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ASN Wikibase Occurrence # 194812
Last updated: 31 August 2019
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Date:07-APR-2017
Time:09:48 UTC
Type:Silhouette image of generic B744 model; specific model in this crash may look slightly different
Boeing 747-438
Owner/operator:Qantas
Registration: VH-OJU
C/n / msn: 25566/1239
Fatalities:Fatalities: 0 / Occupants: 364
Other fatalities:0
Aircraft damage: Minor
Category:Serious incident
Location:110 km SE of Hong Kong -
Phase: En route
Nature:International Scheduled Passenger
Departure airport:Melbourne-Tullamarine Airport, VIC (MEL/YMML)
Destination airport:Hong Kong-Chek Lap Kok International Airport (HKG/VHHH)
Investigating agency: ATSB
Narrative:
Qantas Airways flight QF29, a Boeing 747-438, was descending toward Hong Kong International Airport when 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.

Contributing factors:
- After overwriting the hold speed in the flight monitoring computer, the flight crew did not identify the need to re-evaluate the hold speed for the higher than expected hold level.
- Prior to entering the hold, the aircraft’s speed reduced below both the selected and minimum manoeuvring speeds. The crew did not identify that the aircraft was operating below these speeds.
- The reduced speed coincided with the turn to enter the holding pattern and the level capture.
These factors resulted in pre-aerodynamic stall buffeting and probable stick shaker activation.
- The pilot flying attempted to arrest the rate of descent prior to completing the approach to stall actions. The pilot monitoring did not identify and call out the incomplete approach to stall recovery actions. These combined actions led to pilot induced oscillations and further stick shaker activations.
- 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)
- The passenger in seat 63C was not wearing a seatbelt at the time of the stick shaker activations.

Sources:

http://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-044/
https://www.flightradar24.com/data/aircraft/vh-oju#cfac28c

Accident investigation:
cover
  
Investigating agency: ATSB
Status: Investigation completed
Duration: 1 year and 11 months
Download report: Final report


Images:

Photo of VH-OJU courtesy AirHistory.net


London - Heathrow (EGLL / LHR)
5 March 2012; (c) Mick Bajcar



graphical representation of recorded flight data from stick shaker incident significant points of the occurrence are annotated. Source: ATSB

Revision history:

Date/timeContributorUpdates
14-Apr-2017 07:07 harro Added
14-Apr-2017 07:41 harro Updated [Photo, ]
14-Apr-2017 08:26 harro Updated [Narrative]
27-Mar-2019 08:44 harro Updated [Time, Total occupants, Damage, Narrative, Photo, Accident report, ]

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