Safety Investigation Report 2018:1 Factual Information/1.18/1.18.1
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
1.18 ADDITIONAL INFORMATION
1.18.1 Provision of Air Traffic Services and Areas of Responsibilities
1) Introduction
For the provision of Air Traffic Services (ATS), the Kuala Lumpur FIR is divided into seven Sectors, namely Sector 1, Sector 2, Sector 3, Sector 4, Sector 5, Sector 6 and Sector 7.
Each Sector has a specified area of responsibility. Sectors 1 to 5 are manned by Sector Planning and Radar Controller jointly responsible for the safe, efficient and orderly provision of air traffic control service, flight information service and alerting service in their Sectors. Each Sector has an Assistant Flight Data (AFD) Controller.
Sector 6 is manned by a Radar Controller and supported by the Sector 1 Planning Controller and Sector 1 AFD Controller. Sector 7 is manned by a Radar Controller and supported by the Sector 2 Planning Controller and Sector 2 AFD Controller.
- a) Responsibilities of Sector Radar Controller:
- • Handle all radiotelephony functions;
- • When necessary, coordinate to effect transfer of radar identity and control;
- • Monitor the Sector Inbound List (SIL) to ensure appropriate action for orderly acceptance, control and transfer of aircraft; and
- • Comply with instructions issued by FLOW control.
- b) Responsibilities of Sector Planning Controller:
- • Plan and coordinate as necessary for the management of all flights that will operate in their sectors; and
- • Ensure that the information on the electronic flight strips (EFS) is updated.
The Radar and Planning Controllers will make available to each other information that is essential to enable them to carry out their responsibilities, e.g. change in cruising level/altitude or revision to transfer of control point estimates.
- c) Responsibilities of Controllers at AFD Position:
- • Assist the Planning Controller by ensuring that information displayed on the EFS is kept updated in a timely manner;
- • Ensure that essential information found on the EFS is also available on the paper strips;
- • Display the paper strips on the display board in the correct manner;
- • Make paper strips available to the EXE Controller if requested;
- • Wrap up all used strips, and place them at a common place for collection; and
- • Clear wrong ADP Message Queues as follows:
2) Sector 3 Area of Responsibility
- a) Sector 3 is responsible for the provision of air traffic services in controlled airspace and outside controlled airspace above FL145 within:
That airspace from VKL to PIBOS then to 033658N 1022253E then to 040051N 1034109E at the border of Peninsular Malaysia/Singapore International Boundary, thence southwards along the FIR boundary to 012652N 1034540E thence northwards to 021958N 1034235E (10 nm west of VMR) thence westwards to DAMAL thence northwards along the airway R325 to SAROX (but excluding ATS Route R325) thence along the airway G334 to VKL but excluding the Kuantan TMA.
- b) Sector 3 is also responsible for the provision of FIS and Alerting Service in the South China Sea Corridor (SCSC). The lateral and vertical limits of the SCSC (Refer Table 1.18A [below]) are as follows:
| Laterals Limits | Vertical Limits |
| From 023600N 1044500E to 020000N1070000E and along 020000N till the Singapore/Kota Kinabalu FIR Boundary, thence along this Boundary to 060000N 1132000E, thence along 060000N till the Singapore/Kuala Lumpur FIR Boundary, thence along this Boundary to 023600N 1044500E | West of 105E FL150 |
Table 1.18A - Lateral and Vertical Limits of South China Sea Corridor
- c) Sector 3 encompasses the following ATS routes or route segments (Table 1.18B [below]):
| Routes | Segments | Routes | Segments |
| A224 | VMR - VJR | N884 | VMR – LENDA |
| B338 | VTK - VMR | N891 | PU – MANIM |
| B469 | VPK - PU | N892 | KIBOL - VMR |
| G334 | VKL - UKASA - VPT - KIBOL |
R221 | VMR - VPT |
| G582 | Sector 1 boundary - VPK |
R325 | MATSU - SAROX (FL280 & below) |
| G584 | VKL – VPK | W533 | VKL - VKN - VKE |
| L629 | VPK - BUVAL | W540 | VPK - A/VKE (FL235 & below) |
| L635 | VPK - DOVOL | Y331 | PIBOS - TAXUL |
| L642 | VMR - EGOLO | Y332 | TAXUL - PADLI |
| M751 | VPK - A/VKE (FL240 & above) |
Y333 | PADLI - BUVAL |
| M758 | VPK - ISDEL | Y334 | PADLI - DOVOL |
| M761 | VPK - KETOD | Y335 | PADLI - IDSEL |
| M763 | VPK - TAXUL | Y336 | ISTAN - PADLI - KETOD |
| M771 | VMR - RAXIM | - | - |
Table 1.18B - ATS routes or route segments of Sector 3
Note :
SAROX is not a waypoint on R325. It is a waypoint on G334 that intersects R325. It is used here for ease of reference.
