Aviation safety investigations & reports

In-flight upset involving Boeing 747-438, VH-OJU, 110 km SE of Hong Kong Airport, on 7 April 2017

Investigation number:
AO-2017-044
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 7 April 2017, a Qantas Airways Boeing 747-438, registered VH-OJU, was operated as scheduled passenger flight QF29 from Melbourne, Victoria, to Hong Kong International Airport, in the Hong Kong Special Administrative Region of the People's Republic of China. On board were 17 crew and 347 passengers.

While descending toward Hong Kong International Airport, air traffic control instructed the flight crew to hold at waypoint BETTY.

When entering the holding pattern, the aircraft’s aerodynamic stall warning stick shaker activated a number of times and the aircraft experienced multiple oscillations of pitch angle and vertical acceleration. During the upset, passengers and cabin crewmembers struck the cabin ceiling and furnishings.

A lavatory smoke alarm later activated, however, the cabin crew determined the smoke alarm to be false and silenced the alarm. The aircraft landed at Hong Kong International Airport without further incident. Four cabin crewmembers and two passengers suffered minor injuries during the incident and the aircraft cabin sustained minor damage.

What the ATSB found

The ATSB found that while planning for the descent, the flight crew overwrote the flight management computer provided hold speed. After receiving a higher than expected hold level, the flight crew did not identify the need to re-evaluate the hold speed. This was likely because they were not aware of a need to do so, nor were they aware that there was a higher hold speed requirement above FL 200. Prior to entering the hold, the speed reduced below both the selected and minimum manoeuvring speeds. The crew did not identify the low speed as their focus was on other operational matters.

The ATSB also found that due to a desire to remain within the holding pattern and a concern regarding the pitch up moment of a large engine power increase, the pilot flying attempted to arrest the rate of descent prior to completing the approach to stall actions. In addition, the pilot monitoring did not identify and call out the incomplete actions. This resulted in further stall warning stick shaker activations and pilot induced oscillations that resulted in minor injuries to cabin crewmembers and passengers.

Additionally, the operator provided limited guidance for hold speed calculation and stall recovery techniques at high altitudes or with engine power above idle. This in turn limited the ability of crew to retain the necessary manual handling skills for the recovery.

What’s been done

In response to the occurrence, the operator updated flight crew training lesson plans and commenced retraining of flight crew in more complex stall recovery events. The operator also amended the Boeing 747-400, 787 and 737 flight crew training manuals and updated flight crew ground school lesson plans to ensure standardisation of training.

Safety message

Balancing competing attention or decision demands can interrupt trained flight crew responses leading to procedures not being completed in full, particularly so if flight crews are not receiving comprehensive and regular training in the application of these skills.

Comprehensive theory and practical training can ensure that flight crews have a complete understanding of aircraft systems and maintain effective manual handling skills. This training should provide flight crew with the knowledge to correctly configure the aircraft’s automatic flight systems and manual handling skills to respond adequately to in-flight upsets.

 

Download final report
[Download  PDF: 1.48MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

General details

Sources and submissions

Safety Issues

Go to AO-2017-044-SI-01 - Go to AO-2017-044-SI-02 -

Stall prevention and recovery at high altitudes

The operator provided flight crew with limited training and guidance in stall prevention and recovery techniques at high altitudes or with engine power above idle.

Safety issue details
Issue number: AO-2017-044-SI-01
Who it affects: Qantas Airways Boeing 747 flight crew
Status: Adequately addressed

Re-evaluating hold speeds for a change in altitude

The operator provided flight crew with limited training and guidance relating to the need for crew to re-evaluate their holding speed for a change in altitude.

Safety issue details
Issue number: AO-2017-044-SI-02
Who it affects: Qantas Airways Boeing 747 flight crew
Status: Adequately addressed
General details
Date: 07 April 2017   Investigation status: Completed  
Time: 0948 UTC   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): Hong Kong International Airport, SE 110 Km   Investigation phase: Final report: Dissemination  
State: International   Occurrence type: Stall warning  
Release date: 27 March 2019   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: Minor  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 747-438  
Aircraft registration VH-OJU  
Serial number 25566  
Operator Qantas Airways  
Type of operation Air Transport High Capacity  
Sector Jet  
Damage to aircraft Minor  
Departure point Melbourne, Vic.  
Destination Hong Kong, China  
Last update 27 March 2019