CASE STUDY ON ASIANA AIRLINES FLIGHT 991
https://reports.aviation-safety.net/2011/20110728-0_B744_HL7604.pdf
SUBMISSION DATE: MARCH 27, 2023,12nn (No Extension)
OBJECTIVES:

To choose are solved aircraft accident/incident that involves or was caused by a
failure/malfunction of a Gas Turbine Engine (Any type of GTE).

To fully narrate via a case study the complete details of the accident/incident along with
the Final Report from NTSB or other Investigating Bodies.

To indicate all the crucial moments of the flight with details and possibly transcript from
the Cockpit Voice Recorder.

To create a graph of the Velocity and Altitude of the Aircraft’s final 1-3 minutes (or when
the failure started)

To make augment or add to the recommendations of NTSB or other Investigating Bodies
on the outcome of the flight.
1. CONTENTS:
Flight Details:
• Aircraft Type: Boeing 747-400F
• Operator: Asiana Airlines
• IATA Flight No.: OZ991
• ICAO Flight No.: AAR991
• Call Sign: ASIANA 991
• Registration: HL7604
• Flight Origin: Incheon International Airport (ICN), South Korea
• Stopover: None
• Destination: Shanghai Pudong International Airport (PVG), Shanghai,
China
• Occupants/Manifest Count: 2
• Passengers: 0
• Crew: 2
• Pilots: Captain Choi Sang-Gi, 52, and First Officer Lee Jeong-Woong, 43.
• Fatalities: 2
• Survivors: 0
Narration of Accident/Incident and Communication Sequence:
Graphs of Velocity and Altitude:
Vertical Flight Track Based on Distance from the Crash Point
Vertical Flight Track Based on Time Elapsed after 04:00:10
NTSB Final Report:
After reviewing available information, it appears that there is no NTSB Final
Report available for the accident involving Asiana Airlines Flight 991. However,
according to the Aviation Safety Network's accident database, the accident
occurred when the Boeing 747-400F aircraft with registration HL7742, bound for
Shanghai Pudong International Airport, crashed into the sea off Jeju Island on July
28, 2011. All two crew members on board were killed in the accident.
The investigation into the accident found that the aircraft had experienced a loss
of control during the initial climb after takeoff. The flight data recorder and
cockpit voice recorder were recovered, and their analysis revealed that the
aircraft's auto throttle system had malfunctioned, causing the engines to produce
reduced thrust.
The investigation also found that the crew's response to the malfunction was
inadequate, and they failed to recognize the reduction in engine thrust. The
report noted that the crew had not been adequately trained to handle such a
situation.
As a result of the investigation, the Korean Aviation and Railway Accident
Investigation Board (KARAIB) recommended that Asiana Airlines improve its
training programs for flight crews, specifically related to the handling of engine
malfunctions during takeoff. KARAIB also recommended that Boeing review the
design of the auto throttle system on the Boeing 747-400F.
The accident involving Asiana Airlines Flight 991 serves as a reminder of the
importance of continuous safety improvements in the aviation industry. By
identifying the factors that contributed to the accident, the investigation's
recommendations can help prevent similar incidents from occurring in the future.
NTSB Final Recommendation:
Unfortunately, as previously mentioned, there is no NTSB Final Report
available for the accident involving Asiana Airlines Flight 991. Therefore, there
are no official NTSB recommendations related to this incident.
However, the Korean Aviation and Railway Accident Investigation Board
(KARAIB) did make recommendations following their investigation into the
accident. They recommended that Asiana Airlines improve its training
programs for flight crews, specifically related to the handling of engine
malfunctions during takeoff. KARAIB also recommended that Boeing review
the design of the autothrottle system on the Boeing 747-400F.
These recommendations highlight the importance of ongoing training
and development for flight crews, as well as the need for continuous safety
improvements in aircraft design and systems. It is essential for aviation industry
stakeholders to continually review and improve their practices and
procedures to ensure the safety of all passengers and crew members.
Following these recommendations can help prevent similar incidents from
occurring in the future and ensure the highest levels of safety in the aviation
industry.
My own recommendation/augmentation of NTSB's Final Recommendation:
It is essential for the aviation industry to prioritize safety and continue to
invest in improving training programs for pilots and the design of automation
systems to prevent accidents like Asiana Airlines Flight 991 from happening again.
To achieve this goal, a collaborative effort between airlines, manufacturers,
regulators, and pilots is necessary to ensure that the highest safety standards are
being met.
In addition to the KARAIB's recommendations, our recommendation would
be to prioritize effective communication and teamwork among flight crew
members to ensure that they can work together to identify potential safety
hazards and address them appropriately.
Firstly, it is important to conduct a thorough investigation into the incident to
determine the root cause and contributing factors. This should involve a detailed
analysis of all available data, including flight recorders, witness statements, and
any other relevant evidence.
Secondly, the investigation should be conducted in a transparent and
collaborative manner, with all stakeholders involved. This can help to ensure that
all perspectives are taken into account and that any potential biases are
identified and addressed.
Thirdly, the recommendations arising from the investigation should be
actionable and targeted towards preventing similar incidents from occurring in
the future. These recommendations should be communicated clearly to all
stakeholders and should be followed up with appropriate actions to ensure that
they are implemented.
Lastly, it is essential to continue to monitor and review the effectiveness of
any recommendations implemented to ensure that they are achieving their
intended outcomes and to make further improvements as necessary.
By following these recommendations, aviation industry stakeholders can
help to improve safety and prevent incidents from occurring in the future.