Safety Investigation Report 2018:3 Findings and Conclusion/3.1 Findings
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SAFETY INVESTIGATION REPORT
Safety Investigation Report MH370/01/2018
This page contains an extract from the Safety Investigation Report MH370/01/2018 and Appendices released by The Malaysian ICAO Annex 13 Safety Investigation Team for MH370, and dated 2 July 2018.
SAFETY INVESTIGATION REPORT
MH370 (9M-MRO)
3.1 Findings
3.1.1 Diversion from Filed Flight Plan Route
- 1) Flight MH370 had diverted from the Filed Flight Plan route.
- 2) There is no evidence to indicate that MH370 was evading radar.
- 3) Only the transponder signal of MH370 disappeared from the ATC Controller radar display whilst the (radar) position symbols from other aircraft were still available.
- 4) The reason for the transponder information disappearing from the aircraft could not be established.
- 5) It could not be established whether the aircraft was flown by anyone other than the pilots.
- 6) The reconstruction flight conducted on the B777 flight simulator had established that the turn back was likely made while the aircraft was under manual control and not the autopilot. However, it could not be established that the other two turns over the south of Penang and the north of MEKAR were made under manual control or autopilot.
- 7) The aircraft primary radar target was designated as ‘friendly’ by the Royal Malaysian Air Force as it did not pose any threat to national airspace security, integrity and sovereignty.
- 8) There were uncertainties on the position of MH370 by both Kuala Lumpur ACC and Ho Chi Minh ACC.
Comments and Notes
3.1.2 Air Traffic Services Operations
- 1) Kuala Lumpur Air Traffic Services
- a) KL ATSC operation was normal with no significant observation until 1720 UTC [0120 MYT].
- b) KL ACC controllers transferred MH370 to Ho Chi Minh ACC at 1719:26 UTC, 3 minutes before the original estimate time of the transfer of the control point.
- c) HCM ACC did not notify KL ACC when two-way communication was not established with MH370 within five minutes of the estimated time for the transfer of control point.
- d) KL ACC controllers relied solely on position information of the aircraft provided by MAS Flight Operations Despatch Centre rather than checking up with other ATC authorities.
- e) The Air Traffic controllers did not initiate, in a timely manner, the three standard emergency phases in accordance with the standard operating procedures.
- f) There is no record to suggest that the KL ACC controllers took any action to alert the RMAF Joint Air Traffic Control Centre (JATCC).
- g) There is no evidence to suggest that the Air Traffic controllers at KL ACC had kept continuous watch on the radar display.
- h) KL ACC controllers did not comply fully with established ATC procedures.
- 2) Ho Chi Minh Air Traffic Services
- a) There were uncertainties on the position of MH370 by both KL ACC and HCM ACC.
- b) The command of the English language in the coordination process between KL ACC and HCM ACC needs improvement.
- c) HCM ACC did not notify KL ACC when two-way communication was not established with MH370 within five (5) minutes of the estimated time for the transfer of control point.
Comments and Notes
3.1.3 Flight Crew Profile
- 1) General and Specific Human Factors Issues
- a) There is no evidence to suggest any recent behavioural changes for the PIC, FO and cabin crew.
- b) There is no evidence to suggest a pattern of regular over-the-counter medication purchase by the PIC. However, the possibility that such medication may have been purchased by cash cannot be excluded.
- 2) Human Factor Aspects of Air Traffic Control Recordings
- a) The voice transmission for the first 3 sets of recordings were those of the FO before take-off and the 4th and 5th sets were from the PIC after take-off.
- b) The last radio transmission “Good Night Malaysian Three Seven Zero” was spoken by the PIC. However, he did not readback the assigned frequency, which was inconsistent with radio-telephony procedures.
- c) The radio-telephony communications conducted by the PIC and the FO with the Air Traffic Controllers revealed no evidence of anxiety or stress detected in the conversations.
3.1.4 Airworthiness & Maintenance and Aircraft Systems
- 1) The maintenance records indicated that the aircraft was equipped and maintained in accordance with existing regulations and approved procedures, except for the instance of the Solid-state Flight Data Recorder Underwater Locating Beacon (SSFDR ULB) battery which had expired in December 2012.
- 2) The aircraft had a valid Certificate of Airworthiness.
- 3) The aircraft was airworthy when dispatched for the flight.
- 4) The mass and the centre of gravity of the aircraft were within the prescribed limits.
- 5) Although it cannot be conclusively ruled out that an aircraft or system malfunction was a cause, based on the limited evidence available, it is more likely that the loss of communication (VHF and HF communications, ACARS, SATCOM and Transponder) prior to the diversion is due to the systems being manually turned off or power interrupted to them or additionally in the case of VHF and HF, not used, whether with intent or otherwise.
