Virgin Australia B738 at Brisbane on Nov 30th 2022, overran runway on takeoff and became airborne
Last Update: November 5, 2024 / 10:19:44 GMT/Zulu time
Incident Facts
Date of incident
Nov 30, 2022
Classification
Incident
Airline
Virgin Australia
Flight number
VA-324
Departure
Brisbane, Australia
Destination
Melbourne, Australia
Aircraft Registration
VH-YFH
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
YBBN
Between Nov 29th 2022 21:00Z and Nov 30th 2022 06:30Z 831 meters of the southern part of runway 01R/19L were unavailable due to works in progress.
On Dec 9th 2022 the ATSB reported, the occurrence was rated a serious incident, and opened an investigation.
On Nov 5th 2024 the ATSB released their final report concluding the probable causes of the serious incident were:
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.
Other factors that increased risk
- Having not reviewed the NOTAMs as part of the approach briefing prior to descent into Brisbane, contrary to the requirements of the operations manual, or on an opportunity basis en route, the flight crew missed an opportunity to correct the incorrect mental model developed for Brisbane's RWY 19L during the turnaround in Melbourne.
- Contrary to the requirements of Part 139 Manual of Standards, the A3/19L intersection departure point take-off run available Movement Area Guidance Sign (MAGS) presented a take-off distance that was more than that available, creating the potential to mislead flight crews about the status of the runway when conducting a departure from that point.
The ATSB analysed:
Introduction
At 1148 on 30 November 2022, a Boeing 737-800 flight from Brisbane to Melbourne, operating as VA324, commenced its take-off run from the A3 intersection of runway 19L (RWY 19L) at Brisbane Airport (BNE). While the aircraft’s flight crew were aware of the upwind threshold being displaced, they were not aware that the take-off distance available for runway 19L had also been significantly reduced due to that displacement and that there were cones across the runway to mark the closed end of the runway.
Consequently, the performance data used for the take-off was incorrectly based on a normal length runway being available. This resulted in insufficient power being applied at the commencement of the take-off for the aircraft to complete the take-off in the declared distance available. This analysis will examine the factors that led to this serious incident and the opportunities to have corrected the misunderstanding of the runway status.
Flight planning in Melbourne
Incorrect mental model for runway 19L
Before the departure from BNE RWY 19L, the flight crew operated a sector from Melbourne (MEL) to BNE as VA319. The VA319 operational flight plan (OFP) component of the flight planning package (FPP) included a dispatcher’s note that identified that the threshold for BNE RWY 01R was displaced, but also contained the statement ‘NO LDW PERF LIMITATION’. This was intended to inform the flight crew that the displaced threshold had not led to any change to the aircraft’s maximum landing weight limitation for the landing into BNE.
The captain, however, misinterpreted this to mean that the displaced threshold had no performance effect for operations on runway 19L, that is, that flight operations engineering (FOE) had determined that there were no specific requirements with respect to the onboard performance tool (OPT) data input due to the threshold displacement. This misunderstanding led to a mental model that the displaced threshold for RWY 01R had no effect on performance requirements for RWY 19L.
Dismissing NOTAM YBBNC1174/22
The operator’s turnaround time between flights was generally scheduled at 40 minutes, of which about 5 was allocated to planning for the next sector. During this short period, there was typically a large volume of NOTAM data to be reviewed and flight critical data identified and actioned. While the grouping of sectors, revisiting of ports, and the use of a dispatcher to provide support, enabled efficiencies related to briefing, the aircraft captain retained overall responsibility for being aware of all relevant data.
To achieve this in the limited time available, the occurrence captain used NOTAM headlines as a guide to the content when assessing the relevance of a NOTAM. The scanning of NOTAMs using their heading is a practice often used by flight crew to enable large volumes of NOTAMs to be reviewed quickly. While the one subject matter and one condition standard for NOTAM construction generally supports this practice, there may be instances where a NOTAM’s headline does not fully reflect data contained within the free text section. NOTAM YBBNC1174/22 was one such NOTAM.
The 33-page VA319 FPP, which was presented to the flight crew in Melbourne, contained 120 NOTAMs over 18 pages. The NOTAMs for BNE included NOTAM YBBNC1174/22 with the headline RWY 01R THR DISPLACED. That NOTAM detailed the reduction in the runway length for operations on 01R/19L, data that was critical for the arrival into Brisbane. During review of the sector’s NOTAMs, the captain sighted the NOTAM headline and identified the NOTAM as being the matter to which the dispatcher had referred to in the note. However, the captain incorrectly dismissed this NOTAM as not being relevant to the flight because they:
- had previously incorrectly interpreted the dispatcher note on the performance effect of the displaced threshold, and therefore this NOTAM, as having no impact on their operations
- expected a landing on RWY 19L in Brisbane and the NOTAM headline made no reference to RWY 19L.
