefing packages, contributing to departures using reduced thrust based on full-length assumptions.
  • The ATSB urged layered defenses such as more conspicuous signage and clearer operational alerts, while Airservices Australia has updated controller procedures on essential aerodrome information and CASA is reviewing guidance in line with ICAO updates.