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ATSB issues report on in-flight upset involving Boeing 747-400
27 March 2019

ATSB issues report on in-flight upset involving Boeing 747-400

Following an ATSB investigation into an in-flight upset involving a Boeing 747-438 near Hong Kong in 2017, Qantas has incorporated more complex stall warning recovery events in recurrent lesson plans for its Boeing 747 flight crews.

The incident occurred in April 2017. While descending toward Hong Kong, air traffic control instructed the flight crew to hold at a waypoint. 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, some passengers and cabin crewmembers struck the cabin ceiling and furnishings, sustaining minor injuries.

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 flight level 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 led to further stall warning stick shaker activations and pilot induced oscillations, which resulted in minor injuries to four cabin crewmembers and two passengers.

The ATSB found the flight crew had limited training and guidance for stall warning recovery techniques at high altitude or with engine power above idle. Inconsistencies were also found in flight crew training of the awareness of the need to re-evaluate holding speed when there are changes in altitude, especially above flight level 200.

Subsequent to the incident, Qantas provided retraining for all Boeing 747 flight crews in stall warning recovery scenarios and amended ground school lesson plans to ensure flight crews were adequately prepared to recover from stall warning activations at high altitudes or with engine power above idle.

Qantas also amended flight crew training manuals relating to hold speed selection and updated ground school lesson plans and information to ensure standardised training and holding pattern training. In addition, Qantas proactively applied these measures across its Boeing 737 and 787 fleets.

U.S. announces Special Committee to review FAA’s aircraft certification process

The U.S. Department of Transportation announced the establishment of an expert Special Committee to review the procedures of the Federal Aviation Administration (FAA) for the certification of new aircraft, including the Boeing 737 MAX. Air Force General (Ret.) Darren McDew, former head of the U.S. Transportation Command, and Captain Lee Moak, former President of the Air Line Pilots Association, have agreed to serve as the interim co-chairs of the Special Committee pending the appointment of other members.

The Special Committee to Review FAA’s Aircraft Certification Process is an independent body whose findings and recommendations will be presented directly to the Secretary and the FAA Administrator. The Special Committee is being formed within the structure of the Safety Oversight and Certification Advisory Committee (SOCAC). The SOCAC will provide advice and recommendations on issues facing the aviation community related to the FAA’s safety oversight and certification programs and activities.

The SOCAC will be composed of individuals representing a diverse group of stakeholders in the aviation industry. The Department is soliciting candidates to be members of the SOCAC through the Federal Register.


FAA updates conflict zone Notam on Pakistan airspace

The U.S. Federal Aviation Administration updated the Conflict Zone Notam on Pakistani airspace, adding potential military activity due too heightened tensions in the Kashmir region.

Flynas passes IATA safety audit

Flynas passed the IATA Operational Safety Audit (IOSA).

Flynas is an Saudi Arabian low-cost airline. It started operating flights in 2007 and currently uses two Airbus A319s; 26 A320s and two A320neos on flights to destinations in Africa, Asia and Europe.

The IOSA programme is an evaluation system designed to assess the operational management and control systems of an airline. IOSA uses internationally recognised quality audit principles and is designed to conduct audits in a standardised and consistent manner. It was created in 2003 by IATA.  All IATA members are IOSA registered and must remain registered to maintain IATA membership.

More information:

Photo of a Flynas A320 (by Konstantin von Wedelstaedt)

List of accidents involving brand new passenger aircraft

This brand new (38 days; TT 202 hours) Boeing 737-800 crashed in September 2006

Two recent accident involving brand new Boeing 737 MAX aircraft caused a global grounding of the type over fears relating to a malfunctioning safety feature specific to the 737 MAX. How does the age of both aircraft relate to previous aircraft accidents?

Focussing on fatal aircraft accidents involving passenger flights, the ASN databases shows (for available data! *) that there was at least one aircraft that crashed within a month of having first flown. A Braniff Lockheed Electra crashed 25 days following its first flight and just 11 days after having been delivered to the airline. A subsequent accident in March 1960 under similar circumstances revealed an engine mount problem on the outboard engines that allowed propeller oscillations to be transmitted to the wings, resulting in a structural failure of the wing in flight. This finding led to operational speed restrictions of the aircraft before modifications were carried out.