The ATSB was unable to conclusively determine whether the first officer reviewed the dispatcher’s notes and sector NOTAMs prior to departure from Melbourne, however, if they did, they missed the relevance of the note, the NOTAM and its attached FOE (flight operations engineering) data.
FOE data not identified
The FPP was the only source available to the flight crew for notification of FOE data changes. Any performance calculation made without the use of the applicable FOE data had an elevated potential to be incorrectly applied. The FOE remark attached to YBBNC1174/22 contained the data necessary to select the correct OPT inputs and correctly calculate aircraft performance data when using the reduced length of runway 01R and 19L in Brisbane.
During the VA319 pre-flight at MEL, the flight crew did not identify the FOE data applicable to operations on Brisbane’s RWY 19L during the review of the NOTAMs. The FOE data appended to NOTAM YBBNC1174/22 was either missed or dismissed due to an expectation that there was no performance effect.
The operator found that performance critical NOTAMs were presented in the same typeface as less critical NOTAMs and that this was contributory to the flight crew not identifying the FOE remark. While this is possible, it was also noted that the remarks were distinguished by a unique heading banner. The ATSB assessed that the incorrect mental model established by the captain was probably the overriding factor which influenced the dismissal of the NOTAM and its associated FOE remark.
Finally, the ATSB considered the possibility that the delayed issue of the complete FPP to the flight crew in Melbourne impacted the crew’s ability to effectively review NOTAMs and associated FOE. However, a full reprint of the FPP’s NOTAMs was available to the crew before departure and the preparations for arrival into Brisbane including the arrival briefing offered another opportunity to review the NOTAMs and identify applicable FOE data.
The Brisbane arrival
Readdressing the NOTAM
The operations manual requirements for an arrival briefing specified runway conditions and applicable NOTAMs for the arrival as items to be addressed in the briefing. It also included a general threat and error assessment for the arrival and landing. NOTAM YBBNC1174/22 contained critical information that merited review under both the briefing and the threat and error assessment.
However, contrary to these requirements, NOTAMs were not reviewed before arrival, nor were they reviewed when the time and opportunity was present during the en route phase of flight between MEL and BNE. While this time was likely allocated to training, the flight crew’s primary responsibility for safety of flight necessitated that, at a minimum, this NOTAM be reviewed. As a result, another opportunity to correct the captain’s (crew’s) mental model of BNE RWY 19 was missed.
ATIS and incorrect landing performance
While the BNE ATIS stated that the runway length of RWY 19L was reduced and specified the reduced landing distance available (LDA), the flight crew did not consider this notification to be relevant to the approach preparations. This was probably a result of the continuation of the misunderstanding of the dispatcher’s note regarding the performance requirements for RWY 19L. This resulted in the flight crew selection in the OPT of the full runway length for the runway input criteria, instead of the reduced length option. While the OPT landing performance data was based on an incorrect runway landing distance available, the calculated stopping solution was based on exiting the runway well before the closed section. Therefore, the landing was not affected by the incorrect runway data input. Further, the aircraft performed in accordance with the calculated data, exiting the runway normally using the planned rapid exit taxiway. The flight crew also did not see any visible restrictions or obstructions either on or around the runway which further supported their incorrect mental model.
While the LDA used in the landing performance calculation was displayed as part of the OPT en route landing performance calculation, the operator’s procedures did not require flight crews to crosscheck the LDA presented by the OPT with any notification of LDA change, such as that stated on the ATIS. Such a check, as recommended by the GAPPRE, could have provided an additional defence to capture the flight crew’s incorrect mental model and landing performance error.
The Brisbane departure
The pre-flight
The flight crew commenced the pre-flight preparations for VA324 with an understanding that YBBNC1174/22 did not impose any limitation on RWY 19L operations. Due to a combination of time pressures and distractions, particularly the delayed arrival into Brisbane and the initial prioritisation of training requirements during departure preparations, the flight crew had reduced time for their review of the VA324 FPP. As a result, the captain dismissed the dispatcher's note alerting the flight crew to the displaced threshold and, while the flight crew reviewed the OFP component of the briefing package prior to departure, they likely did not review the NOTAM package.
Take-off data error
Despite reviewing the ATIS content, due to an enduring belief there were no runway restrictions, the captain used an incorrect normal runway length input to determine the take-off performance figures for the BNE departure. This error was not identified as the first officer used the captain’s input data from the take-off data card (TODC), contrary to the independent take-off performance calculation procedures, resulting in the same incorrect figures.
