The ATSB final report has now been issued.
Investigation: AO-2017-044 - In-flight upset involving Boeing 747-438, VH-OJU, 110 km SE of Hong Kong Airport, on 7 April 2017
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.
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.