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A Virgin Australia 737-800 crossing into a closed section of runway at Brisbane Airport was the result of “distraction” and “misinterpretation” of dispatcher notes, the Australian Transport Safety Bureau has said.
VH-YFH (pictured in Sydney) was operating flight VA324 to Melbourne on 30 November 2022 when it entered and took off from a section of runway that had been closed for works, though was able to complete the departure and travel to Melbourne without incident, the safety watchdog said in its final report.
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According to the ATSB, the flight crew consisted of a training captain and a first officer undertaking “line flying under supervision” as part of the first officer’s conversion onto the 737.
The take-off thrust and speeds set by the flight crew were based on the full runway length being available. However, unrecognised by the crew, the take-off distance available for runway 19L was reduced at the upwind (01R threshold) end by 871m due to runway works.
“The displaced threshold was detailed in dispatcher notes and in a NOTAM – notice to airmen advisory – included in pre-flight paperwork given to the crew prior to their previous flight from Melbourne to Brisbane, as well as in the paperwork for the Brisbane departure,” said ATSB director of transport safety Stuart MacLeod.
“Further, the ATIS broadcast of recorded aeronautical information for Brisbane Airport at the time of the departure also alerted flight crews to the displaced threshold and reduced take-off distance at the time.
“However, during the pre-flight for the flight from Melbourne to Brisbane, the captain misinterpreted the dispatcher notes to mean there were no performance requirements for operations on runway 19L, then on reviewing the relevant NOTAMs headline, incorrectly dismissed the Brisbane NOTAM detailing the displaced runway threshold as not being relevant to their flight.”
An ATSB investigation report notes the crew’s belief that there were no performance requirements for runway 19L was reinforced by the absence of any visible runway works or other indications of restrictions during their landing on the runway after their flight from Melbourne.
“This, combined with time pressures and distractions from prioritising training needs, contributed to the flight crew then inputting the incorrect runway data during pre-flight calculations prior to the departure from Brisbane.”
This resulted in a departure with insufficient runway available due to the aircraft being overweight for that reduced runway length.
“This incident and investigation underscore the importance of flight crews considering possible variations to take-off and/or landing dimensions when determining runway performance data,” MacLeod said.
“This operator’s procedures did account for such changes through notification of performance requirements within their NOTAM system, however, due to a combination of distraction and misinterpretation, they were not identified.”
Since the occurrence, Virgin Australia has implemented a number of safety management, procedural and information-based changes designed to improve flight crew awareness.
“When presented with a number of NOTAMs, dismissing them based on the headline alone increases the risk of missing safety-relevant information,” MacLeod said.
“As an additional defence, flight crews should ensure that the data input into performance data calculations is in conformance with other relevant information, such as the ATIS.”