Due to the use of the full runway length option as the basic runway configuration, the OPT calculator enabled a departure from the A3 intersection with a power derate. However, had the actual reduced runway length option (19L-WIPS) been used, the OPT would have excluded an A3 departure as the aircraft was overweight for such a departure, even with full take-off power. Further, had the A3 intersection departure selection been available for the 19L-WIPS option, the OPT would have notified the flight crew that a take-off from that point on the runway was not permitted.
Due to the incorrect take-off performance calculation, the aircraft did not meet the required performance for its departure from the A3 intersection of RWY 19L. The effect of this meant that the aircraft may have been unable to stop within the declared TORA if the take-off had to be rejected at high speed, and a runway excursion would have occurred. In addition, in the event of engine failure at high speed, the aircraft would probably have been unable to achieve its required performance.
Misleading MAGS
The Part 139 Manual of Standards required that movement area guidance signs (MAGS) located at runway intersection holding points be obscured when a temporarily displaced runway threshold altered the distance displayed by the MAGS. This did not occur while NOTAM YBBNC1174/22 was in effect. The signs presented a take-off distance that was in excess of that available, creating the potential to mislead flight crews about the status of the runway and the distance available when conducting a departure from that point.
While the operator’s procedures required the conduct of a performance data check at the holding point, they did not require consideration of the MAGS data in relation to that check. However, as MAGS were not required by Part 139 at all departure holding points, the mandating of a MAGS check as standard procedure would not have been possible. Nevertheless, obscuring the signs or including an indication of works in progress on the signs, had the potential to alert flight crews to changed conditions and trigger crews to confirm that correct runway data was being used for the take-off performance calculation.
NOTAM:
J4118/22 NOTAMR J4027/22
Q) YBBB/QMTCM/IV/NBO/A/000/999/2723S15307E005
A) YBBN
B) 2211292100 C) 2211300630
E) RWY 01R THR DISPLACED
RWY 01R/19L 871M SOUTH END NOT AVBL DUE WIP
OBST WORKERS AND EQPT 16FT AGL ON RCL 2889M FM START OF TKOF RWY 19L
EFFECTIVE RWY LEN AVBL 2689M
THR RWY 01R DISPLACED 921M MARKED BY FIVE GREEN LGT AND RWY THR IDENT
LGT (RTIL) EACH SIDE OF RWY
DECLARED DISTANCE AND GRADIENT CHANGES
RWY TORA TODA ASDA LDA
01R 2689 2809(1.6) 2749 2579
19L 2689 2749(3.6) 2689 2689
SUPPLEMENTARY TKOF DISTANCES
RWY19L- 2577(1.6) 2626(1.9) 2662(2.2)
TWY A7 AVBL FOR RWY 01R INTL DEP
RWY 01R PAPI, HIGH INTENSITY APCH LGT (HIAL) AND RCLL NOT AVBL
HIGH INTENSITY RWY LGT (HIRL) NOT AVBL
RWY 01R TEMPO PAPI LEFT SIDE 3.0 DEG 75FT AVBL
REFER METHOD OF WORKING PLAN YBBN 22/07
Metars:
YBBN 300300Z 16012KT 9999 -RA FEW023 BKN032 OVC045 21/15 Q1013=
YBBN 300230Z 15011KT 9999 -RA FEW023 BKN032 BKN045 21/16 Q1013=
YBBN 300200Z 15011KT 9999 -RA VCSH FEW028 BKN035 BKN045 21/16 Q1014=
YBBN 300130Z 16011KT 9999 -SHRA -RA FEW022 BKN035 OVC045 22/16 Q1014=
YBBN 300100Z 15010KT 9999 -RA FEW025 BKN032 22/16 Q1014=
YBBN 300030Z 15011KT 9999 -RA FEW025 SCT035 OVC180 22/16 Q1014=
YBBN 292230Z 17008KT 9999 FEW022 SCT050 BKN250 22/17 Q1015=
YBBN 292130Z 17009KT 9999 FEW021 SCT029 BKN040 22/17 Q1014=
YBBN 292100Z 17009KT 9999 VCSH FEW017 SCT022 BKN030 22/17 Q1014=
Aircraft Registration Data
Incident Facts
Date of incident
Nov 30, 2022
Classification
Incident
Airline
Virgin Australia
Flight number
VA-324
Departure
Brisbane, Australia
Destination
Melbourne, Australia
Aircraft Registration
VH-YFH
Aircraft Type
Boeing 737-800
ICAO Type Designator
B738
Airport ICAO Code
YBBN
This article is published under license from Avherald.com. © of text by Avherald.com.
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