MALAYSIA AIRLINES MH370 - DISSECTION OF MALAYSIAN GOVERNMENT SAFETY INVESTIGATION REPORT From 445 pa
I've finally finished carving through the Malaysian Government's SAFETY INVESTIGATION REPORT into MH370.
I've copied and pasted items of particular note or concern. There are some rather scathing and critical observations made by the Investigation Team, and whilst they are not out to apportion blame to anyone, they are certainly not shy in coming forward and highlighting the numerous deficiencies in the ATC systems and general operations of March 08 2014. It is pleasing to note the the Crew all received a clear bill-of-health and exonerated of any responsibility or negligence involved in the case of Malaysia Airlines MH370. But, as I say - the ATC operations of Malaysia and Vietnam both came under heavy attack, and it was easy to see why. You couldn't have done a poorer job and been less prepared for MH370 than what these control centers did - or didn't do, as the case may be.
Of particular interest to me was how the ATSB Final Report at the end of 2017 had a large appendix devoted to images and descriptions of marine life which were alleged to have been covering some of the parts of wreckage which were recovered. It was a thick addition to the main report. But, in the Malaysian Government Report, the marine life gets minimal mention. Probably because things were rather skewered in that department from the very beginning.
[My comments below are within brackets.]
THE MALAYSIAN ICAO ANNEX 13 SAFETY INVESTIGATION TEAM FOR MH370
ANALYSIS OF MALAYSIA AIRLINES MH370/MAS370/9M-MRO REPORT
PREPARED BY DECLAN CURRAN
AUGUST 12 2018
The PIC, an authorised examiner for the Department of Civil Aviation (DCA), Malaysia, was conducting the last phase of line training for the FO, who was transitioning to the Boeing 777 (B777) aircraft type from the Airbus A330. As the FO was certified functional during his last line training flight, no additional pilot was required as safety pilot on MH370. It has been established that the PIC had assigned the FO to be the Pilot Flying for this flight.
1.1.2 Actions by HCM ACC and KL ACC
Kuala Lumpur Aeronautical Rescue Coordination Centre (KL ARCC) was activated at 2130 UTC [0530 MYT]. There is no evidence to show HCM ACC activated its Rescue Coordination Centre.
1.1.3 Diversion from Filed Flight Plan Route
1) Malaysian Military Radar
The Military radar data provided more extensive details of what was termed as “Air Turn Back”. It became very apparent, however, that the recorded altitude and speed change “blip” to “blip” were well beyond the capability of the aircraft. It was highlighted to the Team that the altitude and speed extracted from the data are subjected to inherent error. The only useful information obtained from the Military radar was the latitude and longitude position of the aircraft as this data is reasonably accurate.
At 1721:13 UTC [0121:13 MYT] the Military radar showed the radar return of MH370 turning right but shortly after, making a constant left turn to heading of 273°, flying parallel to Airway M765 to VKB (Kota Bharu).
The Military data further identified the “blip” on a heading of 239° at 1737:59 UTC [0137:59 MYT] parallel to Airway B219 towards VPG (VOR Penang). Heading of this “blip” varied from 239° to 255° at a speed from 532 to 571 kt. The height of this “blip” was recorded between 24,450 ft and 47,500 ft.
[Exceeds maximum ceiling parameters.]
At 1752:31 UTC [0152:31 MYT] the “blip” was observed to be at 10 nm south of Penang Island on a heading of 261°, speed of 525 kt and at a height of 44,700 ft.
At 1801:59 UTC [0201:59 MYT] the data showed the “blip” on a heading of 022°, speed of 492 kt and altitude at 4,800 ft. This is supported by the “blip” detected by Military radar in the area of Pulau Perak at altitude 4,800 ft at 1801:59 UTC [0201:59 MYT]. At 1803:09 UTC [0203:09 MYT] the “blip” disappeared, only to reappear at 1815:25 UTC [0215:25 MYT] until 1822:12 UTC [0222:12 MYT], about 195 nm from Butterworth, on a heading of 285°, speed of 516 kt and at an altitude of 29,500 ft.
It was also noted that, in the absence of autopilot or continuous manual control, an aircraft is very unlikely to maintain straight and level flight. Further, it is extremely unlikely for an aircraft to enter and maintain a turn and then return to straight and level flight for any significant period of time.
3) Ho Chi Minh Air Traffic Services
A visit was made to the office of the Vietnamese Civil Aviation Authority (CAAV) in Ho Chi Minh City on 10 September 2014. In interviews, the Duty HCM Duty ACC Controller who was handling MH370 on that night could not explain why he did not initiate any call to MH370 within the standard 5 minutes as specified in the Letter of Agreement (LOA) between Department of Civil Aviation Malaysia and Viet Nam Air Traffic Management dated 07 July 2001 and effective on 01 November 2001 (Refer Appendix 1.1A - Letter of Agreement between DCA Malaysia and Viet Nam). It was noted that he had only initiated an enquiry on the whereabouts of MH370 at 1739:03 UTC [0139:03 MYT] after a lapse of 12 minutes.
The Duty Controller however had stated that he had initiated calls to other aircraft on the existing frequency and on the emergency frequency of 121.5 MHz. This was neither supported nor collaborated by any documents.
The landline recorded transcripts between KL ACC and HCM ACC suggested that there were confusions on the position of MH370. This was evident when HCM ACC requested KL ACC for information on MH370 at 1739:06 UTC [0139:06 MYT]. This conversation took place:
KL ACC: “MH370 already transferred to you rite?”
HCM ACC: “Yeah…yeah…I know at time two zero but we have no just about in contact up to BITOD…we have radar lost with him…the one we have to track identified via radar.”
When pointed out that neither HCM ACC SSR nor ADS-B showed any presence of a “blip” of MH370, the Duty Controller could not explain why he mentioned BITOD.
The DETRESFA was only declared at 2232 UTC [0632 MYT]. Refer to para. 2.2.7 Table 2.2C, No. 26-28 - Chronology of ATC Events following the Disappearance of MH370; and to para. 2.2.8 1) o) - Activation of Aeronautical Rescue Coordination Centre, for details.
[This is 5 HOURS AFTER MH370 last made contact!]
Based on interviews, HCM ACC had stated that it did not initiate any emergency actions as it did not receive any change of the transfer of control time of IGARI, MH370 did not contact the Centre at the stated time, and it was unable to establish radio communication with MH370.
MH370 was also operating in the airspace delegated to KL ACC and the last air-ground radio contact was with KL ACC. Hence the provision of alerting service for MH370 rests with KL ACC.
These uncertainties were further compounded by the Duty Despatcher, based on MAS Flight Following System (FFS), who mentioned that the aircraft was over the Cambodian airspace[?????] when in fact the filed flight plan routing did not include flying over the Cambodian airspace.
5) Medan Air Traffic Control Radar
The Indonesian Military however stated that they picked up MH370 earlier as it was heading towards waypoint IGARI.
[Yet they did NOTHING! They claimed that it was deemed ‘friendly’ and intimated it was MH370]
6) Bangkok Air Traffic Control Radar
The radar position symbol with SSR transponder code A2157 was detected on the Aeronautical Radio of Thailand Limited (AEROTHAI) radar display at 1711 UTC [0111 MYT] as the aircraft was tracking for waypoint IGARI.
As the flight plan of MH370 did not fall under the purview of Thailand’s FIR, Bangkok ACC did not pay attention to this flight. On playback of the radar recording it was noted that the radar position symbol of A2157 disappeared at 1721:13 UTC [0121:13 MYT]. [!!!!!!]
7) Singapore Air Traffic Services
ii) At 2104:00 UTC [0504:00 MYT], Singapore ACC received a call from Hong Kong ACC enquiring any knowledge of a missing Malaysian aircraft MH370. Hong Kong ACC then requested assistance from
Singapore ACC to contact Lumpur ACC for detailed information. It was evident that Singapore ACC was not aware of the problem until this call was received. Hong Kong ACC however had the knowledge of the missing Aircraft earlier after receiving unconfirmed information from HCM ACC;
1.1.4 Role of Malaysian Military
On the day of the disappearance of MH370, the Military radar system recognised the ‘blip’ that appeared west after the left turn over IGARI was that of MH370. Even with the loss of SSR data, the Military long range air defence radar with Primary Surveillance Radar (PSR) capabilities affirmed that it was MH370 based on its track behaviour, characteristics and constant/continuous track pattern/trend. Therefore, the Military did not pursue to intercept the aircraft since it was ‘friendly’ and did not pose any threat to national airspace security, integrity and sovereignty.
1.1.5 Detection of Hand Phone Signal
A Telco service provider in an interview with the RMP confirmed a signal “hit” occurred at 0152:27 MYT on 08 March 2014, coming from the mobile phone tower (LBS Location Base station) at Bandar Baru Farlim Penang. The signal “hit” however did not record any communication except to confirm that it was in the ON mode signal related to the “hit”. The phone number xxxxxxx was later traced to that registered under the F.O. This was supported by the RMP’s report.
In summary, during the tests, it was found that it was difficult to maintain successful call connectivity above 8,000 ft. However, one brand of phone was able to make a call at 20,000 ft. Only one cell phone service provider recorded the highest call attempts using their 3G network above 8,000 ft. Two service providers could only provide connection below 8,000 ft.
The Telco service provider expert cautioned the Team that the tests would be difficult to conclude and use as scientific/theoretical assumptions for the case of MH370, as the measurement results were only valid for that specific time, flight path, speed, altitude, devices used, and environment during the tests.
Royal Malaysia Police’s Report on Flight Simulator of PIC
The Royal Malaysia Police (RMP) seized the PIC’s home flight simulator from the residence of the PIC on 15 March 2014.