- 6) The recorded changes in the aircraft flight path following waypoint IGARI, heading back across Peninsular Malaysia, turning south of Penang to the north-west and a subsequent turn towards the Southern Indian Ocean are difficult to attribute to any specific aircraft system failures. It is more likely that such manoeuvres are due to the systems being manipulated.
- 7) The SATCOM data indicated that the aircraft was airborne for more than 7 hours suggesting that the autopilot was probably functioning, at least in the basic modes, for the aircraft to be flown for such a long duration. This in turn suggests that the air and inertial data were probably available to the autopilot system and/or the crew.
- 8) The inter-dependency of operation of the various aircraft systems suggests that significant parts of the aircraft electrical power system were likely to be functioning throughout the flight.
- 9) Without the benefit of the examination of the aircraft wreckage and recorded flight data information, the investigation is unable to determine any plausible aircraft or systems failure mode that would lead to the observed systems deactivation, diversion from the filed flight plan route and the subsequent flight path taken by the aircraft.
- 10) No Emergency Locator Transmitter (ELT) signal from the aircraft was reported by the responsible Search and Rescue agencies or any other aircraft.
Comments and Notes
3.1.5 Satellite Communications
- 1) Throughout the flight of MH370 the aircraft communicated through the Inmarsat Indian Ocean Region (IOR) I-3 Satellite and the Ground Earth Station (GES) in Perth, Australia.
- 2) At 1707 UTC (07 March 2014), the SATCOM system was used to send a standard ACARS report, normally sent at every 30 minutes. The ACARS reports expected at 1737 UTC and subsequently were not received. The next SATCOM communication was a log-on request from the aircraft at 1825 UTC, followed by two IFE Data-3 channel setups. From that point until 0011 UTC (08 March 2014), SATCOM transmissions indicate that the link was available, although not used for any voice, ACARS or other data services apart from two unanswered ground-to-air telephone calls. At 0019 UTC, the Airborne Earth Station (AES) initiated another log-on request. This was the last SATCOM transmission received from the AES.
- 3) Data from the last seven ‘handshakes’ were used to help establish the most probable location of the aircraft. Both the initial log-on request and the hourly ping have been termed as a ‘handshake'. Two unanswered ground-to-air telephone calls at 1839 and 2313 UTC (07 March 2014) had the effect of resetting the activity log and hence increased the period between the ground initiated ‘handshakes’.
- 4) The two Log-Ons, at 1825 UTC (07 March 2014) and 0019 UTC (08 March 2014), were initiated by the aircraft most likely due to power interruptions to the SATCOM avionics.
- 5) The power interruption leading up to 1825 UTC was probably due to power bus cycling, the reason for it being unknown. The power interruption leading up to 0019 UTC was probably due to low fuel at this time resulting in the loss of both engines and their respective generators. There was probably enough fuel for the APU to start up and run long enough for its generator to power the SATCOM avionics (SATCOM AES) to initiate a log-on request.
Comments and Notes
3.1.6 Wreckage and Impact Information
- 1) The main wreckage belonging to MH370 has so far not been found. However, a number of debris were found washed ashore near and onto the south eastern coast of Africa.
- 2) Only the parts washed ashore on La Reunion Island (the right flaperon), Tanzania (part of the right outboard flap) and Mauritius (a section of the left outboard flap) were confirmed to be from MH370. Although the name plate was missing, which could have provided immediate traceability to the accident aircraft, the flaperon was confirmed to be from the aircraft 9M-MRO, by tracing the identification numbers of the internal parts of the flaperon to their manufacturing records at EADS, CASA, Spain. Similarly, the Italian part manufacturer build records for the numbers located on the right outboard flap part confirmed that all of the numbers related to the same serial number outboard flap shipped to Boeing for aircraft 9M-MRO. As for the section of the left outboard flap, a part identifier on it matched the flap manufacturer supplied records which indicated a unique work order number and that the referred part was incorporated into the outboard flap shipset line 404 which corresponded to the Boeing 777 aircraft line number 404, registered 9M-MRO and operating as MH370.
- 3) To date, 27 items of debris were considered significant for examination. Of these, other than the flaperon, a part of the right outboard flap and a section of the left outboard flap, 7 items were also considered almost certain to be from MH370.
- 4) Damage examination on the recovered part of the right outboard flap, together with the damage found on the right flaperon indicates that the right outboard flap was most likely in the retracted position and the right flaperon was probably at, or close to, the neutral position, at the time they separated from the wing.
- 5) Recovery of the cabin interior debris suggests that the aircraft was likely to have broken up. However, there is insufficient information to determine if the aircraft broke up in the air or during impact with the ocean.
