Runway excursion Serious incident Boeing 737-8FE (WL) VH-YFH, Wednesday 30 November 2022
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Date:Wednesday 30 November 2022
Time:11:39
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-8FE (WL)
Owner/operator:Virgin Australia Airlines
Registration: VH-YFH
MSN: 40996/3801
Year of manufacture:2011
Engine model:CFMI CFM56-7B
Fatalities:Fatalities: 0 / Occupants: 177
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Brisbane International Airport, QLD (BNE/YBBN) -   Australia
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Brisbane International Airport, QLD (BNE/YBBN)
Destination airport:Melbourne-Tullamarine Airport, VIC (MEL/YMML)
Investigating agency: ATSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The Virgin Australia Boeing 737-800, registered VH‑YFH, commenced its take-off roll from the A3 intersection of Brisbane Airport’s runway 19L. During the take‑off the aircraft briefly entered, and became airborne in, the section of the runway that was closed due to the runway works. The aircraft completed the departure and continued onto its destination where a maintenance inspection subsequently cleared the aircraft of any damage.


Contributing factors
• For the Melbourne to Brisbane sector, the dispatcher notes in the operational flight plan stated that Brisbane runway 01R displaced threshold had no landing weight performance limitation. The captain misinterpreted that note to mean that there were no performance requirements limits for operations on runway 19L.
• While the Brisbane NOTAM with the headline RWY 01R THR DISPLACED contained data concerning a significant reduction in the length of runways 01R/19L, the previously established misunderstanding of this NOTAM and the absence of any reference to 19L in the heading resulted in the captain incorrectly dismissing this NOTAM, which was also probably missed by the first officer.
• The flight crew did not identify the critical performance data that was appended to the Brisbane NOTAM that stated the runway length reduction for 01R/19L prior to the departure from Melbourne.
• The ATIS notification of the reduced length of runway 19L was not recognised or accounted for in the performance calculations for operations on that runway, likely due to the captain’s established belief that there were no performance requirements for runway 19L and the absence of the required independent check by the first officer.
• Due to time pressures and distractions from prioritising training requirements during the preparation for departure from Brisbane's runway 19L, and a previous assessment that it was not relevant, the flight crew dismissed a dispatcher's note alerting the crew to the RWY 01R THR DISPLACED NOTAM. Also, while the crew reviewed the operational flight plan component of the briefing package prior to departure, they probably did not review the NOTAM package.
• Unaware of the reduced available length of the departure runway, which was reinforced by the absence of any visible runway works or restrictions during the previous landing on 19L, the flight crew miscalculated the aircraft's take-off performance data. That resulted in a departure with insufficient available runway due to the aircraft being overweight for that reduced runway length.

Accident investigation:
cover
  
Investigating agency: ATSB
Report number: AO-2022-064
Status: Investigation completed
Duration: 1 year and 11 months
Download report: Final report

Sources:

AO-2022-064

Location

Revision history:

Date/timeContributorUpdates
05-Nov-2024 09:50 ASN Updated [Other fatalities, ]

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