The RMP Forensic Report dated 19 May 2014 documented more than 2,700 coordinates retrieved from separate file fragments and most of them are default game coordinates.
The RMP Forensic Report concluded that there were no unusual activities other than game-related flight simulations.
SECTION 1 – FACTUAL INFORMATION
1.6 AIRCRAFT INFORMATION
1.6.1 Airframe
Manufacturer Boeing Company
Model 777-2H6ER
Serial Number 28420
Manufacturer’s Line No. 404
Variable No. WB175
Registration 9M-MRO
Date of manufacture 29 May 2002
Date of delivery to MAS Delivered new on 31 May 2002
Certificate of Airworthiness M.0938 valid to 02 June 2014
Certificate of registration M.1124 issued 23 August 2006. Replacement of Certificate issued on 17 June 2002
Last Maintenance check
A1 Check on 23 February 2014 at 53,301:17 hours and 7,494 cycles
Total airframe hours/cycles
53,471.6 hours/7,526 cycles (as of 07 March 2014)
1.6.2 Engine
Manufacturer Rolls-Royce
Model RB211 Trent 892B-17
Engine 1 (Left) Serial Number 51463
Date of Construction November 2004
Date Installed 08 May 2013
Last Shop Visit 06 September 2010 to 21 November 2010
Time in Service 40,779 hours, 5,574 cycles (as of 07 March 2014)
Engine 2 (Right) Serial Number 51462
Date of Construction October 2004
Date Installed 15 June 2010
Last Shop Visit 05 February 2010 to 14 April 2010
Time in Service 40,046 hours, 5,508 cycles (as of 07 March 2014)
[These dates don’t seem to make sense. They would indicate that there were other engines fitted prior to these, yet no mention is made to any other engines. Furthermore, Engine 1 was not installed until 9 YEARS later; likewise with engine 2, which had a period of 6 YEARS! Was it fitted to another airframe prior to it being attached to 9M-MRO? This is one aspect of the report where they have alluded to providing ALL the history, which seems faultless in other areas of their report.]
3) Cabin Configuration Change
The fleet of B777 of MAS went through a cabin interior retrofit programme which converted the configuration from 12 First Class seats/33 Business Class seats/233 Economy Class seats to 35 Business Class and 247 Economy Class seats. On 9M-MRO, this re-configuration started on 17 August 2006 and was completed on 08 September 2006. The modification was approved under FAA Supplemental Type Certificate (STC) No. STO1493SE dated 24 January 2005 and DCA’s SOC No. SC2004/98. [Noted due to the plated out window which was observed in photos of forward RHS fuselage, at the Donesk crash site of 9M-MRD. This could be vital information in cross-referencing the two cases.]
8) Engine Health Monitoring
The ACMS will also generate other pre-defined engine reports including engine parameters’ exceedance reports. However, no such EHM reports were received during the flight. Position reports are also transmitted, via ACARS, every 30 minutes.
9) Central Maintenance Computing System
The traffic log of maintenance messages transmitted for the last 10 flights on 9M-MRO were reviewed. There were messages transmitted, indicating that the CMCS was functioning prior to the occurrence flight. However, no maintenance messages were transmitted during the occurrence flight. These messages are transmitted in real time that is, as the faults occur.
1.6.7 Emergency Locator Transmitter
The Fixed and Portable ELT radio beacons interface worldwide with the international Cospas-Sarsat satellite system for Search and Rescue (SAR). When activated and under satellite coverage, such beacons send out a distress signal which can be detected by satellites. The satellite receivers send this information to ground stations. This signal is transmitted to Mission Control Centres (MCC) located in six regions worldwide. The MCC covering the Indian Ocean is managed by the Australian Maritime Safety Authority based in Canberra, Australia.
No relevant ELT beacon signals from the aircraft were reported from the responsible Search and Rescue agencies or any other aircraft.
3) Electrical Power
As the various aircraft systems rely on electrical power, failure of the electrical buses will affect the systems operation which will in turn trigger the corresponding fault messages. These messages are collected by the CMCS which will transmit the messages, via the ACARS, to the Maintenance Control Centre (MCC).
Earlier in the report it was claimed no fault/error message were transmitted.
h) Backup Generators
Each backup generator contains two permanent magnet generators (PMGs) that supply power to the flight control DC electrical system (refer to DC Electrical System). If both IDGs and the APU generator are inoperative, a backup generator powers essential aircraft equipment. To reduce electrical loading on the backup generator, the following systems are inoperative:
•TCAS
•SATCOM
• Right HF radio
c) Flight Management System
The basis of the flight management system is the flight management computer function. Under normal conditions, one Flight Management Computer (FMC) accomplishes the flight management tasks while the other FMC monitors. The second FMC is ready to replace the first FMC if system faults occur.
[Field – I know you are fully conversant with these systems, and I include them merely for the purposes of the uneducated – such as myself!]
Crew Procedure on the operations and programming of the Flight Management System safeguards and protects against incorrect execution of erroneous Information for the Navigation and Performance Data Input. Different levels of verification and cross checking between the Captain and Co-Pilot ensure that any error would be captured and corrected during the crew preparation.
In addition, system logics will also prevent the crew against selection of the wrong co-ordinates from the stored Navigation Database if a particular waypoint code happens to be used by many different places worldwide.
14) Auxiliary Power Unit
The APU generator supplies 120 KVA electrical power at any altitude. The APU can start at all altitudes up to the service ceiling of the aircraft (43,100 ft/13,100 m). Electrical power is available up to the service ceiling and pneumatic power is available up to 22,000 ft (6,700 m).
1.6.9 Aircraft Performance
The satellite data provided evidence that the satellite was in communication with the aircraft until the last transmission at time 0019:29.42 UTC, approximately 7 hours and 37 minutes after take-off from KUL. Refer to Section 1.9.5.
The performance range capability of the aircraft, along with the satellite data, allowed for the creation of multiple flight path profiles that demonstrate that the aircraft had the range capability to reach the 7th Arc.
Many assumptions were also made during the flight path profile creation, including but not limited to, constant altitude and constant speed from Arc 1 to Arc 7, with the restriction that there were no course changes between the arcs. Additional analyses were conducted in Boeing and MAS simulators that continued the analysis after fuel exhaustion and assumed no intervention in the cockpit.
The results of the simulator session showed that the aircraft would roll gently to the left due to residual rudder deflection commanded by the Thrust Asymmetry Compensation (TAC) with the end of flight occurring within a 100 nm2 box that extended 10 nm beyond fuel exhaustion and 10 nm to the left of the flight path. The maximum range after dual engine flame-out would have been achieved through driftdown, with manual control keeping the aircraft in wings level flight, and would extend the range of the aircraft by approximately 120 nm beyond the location of the dual engine flame-out. [Not really relevant here since the aircraft landed on Diego Garcia (FJDG).]
1.6.10 Boeing Patent on Remote Control Take-over of Aircraft
There have been speculations that MH370 could have been taken over control remotely in order to foil a hijack attempt. Some of these speculations have mentioned a US patent that Boeing filed for in February 2003 and received (US 7,142,971 B2) in November 2006 for a system that, once activated, would remove all controls from pilots and automatically fly and land the aircraft at a predetermined location.
According to the patent, existing preventative measures such as bullet-proof doors and the carriage of air marshals on board may have vulnerabilities. The flight crew could decide to open a lockable bullet-proof cockpit door [refer to Section 1.6.8, para. 4)] and air marshals, if used, might be over-powered. In light of the potential that unauthorised persons might be able to access the flight controls of an aircraft, the inventors conceived of a technique to avoid this risk by removing any form of human decision process that may be influenced by the circumstances of the situation, including threats or violence on-board.
The ‘uninterruptible’ autopilot envisioned by the patent could be activated, either by pilots, on-board sensors or remotely via radio or satellite links by the airline or government agencies if there were attempts to forcibly gain control of the cockpit. This system once activated would disallow pilot inputs and prevent anyone on-board from interrupting the automatic take-over. Thus, the personnel on-board could not be forced into carrying out the demands of any unauthorised person(s). To make it fully independent, the system described in the patent would have its own power supply, inaccessible in-flight, so that it could not be disengaged by tripping circuit breakers accessible on-board the aircraft. The aircraft would remain in automatic mode until after landing when ground crew working in conjunction with authorised personnel would be called to disengage the system.
Boeing has confirmed that it has not implemented the patented system or any other technology to remotely pilot a commercial aircraft and is not aware of any Boeing commercial aircraft that has incorporated such technology. [These idiots can’t even LIE properly. Especially when they’ve already ‘coughed’ to Capt. McConnell that the systems are in play. Refer to the law suit which was brought against Boeing – subsequently dismissed by a ‘fraud upon the court.’ Refer to the patent documentation. I’m sure Boeing would be glad to share them once they KNOW that YOU KNOW! The technology was never installed on an aircraft. Really?!]
It should also be noted that the aircraft 9M-MRO was delivered in May 2002 to MAS before the patent was issued in 2006. The aircraft was under the control of MAS for the entire time after delivery except for a short duration at Pudong, Shanghai Airport, China in August 2012, when it underwent wing tip repair by Boeing [refer to Section 1.6.4, para. 2)]. Even then the repair was under the oversight of MAS engineers. Aircraft modification installation data do not indicate that any systems like that described in the patent were installed on the aircraft post delivery and during in-service.
[If the systems were installed BEFORE delivery to Malaysia Airlines, then no modification has been made!]