Comments and Notes
3.1.7 Organisational and Management Information
- 1) Department of Civil Aviation
- a) The regulatory system in Malaysia includes Regulation 201 of MCAR 1996 that applies ICAO Annex 1 to 18 “ipso facto”. However, the resulting regulatory framework under this “ipso facto” regulation in Malaysia does not enable an effective implementation of all ICAO Annex provisions. With the introduction of Annex 19 dedicated to a Safety Management System, applicability date 14 November 2013, the “ipso facto” provision does not include Annex 19.
- b) DCA is looking into the establishment of a State Safety Programme (SSP) for the management of safety in the State that will be applicable on 07 November 2019.
- c) The organisation structure is suitable for DCA at headquarters as the activities are routine and standardised.
- d) On Search and Rescue, there is a comprehensive arrangement in dealing with an aircraft emergency between Malaysia and neighbouring States which requires the provision of A-SAR services on a 24-hours daily basis fulfilling the international obligations.
- e) Kuala Lumpur Air Traffic Control Centre
- i) DCA has a policy of retaining retiring ATCOs on a contract basis to ensure that the number of qualified and rated Controllers remains status quo and that there is a transfer of technology, experience and expertise.
- ii) Although no internal audit had been conducted, it is noted that an audit team will be established consisting of personnel who had previously attended audit courses.
- iii) All ATC training courses were conducted on operational and opportunity basis.
- 2) Malaysia Airlines
- a) Engineering & Maintenance
- i) The Engineering & Maintenance Division was a well-structured maintenance management and maintenance organisation with key positions manned by persons approved by the Department of Civil Aviation (DCA), Malaysia.
- ii) Proper oversight was provided both by internal and external audits. There were no significant audit findings.
- iii) Maintenance personnel were appropriately trained and qualified in accordance with approved procedures.
- b) Flight Operations
- i) There is no evidence of irregularities of both the pilots in terms of their capability, performance and standard to assume command of a B777 and as First Officer respectively prior to the disappearance of MH370.
- ii) There is no evidence of irregularities in terms of Medical & Licencing Validity of both the pilots prior to the disappearance of MH370.
- iii) There is no evidence of irregularities in Roster Schedule and Management.
- iv) The findings of LOSA were very relevant and recommendations were implemented via a Safety Change Process (SCP). MAS had met the average safety standards of most international airlines.
- v) Both the Technical Crew & Cabin Crew were in compliance with CRM requirements.
- vi) During the period of the incident there was no enhanced special security alert status declared by MAS.
- vii) there were no training records available for the FO from the beginning of his simulator training and initial operating experience (IOE) to his present fleet where he was still under training. All the training reports were with him in his personal training file on board the flight.
- viii) Based on past training records, there is no evidence that both the pilots’ performance was below the Company’s standard since their employment with MAS.
- ix) The duration of the scheduled flight with Flight Duty Period (FDP) of less than 8 hours and the training policy justify the 2- man crew operations.
- x) An element of overworked condition in the MAS Operation Control Centre existed.
- xi) The displayed aircraft position on the Flight-Following System was erroneous right from the point where ACARS communication was lost.
- xii) No irregularities were found in the fuel computation and fuel flight plan.
- xiii)No irregularities were found in the aircraft flight plan.
- xiv) The cabin crew were subjected to thorough medical check-ups as a requirement during the initial recruitment before employment and neither the Company nor the Regulatory body made it a requirement after being employed. However, there was no strict monitoring on the crew’s health and mental health in the Standard Operating Procedures (SOP).
- xv) The flight departed within the legal minimum cabin crew requirement.
- a) Engineering & Maintenance
Comments and Notes
3.1.8 Aircraft Cargo Consignment (Lithium Ion Batteries and Mangosteen Fruits)
- 1) The two cargo items in question which were carried on MH370 had also been transported via scheduled flights on MAS before and after the event.
- 2) The Lithium ion batteries (listed as non-dangerous goods), were packed and land-transported out from the production factory to KLIA Sepang in accordance with existing and approved regulations and procedures.
- 3) Extensive tests conducted on the mangosteens packed with water-soaked foam and juice extracts of mangosteens in contact with Lithium ion batteries revealed that this could only be hazardous if exposed to a certain extreme condition and over a long period of time. This was highly improbable on board MH370 which had a comparatively shorter duration of flight time and was under controlled conditions.
- 4) There was no cargo classified as dangerous goods on board MH370. The batteries on board were not classified as Dangerous Goods because the packing adhered to the guidelines as stipulated in the Lithium Battery Guidance Document.
Comments and Notes