A captain’s misinterpretation of a dispatcher’s note and notice to airmen (NOTAM) oversights resulted in a Virgin Australia Boeing 737-800 taking off from section of closed runway.
The serious incident occurred during the late morning of 22 November 2022 as the 737 (YH-YFH) departed Brisbane airport on runway 19L, says the Australian Transport Safety Bureau.
Prior to the previous sector, from Melbourne, the crew had received a dispatcher’s note about a displaced threshold on Brisbane’s runway 01R, the opposite runway to 19L.
“The captain misinterpreted the dispatcher’s note to mean that there were no performance requirements for operations on [runway 19L],” says the ATSB’s final report into the incident.
“The captain reviewed the NOTAMs and based on this misunderstanding, dismissed the NOTAM as not being relevant for their operation.”
The ATSB says it is unclear if the first officer reviewed the dispatcher’s note and NOTAM, but it believes that the “relevance of the note and this NOTAM was probably missed.”
Contributing to their mental image, when the crew arrived from Melbourne on runway 19L they did not observe any works or other markers during their landing roll and exit from the runway.
Moreover, signage at the take-off point suggested that the take-off distance was more than available.
Amid time pressures and distractions involved in training needs – the first officer was converting to the 737- the crew used the full runway length in their performance data calculation for the departure.
The aircraft ended up taking off for Melbourne with insufficient runway and overweight for the reduced runway length.
As a result of the incident, Virgin Australia has implemented measures to improve awareness about runway configuration changes.
Brisbane airport has also updated departure and arrival procedures when runway works are underway. It also redrafted the NOTAM for runways 09R/19L and changed the procedures for displaying the correct runway distance on movement area guidance signs.
“Flight crews must ensure they consider possible variations to take-off and/or landing dimensions when determining runway performance data,” says the ATSB.
“While this operator’s procedures accounted for such changes through notification of performance requirements within their NOTAM system, due to a combination of distraction and incorrect assumption, they were not identified. When presented with many NOTAMs, flight crews need to be aware that dismissing them based on the headline alone increases the risk that safety relevant data may be overlooked.”
The aircraft suffered no damage in the incident, and there were no injuries among the 169 passengers and eight crew.