Airworthiness protocols require that all modifications are approved for installation and a record kept of each modification incorporated. There is no reason to believe any systems like that described in the patent either were or could have been incorporated without the knowledge of MAS.[But they arrived installed in Lufthansa aircraft without their knowledge. Where is the difference?!]
From the foregoing, there is no evidence to support the belief that control of the aircraft 9M-MRO (operating as MH370) could have been or was taken over remotely as the technology was not implemented on commercial aircraft. [Refer to BHUAP & the incorporated ATI componentry.]
1.7.1 Meteorological Situation
Climatologically for the month of March, the position of the sub-tropical high is located over the Gulf of Thailand. The weather is generally dry with very little clouds. The winds are generally light from the surface to the height of 40,000 ft above sea level.
No lightning discharges were detected by the Lightning Detection System of the Malaysia Meteorological Department at the vicinity of last civil radar point from 1600 to 2159 UTC, 07 March 2014 [0000 to 0559 MYT, 08 March 2014].
There was no direct observation of the wind conditions at the last civil radar point, the closest upper air observation was at the Kota Bharu Meteorological Station, taken at 1200 UTC, 07 March 2014 and at 0000 UTC, 08 March 2014 [2000 MYT, 07 March 2014 and 0800 MYT, 08 March 2014] respectively, both reported a temperature of -40oC and wind from the north-east at 15 kt or less at 36,000 ft above sea level.
Light clear air turbulence (CAT) might be expected from 25°N onwards to the destination. However, no significant adverse weather phenomenon was expected for the whole planned flight route.
Wind and Temperature Forecast Chart
The wind and temperature forecast chart PWGE25 for FL340 valid 1800 UTC, 07 March 2014 issued by WAFC Washington showed the jet stream as in the significant weather chart above. The forecast winds at the last civil radar point and last air defence radar point were below 20 kt
Significant Meteorological Information
Significant Meteorological Information (SIGMET) 3 was issued for the GUANGZHOU FIR valid from 12:45 to 16:45 UTC, 07 March 2014 [0200 MYT, 08 March 2014] indicated a thunderstorm forecast north of latitude 27°N and moving eastwards at 50 km/h in the layer
with cloud tops at FL260.
Volcanic Ash Advisory
Volcanic ash advisories issued by Darwin Volcanic Ash Advisory Centre (VAAC) on 07 March 2014 at 06:27 and 18:37 UTC [2045 MYT, 07 March 2014 and 0045 MYT, 08 March 2014] for Sinabung (Sumatra, Indonesia) highlighted volcanic eruption located at 3.10°N 98.23°E (Figure 1.7E [above]) and volcanic ash plume observed up to FL120 and the plume was extending toward the west. [Doesn’t appear to have been any potential threat for 9M-MRO.]
Availability of Meteorological Information
The necessary meteorological information was made available to the crew.
COMMUNICATIONS
High Frequency System
This aircraft was installed with Collins HFS-900 High Frequency (HF) System. The HF communication system on this aircraft uses two HF systems with a common HF antenna to transmit and receive radio frequency (RF) signals in the HF range.
Very High Frequency System
This aircraft was installed with Collins VHF-900B VHF System. The very high frequency (VHF) communication system permits voice and data communication over line-of-sight distances. It permits communication between aircraft or between ground stations and aircraft. The VHF system operates in the VHF aeronautical frequency range of 118.000 MHz to 136.992 MHz.
The VHF communication system on this aircraft uses three VHF systems. Each VHF system has a VHF antenna and a VHF communication transceiver.
The VHF communication system connects with Selective Calling Equipment (SELCAL) decoder that starts an alert when a call comes in for that aircraft.
1.9.3 Air Traffic Control/Mode S Transponder System
This aircraft was installed with a Bendix/King TRA-67A Mode S transponder. The Air Traffic Control (ATC) ground stations interrogate the airborne ATC/Mode S transponder system.
The ATC/Mode S transponder replies to the interrogations in the form of coded information that the ground station uses. The ground station uses a Primary Surveillance Radar (PSR) to get radar returns from aircraft within the radar range. To make a communication link with the aircraft in the radar range, the ground station uses a Secondary Surveillance Radar (SSR) to interrogate the ATC/Mode S transponder. The ground station transmits a side lobe suppression signal to inhibit close ATC replies that come from a SSR side lobe transmission.
Two transponders are installed on the aircraft. A Transponder selector switch on the Transponder panel in the cockpit allows selection of either the left or the right transponder. During normal operations the crew procedure is to leave the left transponder selected on the panel. There is no automatic switching between the transponders if one fails. It must be done manually by the pilots. Failure of either of the transponders will be annunciated in the cockpit. The Left ATC/Mode S transponder gets 115V AC power from the AC Standby bus. The Right ATC/Mode S transponder gets 115V AC power from the Right AC Transfer bus. The dual transponder panel gets 115V AC power from the AC Standby bus. The two transponders are powered by highly reconfigurable AC buses; the left one can be powered by the battery if the left AC bus is unavailable (the AC Standby bus can be powered by the left Transfer bus or the battery), and the AC Transfer busses also have their alternate sources.
There was no message received from the aircraft to report a system failure.
1.9.4 Aircraft Communications Addressing and Reporting System
The Aircraft Communications Addressing and Reporting System (ACARS) is a digital data-link system that manages flight plan and maintenance data between the aircraft and the Ground Service Provider (GSP) by using radio i.e. VHF or satellite communications (SATCOM)
ACARS provides message communication between aircraft and its base (ground). The following messages are transmitted:
• Out of the gate, Off the ground, On the ground, and Into the gate
(OOOI) events:
- Out of the gate event: Departure from the gate with all doors closed and parking brake released;
- Off the ground event: Take-off with the nose gear squat switch extended;
- On the ground event: Touch down with the nose gear squat switch compressed; and
- Into the gate event: Parked at the gate with the parking brake set and the door open.
The ACARS Manager page allows the flight crew to independently select/deselect VHF or SATCOM transmission of data.
For the ACARS operation the Data Communication Management Function (DCMF) of the AIMS uses the voice/data select to set the VHF Communication Transceiver to the data signal mode. At power-up, the DCMF sets the Center VHF Communication Transceiver to the data signal mode. If the Center VHF Communication Transceiver fails, or voice is selected manually by the flight crew, the DCMF selects SATCOM for data transmissions. If SATCOM fails, the DCMF selects the Right VHF Communication Transceiver for data transmissions. The Left VHF Communication Transceiver is voice only. On the event flight, as instructed by Ground Operations via text message shown on the MFD (shown as ‘Switch VHF3 to Voice’), the flight crew would have selected voice on the Center VHF resulting in SATCOM being used for the data transmissions. Refer to page 1 of Appendix 1.9A – ACARS Traffic Log. The use of SATCOM for the ACARS transmissions is evident in the SATCOM Ground Station Logs [refer to Section 1.9.5, para. 4)]. This switching from VHF to SATCOM for the data transmissions is normal practice in MAS for commercial reasons.
In the event that the aircraft ACARS unit has been silent for longer than a pre-set time interval, the ground station can ping the aircraft (directly or via satellite). A ping response indicates a healthy ACARS communication. This ping is different from the Satellite ping or handshake.
Pre-set time interval for MAS B777 is 30 minutes. When the aircraft ACARS is silent for more than 30 minutes, MAS Operation Control Centre (OCC) is required to send a text message via ACARS to the cockpit or to call the cockpit via SATCOM.
1) Aircraft Communications Addressing & Reporting System Traffic Log [ACARS]
Declaration of “there is no evidence that any damaged or leaking packages containing dangerous goods have been loaded on the aircraft at this station” was also written in the NOTOC message.
Position reports were programmed to be transmitted every 30 minutes.
Aircraft position information is also included in the EHM take-off and climb reports. [Below are parts of the ACARS Position Report I have picked up anomalies between the Safety Investigation Report and the computer generated Position Report from the system. There may be nothing amiss. I simply present it in case it is important.]
WIND DIRECTION @ 1651:43 [UTC] @21,193ft [REPORT] – 1.8
[ACARS PRINTOUT] – 91.8
LONGITUDE @ 1701:43 [UTC] @34,998ft [REPORT] - 102.434
[ACARS PRINTOUT] – 102.534
@ 1706:43 [UTC] @35,004ft [REPORT] – 102.713
[ACARS PRINTOUT] – 102.813
1.9.5 Satellite Communications
1) Satellite Communications System Description
The aircraft, 9M-MRO, was equipped with a SATCOM terminal that used the Inmarsat Classic Aero system. The Inmarsat system utilises a constellation of satellites to provide nearly global coverage, the exception being polar areas. The aircraft SATCOM system, also referred to as an Airborne Earth Station (AES) operates on L Band, transmits at 1.6 GHz and receives at 1.5 GHz. For this aircraft, the SATCOM system provided a total of five voice channels and one data channel. The satellite link provides the following functions:
• Audio and text communication;
• ACARS data; and
• In-flight Entertainment (IFE) Equipment connectivity.
The Satellite Data Unit (SDU) receives 115V AC from the Left Main bus. In flight, this bus can be powered by engine mounted generators or the APU generator. Neither the aircraft battery nor the ram air turbine will power the SATCOM system.
d) CTU is the Cabin Telecommunications Unit, which provides an interface between the in-seat handsets and the SDU, for cabin telephony calls, were that functions available. In the case of 9M-MRO, the in-seat phones can only be used for seat-to-seat calling.
2) Satellite Communications Ground Station Logs of the Event – Introduction
Throughout the flight of MH370, the aircraft communicated through the Inmarsat Indian Ocean Region (IOR) I-3 Satellite and the GES in Perth, Australia.