Age (days) Date Aircraft type Operator Fatalities
25 1959-09-29 Lockheed L-188A Electra Braniff 34
34 1967-03-11 DHC-6 Twin Otter 100 Aeralpi 4
38 2006-09-29 Boeing 737-8EH Gol 154
52 1968-03-05 Boeing 707-328C Air France 63
69 1959-02-03 Lockheed L-188A Electra American Airlines 65
72 1960-01-19 Caravelle SAS 42
74 1961-09-23 Fokker F-27 Friendship THY 28
75 1968-04-20 Boeing 707-344C SAA 123
87 1948-01-30 Avro 688 Tudor 1 BSAA 31
90 1965-08-16 Boeing 727-22 United Airlines 30
91 2018-10-29 Boeing 737 MAX 8 Lion Air 189
94 1989-01-08 Boeing 737-4Y0 BMA 47
95 1968-11-23 DHC-6 Twin Otter 200 Cable Commuter 9
107 1961-09-17 Lockheed L-188C Electra Northwest 37
107 1962-07-19 DH-106 Comet 4C United Arab 26
118 1961-09-12 Caravelle III Air France 77
119 1962-06-22 Boeing 707-328 Air France 113
125 1977-09-08 DHC-6 Twin Otter 300 Burma Airways 25
126 1934-12-20 Douglas DC-2 KLM 7
131 2019-03-10 Boeing 737 MAX 8 Ethiopian Airlines 157

Looking at flight hours instead of age since first flight, the ASN databases shows (again, for available data! *):

Flight hours Date Aircraft type Operator Fatalities
19 1948-07-01 Fiat G.212PW ALI 8
35 1948-08-01 Latécoère 631 Air France 52
46 1968-03-05 Boeing 707-328C Air France 63
47 1926-08-18 Blériot 155 Air Union 4
51 1949-05-13 Ilyushin Il-12P Aeroflot 25
70 2002-12-23 Antonov An-140 Aeromist Kharkiv 44
92 1949-08-25 Ilyushin Il-12P Aeroflot 14
109 1960-02-26 Antonov An-10A Aeroflot 32
111 1971-05-23 Tupolev Tu-134A Aviogenex 78
111 1961-09-23 Fokker F-27 THY 28
113 1948-09-04 Lisunov Li-2 Aeroflot 6
124 1974-05-02 Yakovlev Yak-40 Aeroflot 1
124 1961-07-11 Douglas DC-8-12 United Airlines 17
128 1969-03-20 Ilyushin Il-18D United Arab 100
132 1959-09-29 Lockheed L-188A Electra Braniff 34
154 1963-04-04 Ilyushin Il-18 Aeroflot 67
164 1966-10-01 Douglas DC-9-14 West Coast Airlines 18
166 1947-12-18 Ilyushin Il-12P Aeroflot 7
188 1993-03-05 Fokker 100 Palair 83
202 2006-09-29 Boeing 737-8EH Gol 154

The LionAir Boeing 737 MAX 8 that crashed in 2018 had logged 895 flying hours; total hours for the Ethiopian aircraft has not yet been reported.

Important notes:

  • For 54% of all accidents the first flight date nor total aircraft time in flight hours are known. These lists can thus only be used as indicative.
  • For most Russian accidents just the aircraft’s flight hours are known, hence the over-representation of these accidens in the flight hours-table.

FAA extends flight prohibition for Libyan airspace, now allows overflight at FL300 and above

Tripoli FIR (HLLL)

Tripoli FIR (HLLL)

The U.S. Federal Aviation Administration (FAA) issued a new Notam, extending the flight prohibition for certain U.S. aircraft for the Libyan airspace by another two years to March 20, 2021.

This action extends the prohibition of U.S. civil flight operations in the Tripoli FIR (HLLL) at altitudes below Flight Level (FL) 300 to safeguard against continuing hazards to U.S. civil aviation. However, this action also reduces the scope of the prohibition, permitting U.S. civil aviation overflights of the Tripoli FIR (HLLL) at altitudes at and above FL300 to resume, due to the reduced risk to U.S. civil aviation operations at those altitudes.


List of global aircraft groundings in history

On March 13, 2019, all Boeing 737 MAX aircraft were temporarily grounded worldwide by relevant authorities and airlines. The MAX was not the first aircraft in aviation history to be grounded globally.

2019: Boeing 737 MAX
First aircraft in service: 2017
Grounding in effect: March 13, 2019 (some airlines and countries on March 11 and 12)
Regulatory action: FAA Emergency Order (other countries took own regulatory actions)
Grounding lifted: —
Reason for grounding: Fatal accidents involving Lion Air 601 and Ethiopian 302

2013: Boeing 787 Dreamliner
First aircraft in service: 2009
Grounding in effect: January 16, 2013
Regulatory action: Emergency AD
Grounding lifted: April 19, 2013
Reason for grounding: Two lithium ion battery failures on January 7 and January 16.

2000: Concorde
First aircraft in service: 1976
Grounding in effect: August 16, 2000
Regulatory action: Withdrawal of the Airworthiness Certificates of all Concordes
Grounding lifted: November 2001
Reason for grounding: Doubts about the fuel tank safety following the crash of Air France flight 4590.

1982: Yakovlev Yak-42
First aircraft in service: 1980
Grounding in effect: 1982
Regulatory action: unknown
Grounding lifted: October 1984
Reason for grounding: Design fault which caused horizontal stabiliser screw jack mechanism to fail on a Yak-42 on June 28, 1982, killing 132.

