Malaysian A333 at Melbourne on Sep 7th 2023, overran runway on takeoff

Last Update: December 1, 2023 / 11:34:24 GMT/Zulu time

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Photo of Malaysia Airlines 9M-MTL, Airbus A330-300 — Malaysia Airlines 9M-MTL, Airbus A330-300 (Photo credit: byeangel / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Sep 7, 2023

Classification
Incident

Airline
Malaysia Airlines

Flight number
MH-128

Departure
Melbourne, Australia

Destination
Kuala Lumpur, Malaysia

Aircraft Registration
9M-MTL

Aircraft Type
Airbus A330-300

ICAO Type Designator
A333

Airport
Melbourne International Airport, Melbourne

Airport ICAO Code
YMML

A Malaysia Airlines Airbus A330-300, registration 9M-MTL performing flight MH-128 from Melbourne,VI (Australia) to Kuala Lumpur (Malaysia), was departing Melbourne's temporarily shortened runway 34 when the aircraft rotated past the temporarily displaced runway end, the jet blast affected people and objects in the working area past the displaced runway end. The aircraft continued to Kuala Lumpur for a safe landing.

Australia's TSB opened a short investigation into the occurrence stating that no damage and no injuries occurred.

On Sep 18th 2023 a similiar occurrence happened, see Incident: Bamboo B789 at Melbourne on Sep 18th 2023, overran runway on takeoff.

Following the second occurrence Melbourne Airport stopped the works requiring a displaced runway threshold/end pending investigation.

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 9M-MTL:

On the night of 7 September, a Malaysia Airlines Airbus A330-300, registered 9M-MTL was scheduled for a 2330 local time departure to fly as a scheduled passenger transport Melbourne to Kuala Lumpur, Malaysia as flight MH128. The first officer (FO) was the pilot flying (PF), and the captain was the pilot monitoring (PM).

The same flight crew had flown into Melbourne via runway 34 the previous night at about 2030, on another A330-300 aircraft. When approaching Melbourne, the flight crew reported that they checked the NOTAMs, which identified that taxiway E would be closed as a result of WIP that evening. Even though the NOTAM came into effect after they were scheduled to land, the crew contacted air traffic control (ATC), who confirmed that taxiway E could be used to vacate the runway. The aircraft landed without issue.

At around 2100 on 7 September, prior to leaving their hotel, the flight crew each downloaded an electronic copy of the flight briefing package. Both crew indicated they went briefly through the flight plan, including weather and fuel, before travelling to the airport. After arriving at the airport check-in, the flight crew also picked up a hard copy of the briefing package and immediately proceeded through to the aircraft.

The flight crew arrived at the aircraft at about 2245 and reported commencing with the company standard operating procedures (SOP) and checklist to prepare for the flight. This included another review of the flight briefing package.

One of the NOTAMs in the briefing package indicated that, at the time of the scheduled departure, runway 34 had the length reduced by 1,568 m from the northern end due to WIP. It also stated that the take-off run available (TORA) was 2,089 m. Both crew later stated that they were aware of the WIP as a result of checking the runway NOTAMs on approach to Melbourne the previous evening, but missed the NOTAM details while preparing for the occurrence flight. The FO reported going through the NOTAMs on their electronic flight bag (EFB) and indicated that the split screen display may have affected their ability to detect the shortened runway. The captain recalled going ‘briefly’ through the NOTAMs.

Both crew reported listening to the automatic terminal information service (ATIS)9 and writing down the key information. The FO filled out the operator’s predeparture take-off certificate, which had spaces for the time the ATIS was accessed, along with weather information from the ATIS and other flight data. The version of the ATIS that the flight crew accessed was information Oscar which stated ‘reduced runway length in operation’ and gave both the landing distance available (LDA) and the take-off run available (TORA) as 2,089 m. The ATIS audio was broadcast as follows:

MELBOURNE TERMINAL INFORMATION OSCAR, EXPECT GLS OR RNP APPROACH, RUNWAY
THREE FOUR DRY, REDUCED RUNWAY LENGTH IN OPERATION, LANDING DISTANCE
AVAILABLE TWO ZERO EIGHT NINER METRES, TORA TWO ZERO EIGHT NINER METRES,
WIND THREE THREE ZERO DEGREES ONE ZERO KNOTS, VISIBILITY GREATER THAN ONE
ZERO KILOMETRES, CLOUD FEW THREE THOUSAND FIVE HUNDRED FEET, TEMPERATURE
ONE ZERO, QNH ONE ZERO ZERO FIVE, ON FIRST CONTACT WITH MELBOURNE GROUND,
TOWER OR APPROACH, NOTIFY RECEIPT OF INFORMATION OSCAR.

The flight crew proceeded with independent performance calculations using the Airbus EFB software FlySmart. Neither of the crew recalled recognising, after listening to the ATIS, that the runway length was reduced and there were no notes relating to the runway length recorded on the predeparture take-off certificate. Both crew selected the full length of the runway for their independent calculations, which resulted in the selection of a reduced-thrust take-off. The FO reported then cross-checking the two sets of performance figures, which were the same.

ATC cleared the aircraft to push back from the gate at 2329 and the aircraft was subsequently cleared to taxi to holding point K (at taxiway K) at 2337. At 2343, ATC gave the aircraft clearance to line up on runway 34 and, about one minute later, cleared the aircraft for take-off. None of the communications between the flight crew and ATC mentioned the shortened runway, the works in progress or the current ATIS version, which had not changed since the flight crew accessed it.

The crew reported that, in accordance with the airline’s standard operating procedure, the FO (as PF) set the thrust and the captain then put a hand on the throttle levers. The captain reported that at approximately 100 kt, they observed that the runway end lights appeared ‘close’. The captain considered advancing the throttles to take-off/go-around (TOGA)13 thrust, but elected not to, as they felt it may distract or startle the FO. The PF reported that they did not notice the lights.

Aircraft flight data showed that upon reaching the calculated rotation speed (VR) of 159 kt, approximately 75 m before the runway end, the aircraft rotated (weight off the nose landing gear). Both crew recalled that the initial rate of rotation was slow and was subsequently corrected. The data recorded weight off the main landing gear, after the end of the runway, approximately 170 m before the works limit line. The data recorded 21 ft (6.4 m) radio altitude (RA) as the aircraft crossed the works limit.

Once the aircraft was stabilised at 10,000 ft, the crew briefly discussed the proximity of the runway end lights during the take-off. There was no indication of any issue with the aircraft and no contact from ATC to indicate any issue, so the crew continued the flight to Kuala Lumpur.

The airport operator, Australian Pacific Airport Melbourne (APAM) reported that it ceased the runway overlay works the day after the occurrence, pending the outcome of its initial investigation.

After a review of the existing risk assessment for displaced threshold runway works, APAM carried out a number of safety actions (see Safety action) and recommenced the works on 11 September.

There were no further incidents relating to the runway works reported until 18 September.

Metars:
YMML 071430Z 01011KT 9999 FEW025 09/04 Q1005=
YMML 071400Z 35014KT CAVOK 09/04 Q1005=
YMML 071330Z 35013KT CAVOK 10/04 Q1005=
YMML 071300Z 35009KT CAVOK 10/05 Q1005=
YMML 071230Z 35010KT 9999 FEW035 10/06 Q1005=
YMML 071200Z 35012KT 9999 FEW035 10/06 Q1005=
YMML 071130Z 35012KT 9999 FEW035 10/07 Q1005=
YMML 071100Z 35012KT 9999 FEW035 11/07 Q1005=
YMML 071030Z 35012KT 9999 FEW028 12/08 Q1004=

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