The Australian Transport Safety Bureau found that crews failed to adequately absorb or act on a temporary runway-length reduction at Melbourne Airport, despite written notices and airport audio updates, due to expectations, workload, and time pressure.

Airservices Australia and the Civil Aviation Safety Authority are proposing changes to air traffic control procedures to improve the communication of runway-length information.

The incidents triggered an investigation into communication and situational awareness around runway changes, highlighting risks to ground staff and aircraft performance during takeoff.

Warnings about take-off conditions were incomplete, with NOTAMs and ATIS/automatic terminal information system updates not being properly acted on by flight crews.

Following the first incident, Melbourne Airport issued a safety alert to all airlines and questioned Malaysia Airlines, signaling a prompt safety response to the near-misses.

In September 2023, two near-collision takeoffs occurred when runways were temporarily shortened during night-time resurfacing, nearly putting aircraft in conflict with ground vehicles.

The incidents involved a Malaysia Airlines Airbus A330-300 and a Bamboo Airways Boeing 787-9, with the former overrunning the runway by about seven meters and the latter lifting off just 4.5 meters from ground staff, though no injuries occurred.

The runway was shortened from a full length of 3,657 meters to 2,089 meters, and each near-miss involved takeoff overshoots spaced 11 days apart.

Airlines updated dispatcher procedures in response, and ICAO introduced standards for highly visible signage to alert crews to temporary runway changes; Australia’s authorities are considering improvements to aerodrome information delivery to flight crews.

The safety bureau underscored the need for clear, timely notices and checks so crews and ground staff are aware of temporary runway configurations to prevent similar near-misses.

ATSB described the events as a near-disaster, prompting a broader risk review and calls for clearer, timely dissemination of information.

The ATSB chief described the incidents as serious and dangerous, noting near-misses occurred with fully loaded aircraft near large ground personnel, with luck averting catastrophe.