Safety Investigation Report 2018:1 Factual Information
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SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
SECTION 1 – FACTUAL INFORMATION
SECTION
TITLE
1
FACTUAL INFORMATION
1.1
1.1.1
1.1.2
1.1.3
Diversion from Filed Flight Plan Route
- Malaysian Military Radar
- DCA Civilian Radar Data from Kota Bharu – Sultan Ismail Petra Airport Runway
- Ho Chi Minh Air Traffic Services
- Kuala Lumpur ACC Radar
- Medan Air Traffic Control Radar
- Bangkok Air Traffic Control Radar
- Singapore Air Traffic Services
1.1.4
1.1.5
1.1.6
1.2
1.3
1.4
1.5
1.5.1
Introduction
1.5.2
Malaysia Airlines Training and Check Records
1.5.3
Pilot-in-Command
- 1) Personal Profile of Pilot-in-Command
- 2) Royal Malaysia Police’s Report on Flight Simulator of PIC
1.5.4
1.5.5
1.5.6
1.5.7
1.5.8
1.5.9
1.5.10
1.5.11
1.5.12
1.6
1.6.1
1.6.2
1.6.3
1.6.4
Airworthiness and Maintenance
- 1) Aircraft Maintenance Schedule
- 2) Major Repair
- 3) Cabin Configuration Change
- 4) Mandatory Occurrence Reports
- 5) Airworthiness Directives
- 6) Technical Log
- 7) Deferred Defects (Maintenance Report 2)
- 8) Engine Health Monitoring
- 9) Central Maintenance Computing System
1.6.5
1.6.6
1.6.7
1.6.8
Aircraft Systems Description
- 1) Air Conditioning and Pressurisation
- 2) Autopilot Flight Director System
- a) Take-off Mode
- b) Roll Modes
- c) Pitch Modes
- d) Landing Modes
- e) Autothrottle (Thrust Management Computing Function)
- f) Autothrottle Modes
- 3) Electrical Power
- a) Electrical Load Management System
- b) Alternating Current Electrical System Power Sources
- c) Integrated Drive Generators
- d) Auxiliary Power Unit Generator
- e) Alternating Current Electrical Power Distribution
- f) Autoland
- g) Backup Alternating Current Electrical System
- h) Backup Generators
- i) Direct Current Electrical System
- j) Batteries
- k) Flight Control Direct Current Electrical System
- l) Standby Electrical System
- 4) Cabin and Cargo Compartments
- 5) Flight Controls
- 6) Fuel System
- 7) Hydraulics
- 8) Instrumentation
- 9) Airplane Information Management System
- 10) Navigation Systems
- 11) Oxygen Systems
- 12) Central Maintenance Computing System
- 13) Engines
- 14) Auxiliary Power Unit
- 15) Communications
1.6.9
1.6.10
1.7
1.7.1
1.7.2
Comments on the Information Available
- 1) Forecast Charts
- a) Significant Weather Chart
- b) Wind and Temperature Forecast Chart
- 2) Significant Meteorological Information
- 3) Volcanic Ash Advisory
1.7.3
Availability of Meteorological Information
1.8
AIDS TO NAVIGATION – Not applicable
1.9
1.9.1
1.9.2
1.9.3
1.9.4
1.9.5
Satellite Communications
- 1) Satellite Communications System Description
- 2) Satellite Communications Ground Station Logs of the Event – Introduction
- 3) Satellite Communications Ground Station Logs of the Event – Summary
- 4) Satellite Communications Ground Station Logs – Key Observations in Chronological Order
- 5) Frequencies of Log-on Bursts
1.10
AERODROME INFORMATION - Not applicable
1.11
FLIGHT RECORDERS
1.11.1
Solid State Flight Data Recorder
1.11.2
Solid State Cockpit Voice Recorder
1.11.3
Underwater Locator Beacons
- 1) Solid State Data Recorder Underwater Locator Beacon
Battery Expiry
1.12
WRECKAGE AND IMPACT INFORMATION
1.12.1
Introduction
1.12.2
Location of Where the Debris were Found
1.12.3
Details of the Debris
1.12.4
Process for Recovery of Debris
1.13
MEDICAL AND PATHOLOGICAL INFORMATION
1.14
FIRE
1.15
SURVIVABILITY
1.16
TESTS AND RESEARCH - Not applicable
1.17
1.17.1
Department of Civil Aviation Malaysia
- 1) Introduction
- 2) Functions and Responsibilities of Department of Civil Aviation
- 3) Sectors and Divisions of Department of Civil Aviation
- 4) Areas of Focus
- 5) Air Traffic Management Sector
- a) Air Traffic Inspectorate Division
- 6) Airworthiness Sector
- 7) Flight Operations Sector
1.17.2
Malaysia Airlines
- 1) Introduction
- 2) Engineering & Maintenance
- a) Organisation Structure
- b) Maintenance and Design Approval
- c) Training
- d) Base Maintenance
- e) Line Maintenance
- f) Maintenance Authorisation
- g) Safety Management System
- 3) Operations
- a) Flight Operations
- i) Flight Operations Management
- ii) Organisation and Management related to
B777 Operations - iii) Technical Crew
- iv) Technical Crew of MH370
- v) Working Schedule/Roster Schedule and Management
- vi) Safety Management System
- vii) Confidential Human Factors Incident Report
- viii) Flight Operations Quality Assurance
- ix) Line Operations Safety Audit
- x) Crew Resources Management
- xi) Training and Standards
- xii) MAS B777 Training and Standards
- xiii) Multi-Crew Operation MH370
- xiv) Safety and Emergency Procedures
- xv) Technical and Development
- xvi) Fuel Policy
- xvii) Flight Plan Routing
- xviii) Hijack and Sabotage Security Procedures
- b) In-flight Services
- i) Cabin Crew Training
- ii) Crew Performance Appraisal
- iii) In-flight Operation
- iv) Flight and Duty Time Limitations Scheme for Cabin Crew
- v) Safety Report
1.18
1.18.1
Provision of Air Traffic Services and Areas of Responsibilities
- 1) Introduction
- 2) Sector 3 Area of Responsibility
- 3) Sector 5 Area of Responsibility
- 4) Air Traffic Services Operations
- 5) KL ATSC Duty Shift System for Air Traffic Controllers
- 6) Chronology of Activities after Notification by HCM ACC
- 7) Activation of KL Aeronautical Rescue Coordination Centre
- 8) Recorded Telephone Conversations
- 9) Watch Supervisor Air Traffic Services and Sector (3 & 5) Logbook
- 10) Flight Progress Strip
1.18.2
1.18.2 Air Cargo Consignment
- 1) Introduction
- 2) Lithium Ion Batteries
- 3) Mangosteen Fruits
1.18.3
Crew and Passengers on Board MH370
- 1) Total Number of Crew and Passengers
- 2) Nationalities of the Crew and Passengers
- a) Crew
- b) Passengers
- c) Passengers’ Seating Positions
1.19
NEW INVESTIGATION TECHNIQUES – Not applicable