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The ATSB's final investigation report has found that a Boeing 737 passenger aircraft that overran the runway in Darwin in June 2002 did so because of a high approach speed, an inaccurate and unstabilised approach, and poor crew resource management.

Significant safety action has been taken by the operator to address the problems found and to improve training and safety systems to seek to ensure it doesn't happen again.

At about 1135pm on 11 June 2002, Boeing 737-800 registered VH-VOE touched down an estimated 1016 metres from the departure end of Runway 29 at Darwin, overran the runway and came to a stop about 44m into the 90m runway end safety area.

There were no injuries among the 92 passengers and 7 crew when the aircraft crossed the end of the runway at 35-40 knots groundspeed, and the aircraft was undamaged.

The investigation found that the pilot in command continued with an unstabilised approach and did not go around in accordance with company operating procedures. The copilot did not announce that the approach was unstable and call for a go around. A high approach speed led to a long landing and overrun situation.

Runway overruns and excursions are prominent in accidents and serious incidents involving passenger jets and typically involve long and/or fast landings.

Other factors in the Darwin incident included that the non-precision approach was flown at night in circumstances conducive to visual illusions; a displaced runway threshold limited the landing distance available; and that the relatively new operator had at the time an underdeveloped crew landing risk assessment and a safety management system that did not incorporate recommended flight data monitoring programs.

As part the operator's maturation process, it has developed a number of measures that are being implemented over the short, medium and longer terms to improve the training of crews, and the capability of the operators safety management system

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Last update 01 April 2011