Bamboo B789 at Melbourne on Sep 18th 2023, overran runway on takeoff
Last Update: December 1, 2023 / 11:41:23 GMT/Zulu time
Incident Facts
Date of incident
Sep 18, 2023
Classification
Incident
Airline
Bamboo Airways
Flight number
QH-83
Departure
Melbourne, Australia
Destination
Hanoi, Vietnam
Aircraft Registration
VN-A819
Aircraft Type
Boeing 787-9 Dreamliner
ICAO Type Designator
B789
Airport ICAO Code
YMML
Australia's TSB opened a short investigation into the occurrence stating "several unserviceability lights were damaged by the jet blast of VN-A819."
Melbourne Airport stopped the works requiring a displaced runway threshold/end pending investigation.
On Sep 7th 2023 a similiar occurrence had happened, see Incident: Malaysian A333 at Melbourne on Sep 7th 2023, overran runway on takeoff
On Dec 1st 2023 the ATSB released their preliminary report into both occurrences stating:
Runway 34, which was normally 3,657 m long, had been temporarily shortened by 1,568 m from the northern end, due to runway resurfacing works in progress (WIP). The flight crew of both aircraft did not identify that the shortened runway was in place and used the full length of runway 34 for their take-off performance calculations. As a result, the reduced-thrust engine settings used by both flight crews extended the take-off runs beyond the temporary runway end lights into a 450-metre buffer before the works limit line. The jet blast from each aircraft impacted runway unserviceability lights, works lights and marker cones. Personnel were active in the works area at the time of both occurrences, however none were physically injured as a result. There was no damage to either aircraft, or injuries to passengers, and both continued with their planned flights.
The ATSB summarized the sequence of events on VN-A819:
On 18 September 2023 at 2230, a Bamboo Airways Boeing 787-9 aircraft, registered VN-A819, was being prepared to depart Melbourne Airport for scheduled passenger transport flight QH83 to Hanoi, Vietnam. There were 3 flight crew, who were assigned the roles (according to the operator’s terminology) of pilot in command (PIC), PM, and PF.15 For this flight, the PIC sat in the jump seat behind the pilots at the controls, the PM sat in the left pilot’s seat and the PF sat on the right.
The same flight crew had flown into Melbourne via runway 34 at around midday on 17 September, on another Boeing 787-9. At the time of this arrival there were no restrictions on the runway or taxiways.
At approximately 2000, prior to leaving their hotel, the flight crew reported downloading and reviewing the flight briefing package. The aircraft had an inoperative auxiliary power unit (APU) and had one brake unit (of 8 total) deactivated. The crew then had an initial briefing on the planned flight while on the way to the airport.
The flight crew received a hard copy of the flight briefing package at the airport and later reported that additional review of the documents was conducted as a group. The flight dispatcher’s email to the crew, accompanying the briefing package, indicated that there was no special effect on the flight. The PIC reported that the NOTAMs were reviewed at this point and identified that the runway works NOTAM came into effect at 2235 5 minutes after the scheduled departure time (2230). The PIC recalled an intent to read the NOTAMS again when conducting the EFB performance calculations.
The PF and PM reported that after arriving at the aircraft, they obtained ATIS information November. This indicated that runway 16/34 was currently closed due to the runway works, that all runways would be closed from 2225, and from 2235 runway 34 would be operational with a displaced threshold. The relevant part of the ATIS was broadcast as:
MELBOURNE TERMINAL INFORMATION NOVEMBER…RUNWAY ONE SIX THREE FOUR
CLOSED DUE WORKS. FROM TIME ONE TWO TWO FIVE ALL RUNWAYS CLOSED. FROM TIME
ONE TWO THREE FIVE RUNWAY THREE FOUR WITH DISPLACED THRESHOLD FOR ALL
OPERATIONS…
As a result of the APU fault, external power was connected to the aircraft. The crew reported that the power disconnected halfway through flight planning, leaving the aircraft completely dark. Two further power outages resulted in an estimated 40-minute delay until power was stabilised, and a further 30 minutes to prepare the aircraft again. The PF and PM reported that they were experiencing a high workload at the time.
The PF recalled obtaining the up-to-date ATIS information, which had changed to information Oscar from 2220. It stated that runway 09/27 and runway 16/34 were closed due to WIP:
MELBOURNE TERMINAL INFORMATION OSCAR…RUNWAY ZERO NINER TWO SEVEN AND
ONE SIX THREE FOUR CLOSED DUE WORKS. FROM TIME ONE TWO THREE FIVE RUNWAY
THREE FOUR WITH DISPLACED THRESHOLD FOR ALL OPERATIONS …
The flight crew did not recall recognising the runway closures from the ATIS and the PIC did not ultimately re-check the NOTAMs as originally intended.