- d) Delegation of Airspace and Communication Watch
- i) Delegation of Airspace from Kuala Lumpur ACC (Sector 3) to Singapore ACC
The contiguous airspace Areas A, C, E and H along eastern Johor/South China Sea and responsibility for provision of air traffic services in these areas remains delegated to Singapore.
- ii) Communication Watch
Extract from Malaysia AIP ENR 2.1-13
Source: Safety Investigation Report MH370/01/2018
- iii) Singapore will pass to Sector 3 Estimate for flights bound for the Natuna and Matak Islands. Sector 3 in turn, shall notify Aeronautical Mobile Service (AMS) High Frequency (HF) who shall provide additional communications watch in order to discharge its Flight Information Service (FIS)/Alerting Service functions.
- i) Delegation of Airspace from Kuala Lumpur ACC (Sector 3) to Singapore ACC
3) Sector 5 Area of Responsibility
- a) Sector 5 is responsible for the provision of air traffic services in controlled airspace and outside controlled airspace above FL145 within:
That airspace from VKL to PIBOS then to 033658N 1022253E then to 040051N 1034109E at the border of Peninsular Malaysia/Singapore International Boundary, thence northwards along the FIR boundary, thence westwards along the Peninsular Malaysia/Thailand International Boundary to 054342N 1010038E thence southwards to 044021N 1012704E, then to VKL but excluding the Kota Bharu TMA/Terengganu and Kerteh CTRs. Sectors 5 encompasses the following ATS routes or route segments (Table 1.18C [below]):
| Routes | Segments |
| A334 | PASVA – VKB |
| B219 | Butterwort TMA Boundary East – VKB |
| B463 | KADAX – VKB |
| G466 | VKL – VKB |
| M644 | VKB – ABTOK |
| M751 | A/VKE – VKB – GOLUD (FL240 and above) |
| M765 | VKB – VENLI – IGARI |
| R208 | VKL – GUNBO – VKR – IKUKO – IGARI |
| R325 | ANSOM – MATSU (FL 280 and below) |
| W540 | A/VKE – VKB (FL235 and below) |
Table 1.18C - ATS routes or route segments
- b) Delegation of Airspace
- i) Delegation of Airspace from Singapore ACC to Kuala Lumpur ACC (Sector 5)
- 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.
- iii) Communication Watch
To ease air traffic management, communication watch is maintained by Lumpur Sector 5 and Lumpur HF between IKUMI and IGARI along N89. Refer Figure 1.18A - Sector 3 and 5 Area of Responsibilities (below).
