Serious incident British Aerospace BAe-146-200QT VH-SFV, Wednesday 4 January 2023

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Date:	Wednesday 4 January 2023
Time:	18:04
Type:	British Aerospace BAe-146-200QT
Owner/operator:	Pionair Australia
Registration:	VH-SFV
MSN:	E2086
Year of manufacture:	1987
Engine model:	Lycoming ALF502 R-5
Fatalities:	Fatalities: 0 / Occupants: 2
Other fatalities:	0
Aircraft damage:	None
Category:	Serious incident
Location:	8.7 NM SSE of Rockhampton Airport, QLD (ROK/YBRK) - Australia
Phase:	Approach
Nature:	Cargo
Departure airport:	Brisbane International Airport, QLD (BNE/YBBN)
Destination airport:	Rockhampton Airport, QLD (ROK/YBRK)
Investigating agency:	ATSB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
A BAe-146-200, registered VH-SFV and perated by Pionair Australia, operated a freight transport flight in darkness from Brisbane to Rockhampton, Queensland. After discontinuing a required navigation performance approach to runway 33 at Rockhampton because of low cloud, the crew conducted a missed approach and commenced a second approach at 0358 local time.
When commencing the second approach, the captain began descending the aircraft from 3,500 feet above mean sea level at the initial approach fix waypoint SARUS. Prior to crossing the intermediate fix at the waypoint BRKSI, the aircraft descended below the 3,000 ft segment minimum safe altitude (SMSA). The aircraft then continued descending on about a 3° profile and crossed BRKSI at 1,705 ft (1,295 ft below the SMSA) before then also descending below the next SMSA of 1,500 ft a few seconds later.
As the aircraft continued descending toward the minimum descent altitude, the flight crew recognised that the aircraft had descended below the SMSA and immediately commenced a missed approach. At about the same time, the ground proximity warning system activated.

Contributing factors
• Following a missed approach, a second approach descent was commenced early when the captain applied their regular descent technique, but from a lower altitude, while the first officer did not identify the early descent due to an incorrect mental model of the aircraft's position along the approach. This resulted in the aircraft twice descending below segment minimum safe altitudes.
• Due to the time of the approaches and inadequate sleep, both flight crewmembers were likely experiencing a level of fatigue known to adversely affect performance. This, in combination with a period of high workload associated with the second approach, led to the early descent and monitoring errors.

Accident investigation: