Two international airliners carrying hundreds of people narrowly averted disaster when they overshot a runway and took off just metres above airport workers.
Both aircraft flew so close to an active Melbourne airport site that jet blast affected the area, a report says, resulting in a stress-related injury to a worker.
Their flight crews were unaware the runway had been shortened by more than 1.5km for night resurfacing works, resulting in two near misses within a fortnight.
A Malaysia Airlines Airbus A330-300 first overran the runway that had been reduced to about 2km on 7 September 2023, when it took off, passing seven metres above the airport worksite.
Eleven days later, a Bamboo Airways Boeing 787-9 overshot the same strip and took off less than five metres above the night works' vehicles and personnel.
Each plane was carrying more than 200 people at the time.
'Serious incidents'
No one was injured, but a worker reported that the first near-miss caused their vehicle to shake violently.
The second incident resulted in one stress-related injury, the Australian Transport Safety Bureau (ATSB) report says.
"These were serious incidents," the bureau's chief commissioner Angus Mitchell told reporters on Tuesday.
"In both cases, we had a fully loaded and fuelled aircraft with over 200 personnel on board coming within metres of fixed equipment on the ground and with works equipment.
"So it was by luck in this case that we didn't have an impact."
'Workload and time pressures'
All crews had been notified about the reduced runway through flight notices and the airport's information service radio broadcasts.
However, crews on the two international airliners involved in the near misses had not identified the information due to "expectations, workload and time pressures".
They consequently used standard take-off performance calculations, with reduced engine thrust causing them to overshoot.
The flight crews also failed to confirm the shortened runway with air traffic control, which in turn failed to challenge them.
Dispatchers, who brief flight crews, had noted the reduced runway but did not emphasise it because it affected the take-off thrust required, which is the pilot's responsibility.
"To those workers on the ground it was a terrifying experience," Mitchell said.
"That's why we've been so detailed in the investigation, but also in our safety recommendations to ensure that this type of thing does not occur, particularly in Australia, again."
What happens next?
Both airlines have updated their procedures to ensure that changes to runway distances are directly communicated to flight crews.
Airservices Australia — in consultation with the Civil Aviation Safety Authority — is reviewing its air traffic control procedures as a result of the near misses.
The ATSB has recommended the International Civil Aviation Organization review air traffic control communication procedures to crews on "safety-critical" aerodrome conditions.
The international body has already committed to introducing additional highly visible signage to alert crews of runway changes.
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