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The Australian Transport Safety Bureau today released its report on the Qantas B747-400 runway overrun accident at Bangkok International Airport on 23 September 1999.

The ATSB investigation was undertaken under a delegation from the Aircraft Accident Investigation Committee of Thailand given on 18 November1999.

ATSB Executive Director Kym Bills said: "The Qantas Bangkok runway overrun was a serious accident that fortunately did not result in fatalities and serious injuries. It was a wake-up call to Qantas who may have been lulled into a false sense of security by their very good safety record. Qantas provided excellent cooperation throughout the investigation and ATSB is pleased that Qantas has actively responded to the deficiencies found during our investigation."

"Like most major accidents, QF1 resulted from a complex mixture of active failures, inadequate defences and organisational factors - these are spelled out in our investigation report without fear or favour but not apportioning 'blame'."

The investigation found that the accident occurred when the B747-400 landed well beyond the normal touchdown zone and then aquaplaned on a runway that was affected by water following very heavy rain. The crew omitted to use either full or idle reverse thrust during the landing. The aircraft was still moving at 88 kts (163 km/h) at the end of the runway and stopped 220 m later in soft turf with its nose on the airport perimeter road. A precautionary evacuation was made using emergency escape slides about 20 minutes later.

Although the flight crew and cabin crew made a number of errors, many of these were linked to deficiencies in Qantas's operational procedures, training and management processes. CASA's regulations covering contaminated runways and emergency procedures were also found to be deficient, as was its surveillance of airline flight operations. Qantas and CASA either have made, or are in the process of making, significant changes in the areas where deficiencies were identified including the development by CASA of a systems-based surveillance audit approach.

"This investigation is one of the most comprehensive and exhaustive ever conducted by the ATSB (or its predecessor the Bureau of Air Safety Investigation). I believe that the ATSB investigation, and the safety enhancements made following the accident, constitute a major contribution to aviation safety in Australia," Mr Bills said.

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Last update 01 April 2011