The aircraft operator conducted its own investigation of the incident and as a result advised the ATSB that:
The operator’s Safety Systems Manager recommended:
- that, due to the potential consequences of the event, all involved aircrew undergo retraining in the specific safety management subjects of Reporting Requirements, TEM, human factors, and CRM; and
- that the Flight Crew additionally undergo simulator and line training.
Operational procedures were amended, as follows:
- incorporated a centre-line confirmation procedure by the First Officer prior to commencing the take-off roll;
- expanded the policy contained in the company manuals for runway verification prior to take-off;
- additional text was added to the Airport and Runway Data Manuals emphasising crew awareness of operational readiness platforms, and circumstances where no centreline lighting exists; and
- a training module was incorporated into a simulator cyclic session to focus the attention of crews on the importance of ensuring that the aircraft is on the centreline prior to take-off.
The ATSB is satisfied that the action taken by the operator adequately addresses the safety issue.