At 2222 the crew requested flight clearance to Hanoi. In providing clearance, ATC advised the flight crew to expect to take off from runway 34 and that the ATIS information was now Oscar, which was acknowledged by the crew. At 2229, due to the APU fault, the crew requested to start one engine at the gate while connected to ground power, which was approved.
ATIS information Papa was broadcast from 2233, stating that the reduced runway length was in operation and provided the associated runway declared distances:
MELBOURNE TERMINAL INFORMATION PAPA…REDUCED RUNWAY LENGTH IN OPERATION
TORA TWO ZERO EIGHT NINER METRES, TODA TWO ONE FOUR NINER METRES, ASDA TWO
TWO THREE NINER METRES, LANDING DISTANCE AVAILABLE TWO ZERO EIGHT NINER
METRES. RUNWAY THREE FOUR DEPARTURES FROM TAXIWAY KILO. CENTRELINE LIGHTS
NOT AVAILABLE. RUNWAY ZERO NINER TWO SEVEN CLOSED DUE WORKS…
The flight crew did not access this ATIS version. At 2240, after starting one engine, the flight crew requested and received clearance to push back from the gate and, at 2246, received clearance to taxi to holding point K. About a minute later, ATC contacted the flight crew to advise that their transponder wasn’t showing on the radar, which the crew acknowledged and corrected.
The aircraft held for about 3 minutes at holding point K for incoming traffic and, at 2254 was cleared to line up on runway 34. A minute later, ATC asked the flight crew, ‘confirm you have information Papa’. The crew did not respond to the request.
About 25 seconds later, after engaging with another aircraft, ATC called VN-A819 again. Once acknowledged, ATC again asked the crew to ‘confirm you have ATIS information Papa’, to which the PM replied, ‘information Papa copy’. At 2256, on receipt of their response, ATC gave the flight take off clearance.
During post-occurrence interviews, the PF and PIC recalled that they recognised the ATIS version change from Oscar to Papa at this time, but they had not accessed information Papa. The crew indicated that their expectations around the ATIS change were normally to do with the QNH or wind and that any important change in the information would have been directly communicated by ATC rather than the ATIS. At the time of the question from ATC, the PF indicated they felt pressure already being lined up on the runway, with their traffic display showing an aircraft on approach a few miles out behind them.
Flight path data provided by Bamboo Airways identified the point of weight off the main landing gear as just past taxiway E. Based on witness reports and review of CCTV footage, Melbourne airport estimated the height over the works limit to be 3–5 m (10–16 ft).
During the take-off run, the flight crew observed that the runway end lights were much closer than normal. After take-off was completed, the crew discussed the proximity of the runway end lights.
There was no indication of any fault with the aircraft and no contact from ATC to indicate any other issue. The crew therefore continued the flight to Hanoi.
After this occurrence, APAM ceased works for the remainder of the evening and, on the following day, cancelled any further displaced threshold works for the remainder of the runway overlay project.
Metars:
YMML 181430Z 25006KT 220V010 CAVOK 14/11 Q1010 RF00.0////./ BKN150 BKN175=
YMML 181330Z 28003KT CAVOK 14/11 Q1011=
YMML 181230Z 34005KT 290V090 CAVOK 13/11 Q1012 RF00.0////./ BKN160 VIRGA=
YMML 181200Z 04004KT CAVOK 13/11 Q1013=
YMML 181130Z 31001KT CAVOK 13/10 Q1013 BKN180 VIRGA=
YMML 181100Z 36004KT CAVOK 14/10 Q1013 BKN170 VIRGA=
YMML 181030Z 29004KT CAVOK 14/11 Q1014=
YMML 181000Z 24004KT 120V260 CAVOK 13/10 Q1013 RF00.0////./ BKN155 BKN175=
Related NOTAM:
H5678/23 NOTAMN
Q) YMMM/QMRLC/IV/NBO/A/000/999/3740S14451E005
A) YMML
B) 2309060000 C) 2309270600
D) 2309060000 TO 2309060600
2309130000 TO 2309130600
2309200000 TO 2309200600
2309270000 TO 2309270600
E) RWY 09/27 CLSD DUE WIP
REF TO METHOD OF WORKING PLAN 2023-4 STAGE R1
Incident Facts
Date of incident
Sep 18, 2023
Classification
Incident
Airline
Bamboo Airways
Flight number
QH-83
Departure
Melbourne, Australia
Destination
Hanoi, Vietnam
Aircraft Registration
VN-A819
Aircraft Type
Boeing 787-9 Dreamliner
ICAO Type Designator
B789
Airport ICAO Code
YMML
This article is published under license from Avherald.com. © of text by Avherald.com.
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