ATSB report reveals what caused plane’s missed landings at Rockhampton

An Australian Transport Safety Bureau investigation revealed the alarming key factors behind a freight plane’s descent below the minimum safe altitude in Rockhampton early this year.

The BAE 146 is a 4-engine, high-wing, regional jet aircraft. VH-SFV was manufactured in 1987 and was configured for airfreight operations. Pic: ATSB

An Australian Transport Safety Bureau investigation revealed the likely factors behind a freight plane’s descent below the minimum safe altitude in Rockhampton early this year.

The investigation report, which was released on December 13, found the pilots of a BAE 146 freighter were likely experiencing fatigue and were dealing with a high workload.

On the morning of January 5, two pilots were operating a Pionair Australia BAE 146-200 on a night freight flight from Brisbane to Rockhampton.

At about 3:30am the crew began a straight-in, required navigation performance (RNP) approach to Rockhampton’s runway 33, but discontinued due to low cloud.

After the missed approach the crew climbed the plane to 4500ft and entered a holding pattern before descending to the minimum holding altitude of 3500ft.

ATSB Chief Commissioner Angus Mitchell said the normal practice for a straight-in approach was to have the aircraft descending to cross the initial approach fix at about 5000ft, and to continue descending to the next waypoint while remaining above the 3000ft minimum safe altitude.

The BAE 146 is a 4-engine, high-wing, regional jet aircraft. VH-SFV was manufactured in 1987 and was configured for airfreight operations. Pic: ATSB

“However, prior to this second approach, the flight crew were conducting the holding pattern at 3,500ft,” he said.

“The aircraft subsequently passed through the initial approach fix on its second approach at that lower altitude, but the captain commenced descending as per their normal practice – resulting in the aircraft incorrectly descending along a profile consistent with being one approach segment further along than its actual position.”

The plane subsequently descended below the minimum safe altitude for the first two segments of the RNP approach to the runway.

As the plane descended towards the minimum descent altitude in the second segment of the approach, the pilots recognised their low altitude, and commenced another missed approach.

At about the same time, the ground proximity warning system activated.

The ATSB found the captain started the second approach descent early, based upon their incorrect application of their preferred regular descent technique.

The first officer did not identify the early descent due to an incorrect mental model of the aircraft’s position in relation to the required flight path.

The ATSB found due to the time of the approaches and inadequate sleep, both flight crew were likely experiencing fatigue.

The investigation also found the operator’s flight crew rosters were within regulations, but they were irregular and disruptive to the flight crew’s sleep patterns.

Mr Mitchell said the ATSB’s SafetyWatch initiative, which highlights broad safety concerns stemming from its investigation findings and occurrence data reported by industry, was improving the management of fatigue as one of its priorities.

“Managing fatigue is a shared responsibility. This incident emphasises the importance of operators providing predictable and stable rosters to support pilots in achieving adequate sleep,” Mr Mitchell concluded.

“It is equally important pilots monitor their own health and wellbeing to ensure they are well-rested, especially when conducting overnight operations.”