1979: McDonnell Douglas DC-10
First aircraft in service: 1971
Grounding in effect: June 6, 1979
Regulatory action: Emergency Order, suspending the Type Certificate
Grounding lifted: July 13, 1979 (June 19 for European airlines)
Reason for grounding: Doubt about the engine pylon assembly not meeting certification criteria following the crash of American Airlines flight 191 .

1954: de Havilland Comet
First aircraft in service: 1952
Grounding in effect: 1954
Regulatory action: Airworthiness Certificate was revoked
Grounding lifted: commercial flights resumed in 1958
Reason for grounding: Two in-flight break up accidents involving BOAC Flight 781 and South African Airways Flight 201.

1947: Douglas DC-6
First aircraft in service: 1947
Grounding in effect: November 11, 1947
Regulatory action:  Voluntary grounding by airlines
Grounding lifted: after four months
Reason for grounding: Grounding following a series of inflight fires including the fatal crash of United Airlines Flight 608 on Oct 24, 1947

1946: Lockheed Constellation
First aircraft in service: 1945
Grounding in effect: July 12, 1946
Regulatory action: Government Order
Grounding lifted: August 23, 1946
Reason for grounding: Grounding following fatal in-flight fire accident of TWA Flight 513 on July 11, 1946

FAA orders the temporary grounding of Boeing 737 MAX aircraft

The FAA is ordering the temporary grounding of Boeing 737 MAX aircraft operated by U.S. airlines or in U.S. territory.

Worldwide concerns over the observed similarities between two recent fatal Boeing 737 MAX accidents (Lion Air 601 and Ethiopian 302) led several countries and airlines to ground the aircraft on March 11 and March 12, 2019.

The FAA states that it received newly refined ADS-B satellite data on the morning of March 13. On the same day, the FAA was notified of “new information from the wreckage concerning the aircraft’s configuration just after takeoff that.” These pieces of evidence led the FAA to decide to issue an Emergency Order for the temporary grounding of the Boeing 737 MAX.

The grounding will remain in effect pending further investigation, including examination of information from the aircraft’s flight data recorders and cockpit voice recorders.


Boeing 737 MAX grounded in several countries following Ethiopian crash

Several countries/airlines have grounded the Boeing 737 MAX as a safety precaution in the wake of the fatal accident involving Ethiopian Airlines flight 302, the second loss of the type after the crash of Lion Air flight 610.


Countries (grounding their operators’ 737 MAX aircraft)

Countries (banning 737 MAX from their airspace)

List of aircraft safely stopped by EMAS during runway overrun incidents


An engineered materials arresting system (EMAS), or arrester bed, is an area at the end of a runway that is created to reduce the severity of the consequences of a runway excursion. The purpose of an EMAS is to stop an aircraft overrun with no human injury and minimal aircraft damage. The aircraft is slowed by the loss of energy required to crush the EMAS material, which usually consists of lightweight, crushable concrete blocks.

The EMAS is predominantly used in the United States. It is installed at 106+ runway ends at 63+ airports, according to the FAA.

List of aircraft safely stopped by EMAS

8 May 1999
A Saab 340 commuter aircraft overran the runway at New York-JFK Airport, NY (30 on board)

30 May 2003
A Gemini Cargo MD-11 overran the runway at New York-JFK Airport, NY (3 on board)

22 January 2005
A Boeing 747 overran the runway at New York-JFK Airport, NY (3 on board)

17 July 2006
A Dassault Falcon 900 overran the runway at Greenville Downtown Airport, SC (5 on board)

19 July 2008
An Airbus A320 overran the runway at Chicago O’Hare Airport, IL (145 on board)

19 January 2010
A CRJ-200 regional jet overran the runway at Charleston-Yeager Airport, WV (34 on board)

1 October 2010
A Gulfstream IV overran the runway at Teterboro Airport, NJ (10 on board)

3 November 2011
A Cessna Citation II overran the runway at Key West International Airport, FL (5 on board)

27 October 2013
A Cessna 680 Citation overran the runway at Palm Beach International, FL (8 on board)

26 January 2016
A Dassault Falcon 20 overran the runway at Chicago Executive Airport, IL (2 on board)

27 October 2016
A Boeing 737-700 overran the runway at New York-LaGuardia Airport, NY (37 on board)

30 April 2017
A Cessna 750 Citation overran the runway at Burbank Airport, CA (2 on board)

4 February 2018
A Beechjet 400A overran the runway at Burke Lakefront Airport in Cleveland, OH (4 on board)

6 December 2018
A Boeing 737-700 overran the runway at Hollywood Burbank Airport, CA (117 on board)

27 February 2019
A Phenom 100 overran the runway at Downtown Airport in Kansas City, MO

Cessna 550 Citation II overran into the EMAS at Key West International Airport in 2011