- i) Delegation of Airspace from Singapore ACC to Kuala Lumpur ACC (Sector 5)
Figure 1.18A - Sector 3 and 5 Area of Responsibilities
Source:
Safety Investigation Report MH370/01/2018
Figure 1.18B - Airspace Delegated to Malaysia by Singapore
Source:
Safety Investigation Report MH370/01/2018
4) Air Traffic Services Operations
- a) The disappearance of MH370 occurred in the Singapore FIR where the airspace is delegated to KL ACC. The portion of airspace delegated is RNAV route M765 between VENLI13 and IGARI14 , and the portion released is ATS route R208 between IKUKO 15 and IGARI. (References: Malaysia Aeronautical Information Publication (AIP) ENR 2.1-15 (Figure 1.18B [below]), ENR 3.1-10 and ENR 3.3-5 and Manual of Air Traffic Services [MATS] Vol. 2 page 2-2-10 paragraphs 2.4.3.1 & 2.4.3.2).
- b) KL ACC is responsible for the provision of Air Traffic Control Service, Flight Information Service and Alerting Service to all aircraft within Kuala Lumpur FIR and the “released airspace” on ATS route R208 and the “delegated airspace” on RNAV route M765 (Figure 1.18B [above]).
- c) MATS part 9, page 9-6-5 para 6.7.2 states that:
“If alerting service is required for an aircraft that is flight planned to operate through more than one FIR including the airspace delegated to the Kuala Lumpur and Kota Kinabalu ATSCs and, the position of the aircraft is in doubt, the responsibility for coordinating such service shall normally rest with the ATSC of the respective FIRs:
- a) Within which the aircraft was flying at the time of last radio contact;
- b) That the aircraft was about to enter when last radio contact was established at or close to the boundary of the two FIRs.
- d) Operational Letter of Agreement for the Provision of Search and Rescue Services between the Department of Civil Aviation Malaysia and the Department of Civil Aviation Singapore dated August 1984 page 6 para. 7.1 states that:
“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”
Para. 3.2.2, page 3 of the same agreement, para. (d) above states that:
“When a transfer of responsibility for the overall SAR co-ordination is to take place, either from subsequent establishment of an aircraft’s position or movement, or because an RCC other than the one initiating the action is more favourably placed to assume control of the mission by reason of better communication, proximity to the search area, more readily available facilities or any other reasons, the following procedures shall be adopted:
- i. direct discussions, wherever possible, shall take place between the Search and Rescue Mission Co-ordinators (SMCs) concerned to determine the course of action.
- ii. if it decided that a transfer of responsibility is appropriate for the whole mission or part thereof, full details of the SAR mission shall be exchanged.
- iii. the initiating RCC shall continue to retain responsibility until the accepting RCC formally assumes control for the mission.
_______________________________________________
13 Coordinates VENLI: 062846N 1024900E
14 Coordinates IGARI: 065612N 1033506E
5) KL ATSC Duty Shift System for Air Traffic Controllers
- a) The duty shift system (Table 1.18D [below]) on 07 March 2014 for Air Traffic Controllers was as follows:
Sectors 1, 2, 3, 4 and 5 were manned by a Radar Controller, a Planning Controller and an Assistant Flight Data Controller in each Sector from 1100-1600 UTC [1900-2400 MYT]. Sector 6 was manned by a Radar Controller and Sector 7 was not manned.
Day Shift Period 1 Afternoon • 0500 UTC [1300 MYT] - 1100 UTC [1900 MYT] 2 Morning & Night • 2300 UTC [0700 MYT] - 0500 UTC [1300 MYT] and
• 1100 UTC [1900 MYT] - 1600 UTC [2400 MYT]3 Midnight shift • 1600 UTC [0000 MYT] - 2300 UTC [0700 MYT] 4 Off duty Table 1.18D - Duty Shift System for Air Traffic Controllers
- b) From 1600 UTC [0000 MYT] until 2200 UTC [0600 MYT], the number of Controllers in the KL ATSC were scaled down by or to half to enable the Controllers to take a rostered break - the first half from 1600 UTC [0000 MYT] to 1900 UTC [0300 MYT] and the second half from 1900 UTC [0300 MYT] to 2200 UTC [0600 MYT], as follows:
- • Sector 1, Sector 2 and Sector 4 each were manned by a Radar Controller with an AFD Controller.