The ACARS reports expected at 1737 UTC and 1807 UTC were not received. The next SATCOM communication was a log-on request from the aircraft at 1825 UTC. From that point until 0011 UTC, 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 AES initiated another log-on request. The log-on acknowledge was the last transmission from the SATCOM.
The SATCOM link was available for most of the flight, excluding a period of between 22 and 78 minutes leading up to 1825 UTC, 07 March and a period of less than 8 minutes leading up to 0019 UTC, 08 March 2014. The absence of any aircraft-initiated handshakes, and on-going success of ground-initiated handshakes, indicates that power to the SATCOM was maintained other than the two periods stated above.
Data from the last seven ‘handshakes’ were used to help establish the most probable location of the aircraft. Initially only the first six of these ‘handshakes’ were considered to be complete. The seventh and last ‘handshake’ that was automatically initiated by the aircraft, was originally assessed as a partial ‘handshake’. Subsequent analysis confirmed the 7th handshake could be used to help determine the most probable flight path. Two unanswered ground-to-air telephone calls had the effect of resetting the activity log and hence increased the period between the ground initiated ‘handshakes’.
The SATCOM link was available for most of the flight, excluding periods leading up to 1825 UTC, 07 March and 0019 UTC, 08 March 2014.
1707:48
Last DATA-2 ACARS Message received at the GES. No further SATCOM Data-2 ACARS messages or acknowledgements were received at the GES for the remainder of the flight. This is abnormal and suggests that the on-board ACARS equipment either failed, or was disabled or powered down at some time between 1707:48 and around 1825:00.
0019:29
SATCOM Log-On, initiated from the aircraft terminal. This is the seventh ‘handshake’.
a. For there to have been a Log-On at this time, there must have been a prior loss of the SATCOM link. This link loss must have occurred at some time after 0010:58, when the SATCOM responded to a Log-On interrogation.
b. This Log-On request suggests that whatever caused the SATCOM link loss to occur had been reversed.
1.11.1 Solid State Flight Data Recorder
The SSFDR was attached with a ULB as below:
• S/N: SC26210
• ULB Expiry Date: December 2012 [ULB = Underwater Locator Beacon]
1.11.2 Solid State Cockpit Voice Recorder
The SSCVR was attached with ULB as below:
• S/N: Not Recorded
• ULB Expiry Date: June 2014 [ULB = Underwater Locator Beacon]
1) Solid State Flight Data Recorder Underwater Locator Beacon Battery Expiry
According to maintenance records, the solid state flight data recorder (SSFDR) Underwater Locator Beacon’s (ULB) battery expired in December 2012. There is no evidence to suggest that the SSFDR ULB battery had been replaced before the expiry date. The SSCVR ULB battery however was replaced, as scheduled, with the next expiry in June 2014.
Technical Log records showed that the SSFDR (together with the ULB) was replaced on the aircraft on 29 February 2008. Component installation records for the ULB showed that at the time the SSFDR was replaced on aircraft the expiry date for the battery was December 2012.
1.12.3 Details of the Debris [Most of the parts received were ‘almost certainly’ or other claims, which indicated the examining team could not positively confirm specific parts as originating from MH370 (9M-MRO). Out of a ‘reported 27 pieces’ only THREE were ‘Confirmed’ as originating from the aircraft. However, this does NOT explain how these pieces arrived at the location they were retrieved from; nor whether they were ‘placed’ into the sea/shore, or arrived there of their own accord. Accordingly, this is NO INDICATION of an aircraft involved in a sea impact [or otherwise]. Rather, there are questions as to how these pieces of wreckage were not found in smaller pieces AND many many more besides. This especially from a wide-body heavy jet comprising over 3,000,000 pieces.]
1) Item 1 - Right Flaperon
The item was retrieved by the local French authorities
and shipped to General Delegate of Armament Aeronautical Technique (DGA/TA) facility in Toulouse for detailed examination. Because of a court case pending in Paris, the part was taken custody by the French Investigative Judge, as evidence for a criminal investigation. In addition, the flaperon was covered with a colony of barnacles. Most of them were on the upper surface (extrados).
2) Item 2 - Right Wing No. 7 Flap Support Fairing
Item No. 2 was found on 27 December 2015 in Daghatane Beach, Mozambique.
The item was brought to ATSB Laboratory in Canberra for detailed examination and analysis. The part was identified from a number stencilled on the part (676EB), as a segment from a Boeing 777 flap track (support) fairing (Fairing No. 7) from the right wing. All measurable dimensions, materials, construction and other identifiable features conformed to the applicable Boeing drawings for the identified fairing. It was concluded that the item is almost certain from MAS B777 aircraft, registered 9M-MRO.
3) Item 3 - Right Horizontal Stabilizer Panel Piece
Item No. 3 was found on 27 February 2016 in Valankulo, Paluma Sandbank, Mozambique.
The item was brought to ATSB Laboratory in Canberra for detailed examination and analysis. The part was primarily identified from images showing the materials, construction and “NO STEP” stencil, as a segment of a Boeing 777 right horizontal stabilizer panel. All measurable dimensions, materials, construction and other identifiable features conformed to the Boeing drawings for the stabiliser panel. It was concluded that the item is almost certain from MAS B777 aircraft, registered 9M-MRO.
4) Item 4 - Engine Nose Cowl
Item No. 4 was found on 22 March 2016 in Mossel Bay, South Africa.
The item was brought to ATSB Laboratory in Canberra for detailed examination and analysis. The part was identified from the partial Rolls-Royce stencil as a segment from an aircraft engine cowling. The panel thickness, materials and construction conformed to the applicable drawings for Boeing 777 engine cowlings. There were no identifiers on the engine cowling segment that were unique to 9M-MRO, however the Rolls-Royce stencil font and detail did not match the original from manufacture. The stencil was consistent with that developed and used by MAS and closely matched exemplar stencils on other MAS B777 aircraft. There were no significant differentiators on the cowling segment to assist in determining whether the item of debris was from the left or right side of the aircraft, or the inboard or outboard side of the cowling. It was concluded that the item is almost certain from MAS B777 aircraft, registered 9M-MRO.
5) Item 5 - Door R1 Stowage Closet
Item No. 5 was found on 30 March 2016 in Rodrigues Island of Mauritius.
There were no identifiers on the panel segment that were unique to 9M-MRO, however the pattern, colour and texture of the laminate was only specified by MAS for use on Boeing 747 and 777 aircraft. There is no record of the laminate being used by any other Boeing 777 customers.
It was concluded that the item is almost certain from MAS B777 aircraft, registered 9M-MRO.
6) Item 6 - Right Hand Engine Fan Cowling
Item No. 6 was found on 24 April 2016, south of Chidenguele, Mozambique.
It has been concluded that the debris is part of the Right Fan Cowl of a B777. As the right fan cowls on both the engines are similar, there is no conclusive evidence to determine whether it belongs to the left (No. 1) or right (No. 2) engine. Based on the other features on the recovered part it has also been determined that the part is almost certain from MH370 (aircraft registered as 9M-MRO).
7) Item 7 - Unidentified Part
Item No. 7 was found on 30 April 2016 on Anvil Bay, Chemucane, Mozambique. The item was brought back to Malaysia for identification and further examination by the Team.
There is no conclusive evidence to determine the origin of this part with respect to the aircraft however it is likely to be a part of a panel of the wing to body fairing on a B777 and it is likely to be from MH370 (aircraft registered as 9M-MRO).
8) Item 8 - Flap Support Fairing Tail Cone
Item No. 8 was found on 24 May 2016 on Gris Gris Beach, Mauritius.
Initial assessment indicated that this could be a flap support fairing tail cone of a B777. The part was identified from the legible numbers that were observed on the inner surface. The following part number 113W9154-401 and serial number 407 were visible on one side. The profile of the part resembled the wing flap support fairing tail cone.
The part number was cross referenced to the Boeing component maintenance manual and drawings. This identified it as a component of the wing flap fairing assembly and the fit closely matched that of the No. 1 flap support fairing. As the records of where these fairing tail cones are fitted are not normally kept by airlines, the serial number 407 could not be tracked to any particular aircraft.
Based on the legible numbers and the fit, it is confirmed that it is the tail cone of the No. 1 flap support fairing of B777 and highly likely to be from MH370 (aircraft registered as 9M-MRO).
9) Item 9 - Left Wing Trailing Edge Panel
The item was found on 22 May 2016 in Macenta Peninsular, Mozambique.
The item matched the left part (outboard section) of the Upper Fixed Panel forward of the flaperon on the left wing.
The item is confirmed to be the outboard section of the “Upper Fixed Panel forward of the flaperon” on the left wing. The debris is highly likely to be from MH370 (aircraft registered as 9M-MRO).
10) Item 10 - Left Outboard Flap
Item No. 10 was found on 08 May 2016 at Ilot Bernache, Mauritius. A part number was identified on a section of the debris, identifying it as a trailing edge splice strap, incorporated into the rear spar assembly of a Boeing 777 left outboard flap. This was consistent with the appearance and construction of the debris.
Adjacent to the part number was a second part identifier. The flap manufacturer supplied records indicating that this identifier was a unique work order number and that the referred part was incorporated into the outboard flap shipset line number 404 which corresponded to the Boeing 777 aircraft line number 404, registered 9M-MRO and operating as MH370.
11) Item 11 - Seat Back Trim Panel Encasing IFE Monitor
Item No. 11 was found on 06 June 2016 on Riake beach, Nosy Boraha Island, Madagascar.
This part is confirmed to be the seat back trim panel for encasing the IFE monitor and is highly likely to be from MH370 (aircraft registered as 9M-MRO).
