Safety Investigation Report 2018:2 Analysis/2.3 Medical Human Factors
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SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
2.3 MEDICAL/HUMAN FACTORS ISSUES
2.3.1 Introduction
This section analyses general human performance issues such as the medical history, professional qualifications, training, factors related to mental and physical fatigue, crew-to-ground communications, psycho-social events, and other relevant factors.
The analysis was done based on the following sources gathered from:
- 1) Personal records/files of the PIC, FO and the cabin crew from MAS.
These documents included the log book, certificates, licenses, medical records and any disciplinary/administrative actions; - 2) Investigation details from the Polis Di Raja Malaysia (PDRM) - Royal Malaysia Police. These were statements obtained from the next of kin
and relatives, doctors/care givers, co-workers, friends and acquaintances; financial records of the flight crew, CCTV recordings at KLIA and analysis of the radio transmission made between MH370 and ground Air Traffic Control; - 3) Medical records from private health care facility and from MAS Medical Centre; and
- 4) Interviews with MAS staff and several of the next of kin of the crew.
The analysis attained from documentations, CCTV recordings and interviews were conducted ethically, based on professional assessments code of practice of the Team.
2.3.2 General Human Performance Issues
- 1) The flight-crew’s medical background and recent activities were examined. All medical files reviewed showed no significant health- related issues. Information derived from interviews with the medical health care professionals in the MAS organisation, members of the family and some friends of the flight crew, and study of the available medical records indicate that the PIC and FO were in good health and certified fit to fly at the time of the flight.
- 2) The Team noted that the medical records or reports of the flight crew obtained from the MAS Medical Centre facility did not include medical records or reports from other medical facilities. In fact, the Team has found a medical record of the PIC from another private medical centre which was not recorded in the MAS Medical Centre. The records from the MAS Medical Centre as well as the records from private clinics regularly visited by both the flight crew also seemed to be mainly records related to minor ailments such as coughs and colds and may not be reflective of the complete medical record of the individuals in question.
- 3) Based on the available medical records, only one cabin crew member, the In-Flight Supervisor, was known to have a history of previous seizures in 2013 but was subsequently certified fit to fly. However, all the cabin crew were fit to fly at the time of the flight.
- a) All cabin crew were adequately rested before the flight based on the flying records.
- b) There is no evidence that members of the cabin crew had received any flight training, based on the ‘Basic Flying Training’ and ‘Aircraft Type Conversion Training’ (B777) records of the Company and records of DCA.
- 4) Both the PIC and FO held valid airman licenses and medical certification. They had received all the required training. It was concluded that both the PIC and FO were properly trained, licensed and qualified to conduct the flight.
- 5) Based on the flying records from the Scheduling Office, both the PIC and FO were within duty-time limits and therefore were adequately rested before the flight.
- 6) The interpersonal relationship between the PIC and FO was examined. There were no reports of any conflicts or problems between the PIC and FO prior to the flight or before the day of the flight. This is the first time the PIC and FO have flown together after the latter completed his upgraded training to the B777. The Team did not find any evidence of a strain in the relationship between the two. It was the FO’s last Line Training flight before he was scheduled to be checked out. The FO’s training progress was within the performance of new FOs promoted to the B777 from the smaller fleet.
2.3.3 Specific Human Factors Issues
In this section, the specific personal relationships, financial background, personal insurance coverage and benefits, past medical and medication history, as well as the recent behaviour of the PIC, FO and all the cabin crew were examined.
- 1) Personal Relationships
Information obtained from family and friends of both the PIC and FO suggested no recent changes or difficulties in personal relationships. There was nothing significant observed by the family and friends of the crew. The PIC and FO as well as the crew were not experiencing difficulties in any personal relationships. - 2) Pilot-in-Command
The investigation into the personal and professional career revealed that the PIC had flawless safety records with a smooth career pathway to his existing position as a Type Rating Examiner on the B777 and has been well respected throughout his flying career. He was considered a leading pilot who was given privileges to be an instructor and examiner. - 3) First Officer
The investigation into the personal and professional career revealed that the FO had a good safety record with a smooth career pathway to his existing position as a Co-pilot under training on the B777-200ER. The investigation into the FO’s personal and professional history revealed no disciplinary records. - 4) Cabin Crew
There is no evidence to suggest that any members of the cabin crew had experienced career-related incidents or mishaps resulting in major disciplinary records. - 5) Financial Background and Insurance Coverage
Information obtained on the financial background for the PIC, FO and all the cabin crew showed no evidence of financial stresses or impending insolvency. Analysis of the bank financial statements did not reveal any incidents of unusual financial transactions.
Based on the available data, investment or trading accounts owned by the PIC were mainly inactive or dormant. The FO and cabin crew have no investment or trading accounts. Insurance coverage records were unremarkable which include generally life insurance policy, motor vehicle insurance policy, medical insurance policy and personal accident policy. There is no evidence of recent or additional insurance cover purchased by the PIC, FO or any members of the cabin crew. - 6) Past medical and medication history
In the course of the investigation, it was confirmed that the PIC sustained a spinal injury as a result of a paragliding accident in January 2007. He was medically certified to have recovered from the injury, and there is no record of him being on long term medication for this, or other medical ailments. Scrutiny of his credit card transactions failed to reveal a pattern of regular purchase of over- the-counter medication of any significance, either in local or overseas pharmacies. The possibility that such medication may have been purchased by cash cannot be excluded.
The Team has further investigated the overseas over-the-counter prescriptions as there was no recorded transaction on the PIC’s credit card on any medications purchased. The Team specifically investigated the possibility of mental/stress-related ailments in the PIC and concluded that there is no medical record or other documentation of the PIC having received psychiatric treatment.
Similarly, there was no documented unusual health-related issues involving the FO. Other than the Inflight Supervisor, the other members of the cabin crew have no significant health-related issues. - 7) Recent Behaviour
According to family members and work associates who interacted with the PIC, FO and the cabin crew on the day of the flight and on their most recent flights, there were no behavioural signs of social isolation, change in habits or interest, self-neglect, involvement in drug or alcohol abuse. There were no significant behavioural changes observed on all the CCTV recordings for the PIC, FO and cabin crew related to the flight. - 8) Overall Comments
Evidence from the medical/human factors issues showed no unusual issues on the PIC, FO and cabin crew.
2.3.4 Human Factor Aspects of Air Traffic Control Recordings
- 1) Voice analysis
No Cockpit Voice Recorder (CVR) and Flight Data Recorder (FDR) analysis could be done as the wreckage is yet to be found. From the available information, the speech segments for the first 3 sets of audio recordings (Airway Clearance Delivery, Lumpur Ground and Lumpur Tower) were those of the FO before take-off and the 4th and 5th sets of the audio recordings (Approach Radar and Lumpur Radar) originated from the PIC after take-off.
The Team has noted nothing unusual in the conversations by the PIC and the FO with the assigned traffic Controllers. The last sentence of “Good Night Malaysian Three Seven Zero” was spoken by the PIC at 1719:30 UTC [0119:30 MYT]. - 2) Air Traffic Control Recordings
Radiotelephony recordings between the flight crew and the Air Traffic Controllers were analysed for voice recognition and it was verified that the words spoken before take-off and after take-off were that of the FO and PIC respectively. The Team has made comparison of the voice sample analysis recorded previously and found no evidence that there was any stress or anxiety detected in the conversations. It was noticed that the PIC made the same statement of “maintaining flight level three five zero’ twice at 1701.17 UTC [0107.57 UTC [0107.56 MYT]. However, the Team did not find any significance of that statement spoken twice by PIC in a short interval of 6.39 minutes.