- • Sector 3 and Sector 5 were combined and operating from a Controller working position with a Radar Controller and an AFD Controller.
- • The area of responsibility would be that of Sector 3 and Sector 5. Between 1600 UTC [0000 MYT] and 2200 UTC [0200 MYT], Sectors 3 and 5 Assistant Flight Data Controller carried out the duty of Planning Controller.
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, and MATS page 8-2-6, Part 8 Surveillance para 2.4.1 - Controllers may instruct a radar identified aircraft to omit making compulsory position reports unless:
- • the position report is required for control purposes.
There was no instruction by the KL ACC Controller to MH370 to omit making compulsory position report as stated in MATS.
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.
Reference
Manual of Air Traffic Services, Part 9 - Emergencies, page 9-6-5, para. 6.7.2 dated 15/3/2009 No.1 states:
If alerting service is required for an aircraft that is flight planned to operate through more than one FIR including the airspace delegate to the Kuala Lumpur and Kota Kinabalu ATSCs and the position of the aircraft is in doubt, the responsibility for co-ordinating such service shall normally rest with the ATSC of the respective FIRs:
- • within which the aircraft was flying at the time of last air-ground radio contact;
- • that the aircraft was about to enter when last air-ground contact was established at or close to the boundary of two FIRs or control areas;
- • within which the aircraft’s intermediate stop or final destination point is located:
- 1) if the aircraft was not equipped with suitable two-way radio communication, or
- 2) was not under obligations to transmit position reports.
and
ICAO Doc 4444 ATM/501 Procedures for Air Navigation - Air Traffic Management (PANS-ATM), page 9-6, para 9.2.2.2, dated 22/11/07 states:
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:
- a) within which the aircraft was flying at the time of last air-ground radio contact;
- b) that the aircraft was about to enter when last air-ground contact was established at or close to the boundary of two FIRs or control areas;
- c) within which the aircraft’s intermediate stop or final destination point is located:
- 1) if the aircraft was not equipped with suitable two-way radio communication, or
- 2) was not under obligations to transmit position reports.
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” and
- a) The following actions shall be taken:
- 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.
MATS Part 9 para 6.2.3 stipulates that:
“If Controllers have reason to believe that an aircraft is lost, overdue or experiencing communication failure, they shall:
- a) inform appropriate radar units (civil and military) of the circumstances,
- b) request the units to watch out for emergency SSR code display or the triangular radio failure pattern, and
- c) notify these units when their services are no longer required.”
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).
- a) The following actions shall be taken:
_______________________________________________
16Distress Phase - A situation wherein there is a reasonable certainty that an aircraft and its occupants are threatened by grave and imminent danger and require immediate assistance.
17DETRESFA - The code for a Distress Phase
18Transfer of Control Point - A defined point located along the flight path of an aircraft, at which the responsibility for providing air traffic control service to the aircraft is transferred from one control unit or control position to the next.
19Estimate - The time at which it is estimated that an aircraft will be over a position or over the destination.
20ETA - Estimated time of Arrival.
21Uncertainty phase - A situation wherein doubt exists as to the safety of an aircraft or a marine vessel, and the Persons on board.
22RQS - Request Supplementary Flight Plan.
23Alert phase - A situation wherein apprehension exists as to the safety of an aircraft or marine vessel and of the persons on board.
24MAS Operations Centre used the name ‘Flight Explorer’
6) Chronology of Activities after Notification by HCM ACC
The paragraphs (Table 1.18E [below]) describe the chronology of activities after notification by HCM ACC leading to the initiation of the Search and Rescue operations (SAR) and deployment of resources for the MH370 search.