12) Item 12 - Bottom Panel on Wing or Horizontal Stabilizer
Item No. 12 was found on 06 June 2016 on Riake beach, Nosy Boraha Island, Madagascar.
The item was brought back to Malaysia for identification and further examination by the Team. The letters “FB” were clearly visible on the part which indicates that it is a bottom panel on the wing or horizontal stabilizer. An attempt was made to match the part to all the wing and horizontal stabilizer panels with the identification marks ending with “FB”. The thickness and profile of the part did not match any of those panels on the aircraft. However, it could be confirmed that it is very likely to be a part from a Boeing aircraft and likely to be from MH370 (aircraft registered as 9M-MRO). [Does ANY of the highlighted portions immediately above even make sense?!]
13) Item 13 - Unidentified Part
Item No. 13 was found on 06 June 2016 on Riake beach, Nosy Boraha Island, Madagascar.
The item was brought back to Malaysia for the further examination and identification by the Team. The part could not be matched exactly to any part on a MAS B777 aircraft. There were also no identification numbers on the part.
14) Item 14 - Unidentified Part
Item No. 14 was found on 06 June 2016 in Riake beach, Nosy Boraha Island, Madagascar.
The item was brought back to Malaysia for identification and further examination by the Team. The part did not have any distinguishing features to match any on a MAS B777 aircraft. It did not have any identification numbers. The part resembled a cabin interior piece based on the decorative finish, however there was insufficient evidence to positively identify the part to be from an aircraft.
15) Item 15 - Right Wing Trailing Edge Panel
Item No. 15 was found on 06 June 2016 in Riake beach, Nosy Boraha Island, Madagascar.
The item was brought back to Malaysia for identification and further examination by the Team.
It was identified to be the outboard section of the “Upper Fixed Panel forward of the flaperon” on the right wing of a MAS B777 aircraft. The pitch of the fasteners’ holes on the right side (outboard) of the panel was measured to be 2 in. and that matched that on the debris. The debris is highly likely to be from MH370 (aircraft registered as 9M-MRO).
16)Item 16 - Cabin Interior Panel
Item No. 16 was found on 12 June 2016 on Antsiraka beach, Madagascar.
The piece was small and did not have any evidence of part number printed on it. The vinyl cover showed a unique pattern of interior decorative panel on one side and white vinyl on the other side of the piece. The pattern was similar to the one used on MAS 777 cabin interior panels. There were also ‘insert’ holes visible on one of the sides. The part has been determined to be almost certain from MH370.
The detailed examination was conducted by the Team in collaboration with Science & Technology Research Institute for Defence (STRIDE).
17)Item 17 - Unidentified Part
Item No. 17 was found on 12 June 2016 on Antsiraka beach, Madagascar.
This item is a sandwich structure panel with Nomex Honeycomb core of typical aircraft composite structure. No markings were found on this item. Further analysis on this item is difficult due to lack of features to indicate that it could be a B777 part.
18)Item 18 - Right Forward Nose Landing Gear Door
Item No. 18 was found on 12 June 2016 in Antsiraka beach, Madagascar.
The item was brought back to Malaysia for the identification and further examination by the Team.
The part did not have any identification numbers on it. However, the features on the part resembled the Right Nose Gear Forward Door of a MAS B777 aircraft. The oval depressions on the inner skin and the orientation of a diagonal, raised bar matched that on the Right Nose Gear Forward Door on the aircraft.
The part is positively identified as the Right Hand Nose Gear Forward Door of a B777. It is highly likely to be from MH370 (aircraft registered as 9M-MRO).????[Since there’s only been FIVE incidents involving Boeing 777 aircraft, and THREE of those dropping with everything ‘present and accounted for’ – Asiana Airlines, SFO [CRASH on land]; British Airways BA38 [CRASH on land], LHR?; and an American Carrier, Continenal or United? [LANDED by F.O after Captain medical condition]; - then the only other two are MH370 [9M-MRO] AND MH17 [9M-MRD]
So, doesn’t this mean they can ‘confirm’ the origin as being off 9M-MRO? Or maybe it was off 9M-MRD? But one was crash on land, and the other crash at sea?! But hang on – which one was on sea and which was on land? Now that’s confusing to those not up to ‘speedbird’ with this case. No wonder they got so confused in their deception atempt. Maybe it’s a good idea to have JUST ONE TEAM DOING THE SPOILATION AND PLANTING OF EVIDENCE. Chinese whispers spring to mind? Anyone?! Especially when there’s TWO aircraft to shuffle between the S.I.O and Donesk, Ukraine.]
19)Item 19 - Right Outboard Flap
Item No. 19 was found on 21 June 2016 in Pemba Island, East of Tanzania.
This is the largest piece found after the flaperon and has been determined to be part of the inboard section of the right outboard flap of a B777. The Italian part manufacturer build records for the numbers located on the part confirm that all of the numbers relate to the same serial number outboard flap that was shipped to Boeing as line number 404. Aircraft line number 404 was delivered to MAS and registered as 9M-MRO.
20)Item 20 - Right Aft Wing to Body Fairing
Item No. 20 was found on 21 June 2016 on Kosi Bay Mouth, Kwa Zulu Natal, South Africa.
The item was brought back to Malaysia for identification and further examination by the Team. Part of the identification number was visible on the debris indicating that it is part of the right aft wing to body fairing panel, 196 MR. Part of the part number, 149W5232-1, was visible with the letter ‘R’ below it, indicating it is a panel on the right side of the aircraft.
This item is confirmed to be part of the right aft wing to body fairing panel from a B777 aircraft. It is highly likely to be from MH370 (aircraft registered as 9M-MRO). [If it’s ‘CONFIRMED’ then it is no longer ‘HIGHLY LIKELY!’]
21)Item 21 - Unidentified Part
Item No. 21 was found on 18 July 2016 in Northern Kwa Zulu Natal, South Africa.
The item was brought back to Malaysia for identification and further examination by the Team. Based on the structure construction, this part could be a small section of a panel from an aircraft. There were no identification numbers on the part and it could not be positively determined from which aircraft and which section it could have come from. It could not be positively determined whether the debris could be from a B777 aircraft.
22)Item 22 - Vertical Stabilizer Panel
Item No. 22 was found on 26 August 2016 on Linga Linga beach Mozambique.
The red/white paint on the panel and the paint configuration appeared to match that of the MAS ‘kite’ logo on the right side of the vertical stabilizer.
The debris is confirmed to be part of the right vertical stabilizer panel of a B777. Based on the red/white livery on the panel it is determined to be almost certain from MH370 (aircraft registered as 9M-MRO).
23)Item 23 - Unidentified Part
This item was recovered from Riake Beach, Nosy Bohara Island, Madagascar in October 2016.
The part structure construction characteristics showed that it was not part of the aircraft structure. It appeared more likely to be from the aircraft interior based on the vinyl and edge sealant which was on the part. The vinyl and sealant colour on the part matched that of the parts generally used in aircraft galleys. Although it appeared to be part of an aircraft interior there is no conclusive evidence to indicate whether the part could have actually originated from an aircraft.
24)Item 24 - Unidentified Part
Two items of fibreglass-honeycomb composite debris were recovered near Sainte Luce on the south-east coast of Madagascar, having reportedly washed ashore in February 2016.
They were hand-delivered to the ATSB on 12 September 2016. The items were initially reported in the media as being burnt.
No manufacturing identifiers, such as a part numbers or serial numbers were present on either item that may have provided direct clues as to their origin. Despite no evidence of overall gross heat damage, two small (<10mm) marks on one side of the larger item and one on the reverse side were identified as damage resulting from localised heating. A burnt odour emanating from the large item was isolated to these discrete areas. The origin and age of these marks was not apparent. However, it was considered that burning odours would generally dissipate after an extended period of environmental exposure, including salt water immersion, as expected for items originating from 9M-MRO.
25) Item 25 - Unidentified Part
This item was recovered from Riake beach, Nosy Boraha Island, Madagascar in July 2016.
The item was brought back to Malaysia for examination and identification by the Team. There were no identification numbers on the part and with the available features it could not be matched to any part on a MAS B777 aircraft.
26) Item 26 - Right Aileron
This item was recovered from Nautilus bay, South Africa on 23 December 2016.
The debris closely matched the inboard section of the Right Aileron on a MAS B777 aircraft.
The numbers on the head of the fasteners on the debris were compared with those on the inboard section of the right aileron on the aircraft. These numbers matched. Additionally, the spacing of the fasteners on the aileron also matched those on the debris. The core and its dimensions also matched those on the inboard section of the right aileron. These confirmed that the debris is part of the inboard section of the right aileron of a B777 aircraft.
Based on the dimensions and fit on the aircraft and the visible fasteners it could be confirmed that the debris is part of the inboard section of the right aileron of a B777 aircraft. It was also determined to be highly likely from MH370 (aircraft registered as 9M-MRO).
27)Item 27 - Right Wing No. 7 Flap Support Fairing
This item was recovered from Mpame beach, South Africa on 27 January 2017.
The item was brought back to Malaysia for identification and further examination by the Team. The possible location of the part on a MAS B777 aircraft was determined.
It was easily matched to the fixed, forward portion of the No. 7 flap support fairing. Item No. 2, found on 27 December 2015 at Daghatane Beach, Mozambique, is also part of the same fairing; however, it is part of the rear, moveable section.
The debris was thoroughly cleaned to reveal any identification numbers. After cleaning, the numbers 113W9211-402, S/N: 406 were found on the inside surface of the debris. The part number 113W9211-402 indicated that the debris was indeed a part of the No. 7 flap support fairing of a B777 aircraft. The serial number, 406 could not be used to link it to any particular aircraft as there were no records available to confirm this.
