B744, en-route, southeast of Hong Kong SAR China, 2017

B744, en-route, southeast of Hong Kong SAR China, 2017

Summary

On 7 April 2017, a Boeing 747-400 crew did not adjust planned speed at an anticipated holding point when the level given was higher than expected. As a consequence of this and distraction, as the new holding level was approached and the turn began, stall buffet, several stick shaker activations and pilot-induced oscillations occurred when the crew failed to follow the applicable stall warning recovery procedure. Descent below the cleared level occurred and the upset caused injuries in the passenger cabin. Whilst attributing the event to poor crew performance, the Investigation also concluded that related operator pilot training was inadequate.

Description

On 7 April 2017, when a Boeing 747-400 (VH-OJU) being operated by Qantas Airways on a scheduled international passenger flight from Melbourne to Hong Kong with an augmenting crew member present on the flight deck entered a holding pattern part way through descent in day VMC, a series of stall protection system activations occurred during an upset involving multiple oscillations in pitch and vertical acceleration. During this upset, four of the cabin crew and two unsecured passengers sustained minor injuries after striking the cabin ceiling and furnishings. A series of toilet smoke warnings which began immediately after the upset were confirmed to be false and were later attributed to damage to the toilet cubicle which had occurred during the event.

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