Refer Radiotelephony Transcripts - Appendices 1.18A to 1.18G - Air-Ground Communications.
a) Chronology of ATC Activities after Notification by HCM ACC
| No. | Time | Activities |
|---|---|---|
| 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. |
| 3. | 1741:23 UTC (0141:23 MYT) |
KL ACC Radar Controller made a “blind transmission” to MH370. |
| 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. |
| 5. | 1750:28 UTC [0150:28 MYT] (0150:27 MYT) |
KL ACC queried HCM ACC if there had been any contact with MH370, HCM ACC’s reply was “negative”. |
| 6. | 1757:49 UTC (0157:49 MYT) |
HCM ACC informed KL ACC that there was officially no contact with MH370 until this time. Attempts on many frequencies and through other aircraft in the vicinity received no response from MH370. |
| 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. |
| 8. | 1807:47 UTC (0207:47 MYT) |
HCM ACC queried for confirmation that MH370 was in Phnom Penh FIR as Phnom Penh did not have any information on MH370. KL ACC indicated it would check further with the supervisor. |
| 9. | 1812:15 UTC (0212:15 MYT) |
KL ACC informed HCM ACC that there was no update on the status of MH370. |
| 10. | 1815 UTC (0215 MYT) |
(No voice recording). Extracted from the Watch Supervisor Log Book: KL ATSC Watch Supervisor queried Malaysia Airlines Operations who informed that MH370 was able to exchange signals with the Flight Explorer. |
| 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. |
| 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. 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]. |
| 13. | 1834:56 UTC (0234:56 MYT) |
HCM ACC queried about the status of MH370 and was informed that the Watch Supervisor was talking to the Company at this time. |
| 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. |
| 15. | 1853:48 UTC (0253:48 MYT |
MH386 which was enroute from KLIA to Shanghai and within HCM FIR was requested by HCM ACC to try to establish contact with MH370 on Lumpur Radar radio frequency. KL ACC then requested MH386 to try on emergency frequencies as well. |
| 16. | 1930 UTC (0330 MYT) |
(No voice recording). Extracted from the Watch Supervisor 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. |
| 17. | 1930:03 UTC (0330:03 MYT) |
KL ACC queried if HCM ACC had checked with next FIR Hainan. |
| 18. | 1948:52 UTC (0348:52 MYT) |
When KL ACC queried whether HCM ACC had checked with the Sanya FIR, HCM ACC informed KL ACC that there was no response until now. |
| See Note 1 below | 1956:13 UTC (0356:13 MYT) |
At 1956:13 UTC [0356:13 MYT] KL ACC queried Malaysia Airlines Operations for any latest information or contact with MH370. |
| 19. | 2025:22 UTC (0425:22 MYT) |
HCM ACC Supervisor queried KL ACC on the last position that MH370 was in contact with KL ACC. |
| 21. | 2109:13 UTC (0509:13 MYT |
Singapore, on behalf of Hong Kong, enquired for information on MH370. |
| 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. |
| 22. | 2120:16 UTC (0520:16 MYT) |
Capt. xxxx [name redacted] of MAS requested for information on MH370. He opined that based on known information, “MH370 never left Malaysian airspace”. |
| 23. | 2130 UTC (0530 MYT) |
Watch Supervisor activated the Kuala Lumpur Aeronautical Rescue Coordination Centre (ARCC). |
| 24. | 2141:20 UTC (0541:20 MYT) |
HCM ACC queried for any updates. |
| 25. | 2214:13 UTC (0614:13 MYT) |
KL ACC queried HCM ACC if SAR was activated. |
| 26. | 2232 UTC (0632 MYT) |
KL ARCC issued a DETRESFA message (Figure 1.18C [below]). |
Table 1.18E – ATC Activities after Notification by HCM ACC
Source:
Safety Investigation Report MH370/01/2018
Note 1: Event 18 contained two entries which have been split here as it seems likely to be a formatting error. The same events are separate in Table 2.2C.
Note 2: The sequence of Events 19, 20 and 21 have been changed based on the time of each event. The correct sequence was shown in Table 2.2C.
b) DETRESFA Message of MH370
Figure 1.18C - DETRESFA Message
Source: DCA Malaysia
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].