Based on the legible part number and the match of the part on the aircraft it is confirmed that the debris is part of the fixed, forward No. 7 flap support fairing of a B777 aircraft, and also determined to be highly likely to be from MH370 (aircraft registered as 9M-MRO).
1.13 MEDICAL AND PATHOLOGICAL INFORMATION
There was no evidence that physiological factors or incapacitation affected the performance of flight crew members on MH370.
ATC
h) Kuala Lumpur Air Traffic Service Centre
The Kuala Lumpur Air Traffic Service Centre (KL ATSC) is headed by a Director and supported by two deputies - Deputy Director for ATSC and Deputy Director for KL TMA - and 243 ATCOs of various grades. The total number of the ATCO posts approved by the Government was 353. As of March 2014, there were 110 vacant posts.
Butterworth Terminal Area
To enable the Military to meet its national operational requirements, a number of control zones, training areas and danger areas have been established. Operational control of these airspaces and responsibility for the provision of air traffic services within these airspaces have been delegated to the military. Coordination procedures between the civil and military authorities have also been established as follows:
Provision of approach control service within lateral limits of Butterworth Control Zone:
• Ground/Sea - 5,500 ft. altitude - FL245,
• Elsewhere 2,500 ft altitude - FL245 with Butterworth Terminal Area.
Air traffic to/from the civilian Penang International Airport (PIA), Alor Setar Airport and Langkawi International Airport is provided by military ATCOs who have been licensed by the ATI Division, which develops and establishes the ANS safety standards and performs safety oversight and to ensure the provision of services to civil traffic. The rationale for such an arrangement is based on the military activities at Butterworth Military Airport (BMA) which is in close proximity to PIA, and other military activities carried out over the high seas in danger areas WMD 412A and WMD 413A (permanently established). Furthermore, the final approach segments of both the PIA and the BMA intersect. No major incident has been recorded with the present arrangement/delegation of authority.
1.17.2 Malaysia Airlines
2) Engineering & Maintenance
b)Maintenance and Design Approval
Engineering & Maintenance Department [EMD]
The EMD was also issued with Design Organisation Approval by DCA Malaysia. This allows the EMD to make minor design changes on the MAS fleet. To administer this, a team of engineers in the Technical Services Department of the EMD were qualified and approved in the various aviation disciplines such as Structures, Systems and Avionics.
a) Flight Operations
The pre-hire test also applied to those joining the airline with previous flying experience from other flying organisations. A significant percentage of MAS pilots came from the Royal Malaysian Air Force (RMAF), mainly those who had served the Air Force as short-commissioned officers. After about seven to ten years of service in the RMAF, they were able to join MAS with recognised flying hours and experience to be accepted as First Officers in the lowest fleet.
On the average it would take at least 15 years of flying in the Company before a pilot could be promoted to command the B777.
xii) MAS B777 Training and Standards
As the training progressed, and if the trainee’s performance was above average, and deemed safe, the carriage of the third pilot would not be necessary beyond this stage of training, based on the recommendation of the earlier trainer (TRI/TRE) in accordance with the training policy.
In such a case, a trainee pilot under IOE would not need a third pilot to accompany the flight, even though he was effectively still in the training phase. This was the case on the day of the eventful flight.
xiii) Multi-crew Operation MH370
During the day of the eventful flight, the FO was on his last training flight before he was due for a check flight on his next flight duty assignment.
If the decision was made that the First Officer was going to be the Pilot Flying, the MAS Flight Operations policy required that the Captain would start and taxi the aircraft up to the take-off point on the runway, after which control of the aircraft would be handed over to the co-pilot to perform the take-off and eventually the landing at the destination. Up to the take-off position at the beginning of the runway, radio communications with the ATC would be the responsibility of the co-pilot. It was a MAS’ written procedure during this phase of the flight that the throttle would be handled by the Captain as PIC, a policy to ease and expedite the rejected take-off manoeuvre if so required. The First Officer would control the rudder and control column as the pilot flying.
iii) In-flight Operation
On board a Boeing 777-200ER aircraft the standard operating cabin crew of 11 was required. The normal cabin crew complement for the Boeing 777-200ER aircraft was as follows:
• 1 In-flight Supervisor
• 2 Chief Steward/Chief Stewardess
• 2 Leading Steward/Leading Stewardess
• 6 Flight Steward/Flight Stewardess
[It is mentioned further on in the Safety Investigation Report that this service flew with only ten cabin crew, which was acceptable and permitted by MAS.]
As per Civil Aviation Regulations 1996 the minimum requirement of the operating cabin crew for B777-200ER fleet is 8 based on the number of exit doors available on the aircraft.
3) Sector 5 Area of Responsibility
b) Delegation of Airspace
i) Delegation of Airspace from Singapore ACC to Kuala Lumpur ACC (Sector 5)
RNAV route M765 between VENLI and IGARI has been delegated by Singapore ACC. Lumpur Sector 5 shall provide air traffic services and carry out coordination with Ho Chi Minh ACC.
ii) Route segment between IKUKO and IGARI on ATS R208 is released by Singapore ACC subject to daily coordination between Singapore ACC and Kuala Lumpur ACC.
4) Air Traffic Services Operations
a) The disappearance of MH370 occurred in the Singapore FIR where the airspace is delegated to KL ACC.
“In the event of an aircraft emergency occurring within
the South China Sea Corridor (SCSC), the KL ATSC shall be responsible to take initial alerting action whilst the Singapore RCC shall be responsible for subsequent coordination of all SAR efforts. While the responsibility for the provision of SAR service within the SCSC rests with Singapore RCC, the Singapore RCC may as provided for in paragraph 3.2.2 delegate responsibility for the overall control of the SAR mission to Kuala Lumpur RCC or Kota Kinabalu RCC, whichever is deemed appropriate”
c) The last radio transmission between KL ACC and MH370 took place at 1719:30 UTC [0119:30 MYT]. A contact should have occurred at around 1722 UTC [0122 MYT] at waypoint IGARI.
Reference is made to Malaysia AIP ENR 6, En-route Charts - IGARI has been designated as a compulsory reporting point,
KL ACC should have declared the Distress Phase16 at 1827 UTC [0227 MYT] and the transmission of the DETRESFA17 message, as KL ACC was the ATS unit last in contact with MH370 at 1719:30 UTC [0119:30 MYT] when MH370 acknowledged the transfer of control by KL ACC at 1719:26 UTC [0119:26 MYT].
MH370 did not contact Ho Chi Minh ACC on radio frequency 120.9 MHz. and Ho Chi Minh ACC was not able to establish two-way communication with MH370.
The Team noted that MH370 was operating in the airspace delegated to KL ACC and the last air-ground radio contact was with KL ACC. MH370 did not contact Ho Chi Minh ACC and Ho Chi Minh ACC was unable to establish radio communication with MH370.
Hence KL ACC shall be responsible for the provision of alerting service for MH370.
At 2232 UTC [0632 MYT] KL ARCC transmitted the first DETRESFA message. A total of 4 hours and 05 minutes had passed from the time the Distress Phase should have been declared.
d) As the ‘custodian’ of the airspace, the KL ACC transferred MH370 to HCM ACC 3 minutes before the estimated time of arrival over the Transfer of Control Point18 (TCP).
The estimate19 of the aircraft for IGARI which was 1722 UTC [0122 MYT] had been passed to, by KL ACC, and duly acknowledged by HCM ACC, as stipulated in the Operational Letter of Agreement between DCA Malaysia and Viet Nam Air Traffic Management.
e) Page 11 of Appendix 1.1A - Establishment of Communication in the Operational Letter of Agreement between DCA Malaysia and Viet Nam Air Traffic Management stipulates that:
“The accepting unit shall notify the transferring unit if two-way communication is not established within five (5) minutes of the estimated time over the TCP”.
At 1739:03 UTC [0139:03 MYT] HCM ACC queried KL ACC for news on MH370.
After MH370 was transferred to HCM ACC, the time of transfer was not recorded manually on the paper Flight Progress Strip as stipulated in MATS Part 2-Gen Section 11 FLIGHT PROGRESS STRIPS.
Manual of Air Traffic Services Part 9, Table 9-2.2 Overdue Action - Radio Equipped Aircraft preliminary action stipulates that:
“When an aircraft fails to make a position report when it is expected, commence actions not later than the ETA20 for the reporting point plus 3 minutes”
b) Full Overdue Action: not later than 30 minutes after the declaration of the Uncertainty Phase:
i. notify the RCC that the Alert Phase23 exists.
ii. notify the RCC that Distress Phase exists if:
-1 hour has elapsed beyond the last ETA for the destination; or
- the fuel is considered exhausted; or
- 1 hour has elapsed since the declaration of the Uncertainty Phase.
At 1741:23 UTC [0141:23 MYT] KL ACC Sector (3 & 5) Controller made a call on the radio frequency 132.5 MHz to MH370 but there was no response from the aircraft.
Event that followed was at the time of 1804:39 UTC [0204:39 MYT] when KL ACC Radar Controller informed HCM ACC:
“…reference to the Company Malaysian Airlines the aircraft is still flying, is over somewhere over Cambodia”. ?????
Thirty-one minutes later, at 1835:52 UTC [0235:52 MYT] MAS Operations Centre (MOC) informed the position of the aircraft was at latitude N14.9 0000 and longitude E109 15500 which was somewhere east of Vietnam. This information was relayed to HCM ACC. At 1930 UTC [0330 MYT] MOC called in and spoke to the Radar Controller, “…admitting that the ‘flight tracker’24 is based on projection and could not be relied for actual positioning or search.” (Watch Supervisor Logbook’s entry).
