Lessons Learned: Distraction/Misinterpretation Contributes to 737 Entering Closed Runway
Distraction, misinterpretation contributed to Virgin Australia 737-800 entering closed runway section during takeoff roll.
A Virgin Australia 737-800 entered a closed runway during its takeoff from Brisbane Airport after its flight crew misinterpreted or missed dispatcher notes, according to information detailing the shortened runway length available due to maintenance work.
The ATSB (Australian Transport Safety Bureau) report details that on the morning of 30 November 2022, the Virgin Australia Boeing 737-800 commenced its takeoff roll from Brisbane’s runway 19L for a flight to Melbourne, with 169 passengers and 8 crew on board. The flight crew comprised a training captain and a first officer undertaking “line flying under supervision” as part of the first officer’s conversion onto the 737 aircraft.
The takeoff thrust and speeds set by the flight crew were based on the full runway length being available. However, unrecognized by the crew, the takeoff distance available for runway 19L was reduced at the upwind (01R threshold) end by 871 m due to runway works. In other words, the 737-800 entered a closed runway during takeoff.
“The displaced threshold was detailed in dispatcher notes and in a NOTAM – notice to airmen advisory – included in preflight paperwork given to the crew prior to their previous flight from Melbourne to Brisbane, as well as in the paperwork for the Brisbane departure,” ATSB Director Transport Safety Stuart MacLeod explained.
“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 prioritizing training needs, contributed to the flight crew then inputting the incorrect runway data during preflight 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 takeoff and/or landing dimensions when determining runway performance data,” Mr. 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,” Mr. Macleod concluded.
“As an additional defense, flight crews should ensure that the data input into performance data calculations is in conformance with other relevant information, such as the ATIS.”
Read the ATSB report: Runway excursion involving Boeing 737-8FE, VH-YFH, at Brisbane Airport, Queensland, on 30 November 2022, publication date, 05/11/2024.
