Safety Investigation Report 2018:3 Findings and Conclusion/3.1 Findings/3.1.7
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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)
3.1.7 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