6) Chronology of Activities after Notification by HCM ACC
1.
1739:03 UTC [0139:03 MYT]
Ho Chi Minh ACC first enquired about MH370 and informed KL ACC that verbal contact was not established with MH370 and the radar target was last seen at BITOD.
2.
1741:22 UTC [0141:22 MYT]
Ho Chi Minh enquired for information on MH370 and KL ACC informed HCM ACC that after waypoint IGARI, MH370 did not return to Lumpur Radar frequency.
4.
1746:47 UTC [0146:47 MYT]
HCM ACC queried about MH370 again, stating that radar contact was established over IGARI but there was no verbal contact. HCM ACC advised that the observed radar blip disappeared at waypoint BITOD. HCM ACC stated that efforts to establish communication were made by calling MH370 many times for more than twenty (20) minutes.
7.
1803:48 UTC [0203:48 MYT]
KL ACC queried HCM ACC on the status of MH370, HCM ACC confirmed there was no radar contact at this time and no verbal communication was established. KL ACC relayed the information received from Malaysia Airlines Operations that the aircraft was in the Cambodian airspace.
11.
1818:50 UTC [0218:50 MYT]
KL ACC queried if the flight plan routing of MH370 was supposed to enter Cambodian airspace. HCM ACC confirmed that the planned route was only through the Vietnamese airspace. HCM ACC had checked and Cambodia had advised that it had no information or contact with MH370. HCM ACC confirmed earlier information that radar contact was lost after BITOD and radio contact was never established. KL ACC queried if HCM ACC was taking Radio Failure action, but the query didn’t seem to be understood by the personnel. HCM ACC suggested KL ACC to call Malaysia Airlines Operations and was advised that it had already been done. [It’s amazing how much bumbling and ‘confusion’ conveniently gave 9M-MRO the perfect ‘head-start’ ‘run’ and go into ‘hiding.’ Hide and seek maybe?!]
12.
1833:59 UTC [0233:59 MYT]
KL ACC Radar Controller enquired with Malaysia Airlines Operations Centre about the communication status with MH370 but the personnel was unsure if the message went through successfully or not. [Are you Friggin’ kidding me!] Malaysia Airlines Operations Centre informed that the aircraft was still sending the movement message indicating it was somewhere in Vietnam and giving the last position as coordinates N14.90000 E109 15500 at time of 1833 UTC [0233 MYT].
14.
1837:34 UTC [0237:34 MYT]
KL ACC informed HCM ACC that MH370 was still flying and that the aircraft was continuing to send position reports to the airline, and relayed to HCM ACC the latitude and longitude as advised by Malaysian Airlines Operations.????
16.
1930 UTC [0330 MYT]
(No voice recording)
Extract from Watch Supervisor’s Log Book:
MAS Operations Centre informed KL ACC that the flight tracker information was based on flight projection and was not reliable for aircraft positioning.
20.
2118:32 UTC [0518:32 MYT]
When HCM ACC queried for information on MH370, KL ACC also queried if any information had been received from Hong Kong or Beijing.
21.
2109:13 UTC [0509:13 MYT]
Singapore, on behalf of Hong Kong, enquired for information on MH370.
7) Activation of KL Aeronautical Rescue Coordination Centre
KL ARCC was activated at 2130 UTC [0530 MYT]. The DETRESFA message was disseminated via the AFTN at 2232 UTC [0632 MYT], 01 hour and 02 minutes later. No activity was recorded in the RCC Logbook between 2130 UTC [0530 MYT] and 2232 UTC [0632 MYT].
1.18.2 Aircraft Cargo Consignment
During the course of the investigation the Team visited and interviewed the relevant people in MAS at KLIA Sepang, Motorola Solutions Penang, MASkargo Sdn. Bhd. (MASkargo) Penang, NNR Global Logistic (M) Sdn. Bhd. Penang, Poh Seng Kian, Muar, Johore (supplier of mangosteen fruit), Freescale Semiconductor, Petaling Jaya, JHJ International Transportation Co. Ltd. Beijing, China (forwarding agent of Motorola Solutions China), Motorola Solutions China, TianJin, China and Beijing GuangChangMing Trading Co. Ltd. Beijing, China. [Motorola was owned by FreeScale Technologies.]
2.1 DIVERSION FROM FILED FLIGHT PLAN
2.1.1 Seven Simulator Sessions
1) Recreating the Left turn past Waypoint IGARI – Session 1
About half-way through the turn, it was obvious that the ‘aircraft’ was not going to make it through the exit waypoint as it was overshooting as there was no tracking information in the FMC. The simulator session was then terminated.
2) Session 2
The ‘aircraft’ made the exit waypoint; however, it took 3 minutes and 45 seconds to achieve it (the recorded radar time was 2 minutes 10 seconds).
3) Session 3
The simulation commenced before IGARI and the ‘aircraft’ turned right on LNAV and tracked to the entry waypoint. Once over the waypoint, the FMC was directed to fly “direct to” to the exit waypoint. The ‘aircraft’ entered a left turn, with a maximum bank-angle of 28° (maximum bank-angle in LNAV is 25°). The ‘aircraft’ made the exit waypoint. However, it took 3 minutes and 3 seconds to achieve it.
5) Session 5 (Manual Flying)
Following discussions, it was agreed that the turn could be executed in LNAV, but not in 2 minutes. It was decided that the bank-angle needed to be increased to reduce the time and that could only be achieved with the autopilot disengaged and the ‘aircraft’ manually flown, with the auto-thrust managing the speed. Similar set-up as Session 2.
6) Session 6 (Manual Flying)
The simulation commenced before IGARI with autopilot and autothrottle engaged and the ‘aircraft’ turned right on LNAV and tracked to the entry waypoint. Once over the waypoint, the autopilot was disengaged and the ‘aircraft’ manually turned to the left. Bank-angle around 35° was used (bank-angle warnings sounded several times).
At about half way through the turn (1 minute mark), the stick-shaker activated. The ‘aircraft’ intercepted the exit waypoint at 2 minutes and 28 seconds.
e) Summary of 6 Simulator Re-enactment Sessions and Common Factors
Based on the six simulator re-enactment sessions conducted as summarised in Table 2.1G (below) and on the common factors in Table 2.1H (below), the Team concluded the following:
i) The turn would have been carried out with the autopilot disengaged, as it was not possible to achieve a turn time of 2 minutes and 10 seconds (as suggested by recorded data) using autopilot. The manoeuvre can be performed by a single pilot. The Team also noted that the aircraft’s flight path from after the turn was consistent with the navigation being set to LNAV and/or heading mode, following published and/or manual waypoints that are not normally used with normal route (published airways between Kota Bharu and Penang).
ii) From the data it was determined that the ‘aircraft’ was on heading mode that varied from 239o to 255o as it flew to the south of Penang where it continued westerly to Waypoint MEKAR where it finally disappeared completely at 1822:12 UTC [0222:12 MYT], about 10 nautical miles north of MEKAR.
iii) Based on the Team’s review of the Military recorded radar display and printout, the aircraft’s flight path could not be determined, and there is no evidence of rapid altitude and/or speed changes to indicate that MH370 was evading radar.
iv) Without further evidence, the reason for the transponder information from the aircraft ceasing could not be determined;
v) It is determined that only the transponder signal of MH370 ceased from the ATC Controller display whilst displays from other aircraft were still available; and
vi) There is also no evidence to suggest that the aircraft was flown by anyone other than the designated MAS pilots. However, the Team does not exclude the possibility of intervention by a third party.
8) Session 7 – Recreating the Right Turn South of Penang Island
Note: A tailwind of 30 knots was needed to achieve this.
2.1.2 Ho Chi Minh Air Traffic Services Operations
Based on the on-site interviews and briefing from the Team’s visit to the Office of the Vietnamese Civil Aviation Authority in Ho Chi Minh City, it was noted that the radar position symbol for MH370 dropped from the radar display at 1720:59 UTC (0120:59 MYT). MH370 had not reached waypoint BITOD which is 37 nm from waypoint IGARI and based on the aircraft speed of 480 kt, it would take approximately five minutes for MH370 to travel from IGARI to BITOD.
The Direct Line Coordination Communication transcripts between KL ACC and Ho Chi Minh ACC suggested that there were uncertainties on the position of the aircraft. [yA THINK?!] This could come about from the level of understanding of the English language. The HCM Duty Controller also could not communicate effectively during the interviews and an interpreter was there to assist him.
2.2.8 ATS Operational Issues after Last Radio Communication with MH370 and subsequent ATS Activities/Actions
Note 5
When Lumpur Radar (Sector 3+5) transferred MH370 to Ho Chi Minh, the radio frequency of Ho Chi Minh was transmitted by Lumpur Radar (Sector 3+5), MH370 responded with “Good night Malaysian Three Seven Zero”, the radio frequency of Ho Chi Minh was not read back by MH370.
There were two instances when radio frequency was not included in the ATC instructions and three instances when radio frequency was included in the ATC instructions, MH370 had read back the radio frequency on two of the instances but did not on the last radio transmission. The Team could not conclude any reason for the absence of the read-back at this stage of the flight but noted that it was not consistent with the previous frequency changes.
(e) Maintaining FL350 Transmitted Twice
The interval between the first and second radio transmission was 6 minutes and 39 seconds.
