A Bamboo Airways Boeing 787-9, registration VN-A819 performing flight QH-83 from Melbourne,VI (Australia) to Hanoi (Vietnam), 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.
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 operators 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 pilots 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 dispatchers 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 wasnt 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 35 m (1016 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.
On Nov 11th 2025 the ATSB released their final report into both events concluding the probable causes were:
Contributing factors
- The flight crews of both aircraft did not recognise that reduced runway length operations were in effect at the time of departure, and conducted reduced-thrust take-offs based on the normal full runway length. This resulted in each aircraft taking off beyond the end of the shortened runway, in close proximity to active runway works.
- Acknowledging the known existing limitations of the NOTAM system, the NOTAM reviews by the flight crews of both aircraft were insufficient to identify that reduced runway length operations would be in effect during their respective departures.
- The Bamboo Airways flight crew were delayed preparing the aircraft for departure due to recurring power outages. As a result of increased workload and perceived time pressure, the crew did not conduct an additional review of the NOTAMs after boarding the aircraft.
- When accessing the Automatic Terminal Information Service through voice-ATIS, the flight crews of both aircraft only recorded the standard information required for take-off performance calculations and did not notice the aerodrome information regarding the reduced runway length.
- When lined up on the runway, the Bamboo Airways flight crew confirmed receipt of updated ATIS information without having accessed it. This was due to the flight crew's expectations that the ATIS change would not meaningfully affect their take-off.
- The Australian Aeronautical Information Publication requirement for flight crews to confirm automatic terminal information service (ATIS) identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance. (Safety issue)
- The International Civil Aviation Organization (ICAO) Annex 11 requirement for flight crews to confirm ATIS identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance. (Safety issue)
- The flight dispatchers for both flights had accounted for the reduced runway length in their take-off performance calculations, but did not highlight this information to the flight crews. Additionally, in the case of VN-A819, the dispatcher included a misleading crew briefing note that indicated there were no significant NOTAMs for the departure.
- Malaysia Airlines did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety. (Safety issue)
- Bamboo Airways did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety. (Safety issue)
- There were no visual aids installed that were designed to alert departing flight crews to the significant change in runway length. In addition, prior to commencing take-off, the flight crew of both aircraft did not see the runway works or equipment lights or did not recognise them as being associated with a reduction in runway length.
- The Part 139 (Aerodromes) Manual of Standards 2019 did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off. (Safety issue)
- The International Civil Aviation Organization (ICAO) Annex 14 standards and recommended practices did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off. (Safety issue)
Other factors that increased risk
- On first contact with the Melbourne ground controller in both occurrences, the flight crews did not confirm ATIS identifier as required, and the ground controllers did not challenge the omission. This removed a level of assurance that the flight crews had received current flight planning information.
- Although APAM had identified and implemented all the required and recommended risk controls for the prevention of a runway excursion on take-off, the level of detail recorded for its risk assessment provided limited assurance that the risks were fully understood, and did not allow for effective re-evaluation of original risk control assumptions.
Other findings
- The tower controller made an additional attempt to confirm the reduced runway length with the VN-A819 flight crew by requesting the ATIS identifier as the aircraft was lined up to take off. However, this ultimately had no effect on the crews recognition.
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
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 operators 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 pilots 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 dispatchers 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 wasnt 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 35 m (1016 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.
On Nov 11th 2025 the ATSB released their final report into both events concluding the probable causes were:
Contributing factors
- The flight crews of both aircraft did not recognise that reduced runway length operations were in effect at the time of departure, and conducted reduced-thrust take-offs based on the normal full runway length. This resulted in each aircraft taking off beyond the end of the shortened runway, in close proximity to active runway works.
- Acknowledging the known existing limitations of the NOTAM system, the NOTAM reviews by the flight crews of both aircraft were insufficient to identify that reduced runway length operations would be in effect during their respective departures.
- The Bamboo Airways flight crew were delayed preparing the aircraft for departure due to recurring power outages. As a result of increased workload and perceived time pressure, the crew did not conduct an additional review of the NOTAMs after boarding the aircraft.
- When accessing the Automatic Terminal Information Service through voice-ATIS, the flight crews of both aircraft only recorded the standard information required for take-off performance calculations and did not notice the aerodrome information regarding the reduced runway length.
- When lined up on the runway, the Bamboo Airways flight crew confirmed receipt of updated ATIS information without having accessed it. This was due to the flight crew's expectations that the ATIS change would not meaningfully affect their take-off.
- The Australian Aeronautical Information Publication requirement for flight crews to confirm automatic terminal information service (ATIS) identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance. (Safety issue)
- The International Civil Aviation Organization (ICAO) Annex 11 requirement for flight crews to confirm ATIS identifier with air traffic control did not provide positive assurance that crews had received the information in full, which included essential information on aerodrome conditions, and there were no standard air traffic control communication procedures for providing this assurance. (Safety issue)
- The flight dispatchers for both flights had accounted for the reduced runway length in their take-off performance calculations, but did not highlight this information to the flight crews. Additionally, in the case of VN-A819, the dispatcher included a misleading crew briefing note that indicated there were no significant NOTAMs for the departure.
- Malaysia Airlines did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety. (Safety issue)
- Bamboo Airways did not ensure that its flight dispatchers highlighted to flight crews all types of flight information most critical for flight safety. (Safety issue)
- There were no visual aids installed that were designed to alert departing flight crews to the significant change in runway length. In addition, prior to commencing take-off, the flight crew of both aircraft did not see the runway works or equipment lights or did not recognise them as being associated with a reduction in runway length.
- The Part 139 (Aerodromes) Manual of Standards 2019 did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off. (Safety issue)
- The International Civil Aviation Organization (ICAO) Annex 14 standards and recommended practices did not recommend, or provide standardised options for, movement area guidance signs or other visual aids to provide enhanced flight crew situational awareness of temporary changes to the runway length available for take-off. (Safety issue)
Other factors that increased risk
- On first contact with the Melbourne ground controller in both occurrences, the flight crews did not confirm ATIS identifier as required, and the ground controllers did not challenge the omission. This removed a level of assurance that the flight crews had received current flight planning information.
- Although APAM had identified and implemented all the required and recommended risk controls for the prevention of a runway excursion on take-off, the level of detail recorded for its risk assessment provided limited assurance that the risks were fully understood, and did not allow for effective re-evaluation of original risk control assumptions.
Other findings
- The tower controller made an additional attempt to confirm the reduced runway length with the VN-A819 flight crew by requesting the ATIS identifier as the aircraft was lined up to take off. However, this ultimately had no effect on the crews recognition.
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
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