The Kuala Lumpur Aeronautical Rescue Co-ordination Centre, Standard Operating Procedure for Search and Rescue, page 11, para 3.1 stipulated:
“The search and Rescue Mission Co-ordinator (SMC) is the officer assigned to co-ordinate response to an actual or apparent distress situation.
In aeronautical search and rescue operations, the SMC is usually in the best position to assess the circumstances of a particular case, and to take whatever steps necessary to promote the safety of life and prevent further loss of property.
The SMC must use his/her best judgment in initiating and coordination operations to ensure use of the most suitable method of planning with least possible delay.
Initial Actions
On receipt of information regarding aircraft in difficulties normally from the Watch Supervisor in the ATCC, or from request of assistance from RSCs, MRCC (vessel or person - maritime distress) or from any adjacent RCCs and is aware that assistance is required the SMC shall act as follows:
- Activate the SAR operation room;
- Appraise the situation.
Continue to take the following actions if emergency situation involves civil aviation accident:
- Declare the Distress phase if not done yet by the Duty Watch Supervisor;
- Notify the SAR Chief and the SAR Co-ordinator (SC);
- Request Supervisor to recall SAR trained staff if deemed necessary;
- Initiate ARCC activation message;
- Assign specific position accordingly (SMC, ASMC… etc.);
- Initiate NOTAM25 actions;
- Initiate RQS26 request from AIS27 and weather report from Meteorological Office if not done yet by the Supervisor;
- Obtain information of aircraft position if necessary by:
- - Information contained in the flight plan or notification;
- - Check all airports or possible alighting areas along the route of flight and within the possible flight range of the aircraft concerned;
- - Notify other aircraft or agencies to attempt establishment of the aircraft’s position, informing them of all known frequencies, request for aircraft lookout made through the ATCC Watch Supervisor);
- - Notify the Police, along the route of flight, and request them to verify alighting areas, or obtain information on the aircraft and its occupants;
- - Request MRCC28 to alert the vessels in the area if the flight is over or near water;
- - Ascertain the type of emergency equipment carried by the missing or distressed craft;
- - When required, request Radar assistance for search from appropriate radar station or Radar Plot.
_______________________________________________
25NOTAM (Notice to Airmen) - A notice issued by, or with the authority of the State and containing information or instruction concerning the establishment, condition change in any aeronautical facility, service, procedure or hazard, the timely knowledge of which is essential to persons concerned with flight operations. NOTAM is distributed by AFTN. (Aeronautical Fixed Telecommunication Network).
26 RQS - Request Supplementary Flight Plan.
27 AIS - Aeronautical Information Service.
28 MRCC - Maritime Rescue Coordination Centre.
8) Recorded Telephone Conversations
From the recorded telephone conversations between the KL ACC Radar Controller and MAS Operations Centre, the Radar Controller at 2123:18 UTC [0523:18 MYT] indicated that he would inform the Watch Supervisor to check on when was the last contact with MH370.
9) Watch Supervisor Air Traffic Services and Sector (3 & 5) Logbook
MATS Part 1 - Admin, page 1-1-7 para 1.7 for recording of entries in the logbook as follows:
- a) The time of entries shall be based on UTC and events recorded in a chronological order;
- b) Entries shall give sufficient details to give readers a full understanding of all actions taken;
- c) The time an incident occurred and the time at which each action was initiated shall be stated.
10) Flight Progress Strip
The FPS (Figure 1.18D below) of MH370 on 07 March 2014 . contains essential flight and control data and is the basic tool to enable Air Traffic Controllers to visualise the disposition of traffic within their area of responsibility including traffic arriving and departing an aerodrome, assess conflicts and control aircraft in a safe manner.
Figure 1.18D - Flight Progress Strip of MH370 on 07 March 2014
Source:
Safety Investigation Report MH370/01/2018