Repetition of radiotelephony communications happens occasionally. While the Team could not determine the reason for the additional transmission at this stage of the flight, it was noted that it was anomalous at this time.
b) Responsibilities of Accepting Air Traffic Control Service Unit on Establishment of Communications
ii) Since HCM ACC had earlier received from KL ACC MH370’s estimate (as 1722 UTC [0122 MYT] for IGARI and also had not been able to establish two-way communication with the aircraft, HC ACC should have notified KL ACC by 1727 UTC [0127 MYT], i.e. 1722 UTC [0127 MYT] plus 5 minutes. Instead HCM only notified KL ACC at 1739 UTC [0139].
c) Marking on MH370 Flight Progress Strip
i) Two markings have been left out on the flight progress strip
(1) The actual time (1721) when MH370 passed over IGARI - FPS’ Estimate IG (abbreviation for IGARI) 1722, and
(2) The transfer of control time (1719) on the FPS.
Since the two recordings on the Flight Progress Strip for MH370 were not marked by the Air Traffic Controllers (Planner and Radar) KL ACC did not have the record of the time of the last radio contact and the actual time of MH370 passing over waypoint IGARI.
e) Recognising Emergency Situations and Air Traffic Control Actions
i) Upon receipt of the query from HCM ACC at 1739 UTC [0139 MYT] that HCM ACC had not been able to establish two-way radio communications with MH370, the Lumpur Sector 3+5 Radar Controller should have realised that MH370 could be experiencing an emergency situation. This was especially so after he had tried to establish radio communication with MH370 by making a ‘blind transmission’ on the VHF radio frequency 132.5 MHz at 1741:23 UTC [0141:23 MYT], without success.
ii) Under such circumstances and upon notification from HCM ACC that there were no two-way radio communications with the aircraft and/or subsequent inquiries to other sources had failed to reveal any news of the aircraft, the Sector 3+5 Radar Controller should have immediately notified the ATSC Duty Watch Supervisor and ARCC that an Uncertainty Phase had existed. By then, the Radar Controller should have commenced full overdue action (not later than 30 minutes after the declaration of an Uncertainty Phase), i.e. notify the KL ARCC that an Alert Phase existed.
When alerting services is required in respect of a flight operated through more than one FIR or control area, and when the position of the aircraft is in doubt, responsibility for coordinating such service shall rest with the ATS unit of the FIR or control area within which the aircraft was flying at the time of last air-ground radio contact:
The responsibility for the provision of alerting service for MH370 therefore rested on KL ACC.
i) Flight-Following System of Malaysia Airlines
(1) In interviews conducted with the MAS duty personnel in charge of the FFS on the night of 07 March 2014, he was not able to explain clearly on the operations of the system due to “lack of training”. The Team was also informed that all the personnel in this unit were not adequately trained to operate this system. The MAS personnel also informed the Team that the FFS could not track aircraft on a real-time basis and that the position information was computer-projected, based on the flight plan of aircraft. He added that the status of an aircraft position would only be updated every thirty (30) minutes. He admitted that he had informed KL ACC that MH370 was in Cambodian airspace as during: “…that point in time, I did not notice that the position was actually projected movement and not actual”.
(3) To understand how the Flight Explorer works, the Team requested for a copy of the Flight Explorer User Manual and was informed that there was none in the office. Later, a copy of the Flight Explorer User Manual was provided to the Team.
Note:
Flight Explorer is a computer-based system which is also known as “Flight-Following System” to track aircraft based on input of the aircraft’s Flight Plan data into the computer. The Flight Plan data generates the flight profile and position of the aircraft and updates every 30 minutes. However, the system does not provide real-time tracking.
Therefore, the information derived from the FFS from ODC did not help at all but, instead, further complicated the situation.
The Team noted that MAS FFS was not part of the KL ACC Air Traffic Services system and it did not provide real-time tracking of flight. The position information of MH370 provided to KL ACC were computer-generated and not actual.
r) Distress Message
(3) Appendix 3, page A3-29 & A3-30
Omission of Field Type 20 - Alerting search and rescue information. This field consists of the following sequence of elements separated by spaces. Any information not available should be shown as “NIL” or “NOT KNOWN” and not simply omitted.
2.4.1 Airworthiness & Maintenance
9) A review of Malaysia Airlines list of Hard Time Components installed on the aircraft showed that the SSFDR ULB battery life was overdue at the time of the occurrence. There was no evidence of other overdue maintenance.
2.4.3 Aircraft Health Monitoring
The Maintenance Control Centre (MCC) of Malaysia Airlines did not receive any fault messages through ACARS during the event flight even up to the time the last ACARS report was transmitted.
2.4.4 Aircraft Systems Analysis
1) Air-conditioning, Pressurisation and Oxygen
The SATCOM handshake data indicated that the aircraft was airborne for approximately 7 hours, 37 minutes (Take-off: 0042 MYT to Last SATCOM Handshake: 0819 MYT). That the aircraft flew quite some distance over a long period suggests that it flew at high altitude.
2) Autoflight
From the simulator sessions it is evident that the turn itself was most likely made with the autopilot disengaged.
It is unclear how the aircraft was flown for the remainder of the flight, however the aircraft made several other turns and rolled out to level flight after the turn after IGARI. 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.
4) Flight Controls and Hydraulics
It is highly likely that the primary flight controls were functional as the aircraft altered the flight path several times and maintained flight for a long duration.
6) Navigation
As for the Flight Management System, it is unclear whether the system was functioning properly throughout the flight. This system is not essential for the operation of the autopilot.
c) Air Traffic Control/Mode S Transponder System
The Left ATC/Mode S transponder gets 115V AC power from the AC Standby bus. The Right ATC/Mode S transponder gets 115V AC power from the Right AC Transfer bus. The dual transponder panel gets 115V AC power from the AC Standby bus. The two transponders are powered by highly reconfigurable AC buses; the left one can be powered by the battery if the left AC bus is unavailable (the AC Standby bus can be powered by the left Transfer bus or the battery), and the AC Transfer busses also have their alternate sources (the Main AC busses). It is likely that the Right Main AC bus was available because otherwise the ADIRU would have lost alignment (which it did not). It is likely that the power sources for one or both transponders were available.
d) Aircraft Communications Addressing and Reporting System
After this last automatic ACARS transmission over the SATCOM, either the ACARS was turned off or the AIMS had a fault that prevented ACARS transmissions while certain other functions such as inertial data forwarding did not appear to be significantly affected.
2.4.5 Summary
From the foregoing discussion it can be generally deduced that there is no evidence to suggest that a malfunction had caused the aircraft to divert from its filed flight plan route. The aircraft’s maintenance history and events prior to the last flight do not show any issues that could have contributed and resulted in the deviation and subsequent changes in the flight path. 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.
Similarly, 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.
The analysis of the relevant aircraft systems taking into account the route followed by the aircraft and the height at which it flew, constrained by its performance and range capability, does not suggest a mechanical problem with the aircraft.
2.5.1 Summary of Key Observations of the SATCOM Ground Station Logs
6) There is no indication of the SATCOM link being manually Logged Off from the cockpit (via a Multi-function Control Display Unit [MCDU]). Such activity would have been captured in the GES logs, but it was not.
2.6.1 Debris Considered for Detailed Examination
There were damages to the internal seal pan components at the inboard end of the outboard flap which were possible with the auxiliary support track fully inserted into the flap. The damages were consistent with contact between the support track and flap, with the flap in the retracted position. The possibility of the damages originating from a more complex failure sequence, commencing with the flaps extended, were considered much less likely.
Two pieces of debris are almost certain from the cabin interior suggesting that the aircraft might have broken up. However, there is insufficient information to determine if the aircraft broke up in the air or during impact with the ocean.
2.6.4 Marine Life Examination
There are however no elements to determine precisely the duration of the growth of the valves examined, and therefore the period covered by the most developed valves. However, based on two experimental studies dealing with growth speeds of pelagic anatifas (Evans, 1958, Inatsuchi et al., 2010), the biggest valves (scutum) could have grown over a few months period. [Very definite and precise information there. Most scientific!]
3) Air Traffic Management Sector
6) Kuala Lumpur Air Traffic Service Centre
b) Findings of Safety Oversight Audit
• KL ATCC had not conducted any Refresher Course for its Controllers. There is no training programme developed for ATC staff. All training is conducted on operational and opportunity basis. In addition, training records for ATC staff were not systematically maintained.
The reasons cited in the audit report were inadequate staffing and inadequate resources to run the programme.
7) Airworthiness Sector
iv) Planning
In the case of 9M-MRO, it was noted that the last C of A renewal for aircraft physical inspection was not carried out by the Airworthiness Inspector but was renewed based on document submission and a physical inspection report by MAS. The last aircraft physical inspection on 9M-MRO was carried out more than one year prior to the aircraft’s disappearance. This is an acceptable practice by the Airworthiness Sector because the annual renewal of the Certificate of Airworthiness is normally supported by an aircraft document/physical inspection report. The mutual arrangement with the operators would indicate that the Sector has a close working relationship with the aviation industry and this arrangement serves to expedite the Certificate of Airworthiness’ renewal process. Based on the above analysis, the system of planning and accomplishment are in order and there is no evidence of any latent condition which may contribute any failures.[Other than a discrete BHUAP and ATI system laying in wait.]
[The one interesting thing about the Malaysian Government MH370 Safety Investigation Report is that it barely touches on the marine life being exhibited on pieces of wreckage; yet the ATSB report which came out late 2017 had an entire large portion covering the marine life [no pun intended.] That gives me even more reason to believe that the new Malaysian Government knows that blanks have been fired up to now – I think the real, live bullets may just be ready to be loaded. After all – why waste significant report space and resources commenting on something such as marine life – which never really factored into the case from the very beginning anyway.]
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