Safety Investigation Report 2018:Section 2

The Safety Investigation Report MH370/01/2018 was released by the The Malaysian ICAO Annex 13 Safety Investigation Team for MH370 in July 2018 as an English version only in portable document format (pdf). The content below is a text extract formatted in html. Images are not included. Links to the five sections of the report are provided below.

Section 1 Factual Information Section 2 Analysis Section 3 Findings and Conclusion
Section 4 Safety Recommendations Section 5 Comments to the Report.

SECTION 2 – ANALYSIS

INTRODUCTION

Section 2 analyses the relevant issues associated with the disappearance of B777200ER aircraft, registered as 9M-MRO, and operating as Flight MH370 on 08 March 2014. Recognising that at the time of issue of this Report, the main aircraft wreckage, including the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) have not been located, this analysis will necessarily be limited by a significant lack of evidence.

The issues that will be covered in this Section include the following:

Diversion from Filed Flight Plan Route; 2. Air Traffic Services Operations; 3. Flight Crew Profile; 4. Airworthiness & Maintenance and Aircraft Systems; 5. Satellite Communications; 6. Wreckage and Impact Information; 7. Organisation and Management of Department of Civil Aviation and Malaysia Airlines; and
Aircraft Cargo Consignment.

2.1 DIVERSION FROM FILED FLIGHT PLAN

2.1.1 Seven Simulator Sessions

To analyse further on how MH370 had diverted from the Filed Flight Plan (FPL) route, the Team conducted a total of seven flight simulator sessions to recreate the two turns of MH370, i.e. six sessions on the left turn past waypoint IGARI and one session on the right turn on reaching the south of Penang Island. Three of the seven sessions were conducted at high speed and the remainders at low speed. The turns were based on the recorded primary radar data that recorded a primary target conducting a left turn from where the SSR code ceased, shortly after the aircraft passed waypoint IGARI. The following data (Tables [below] on data input for the 2.1A to 2.1F first six sessions respectively) were introduced to simulate an actual environment:

Actual weight and meteorological condition prevailing at the time of the turn (extracted from the computerised flight plan); and
Different speed and rate of turns to determine scenarios closest were made available to the Team.

Recreating the Left turn past Waypoint IGARI – Session 1

Initial conditions Fuel 41,200 kg Gross weight 215,410 kg Height 35,000 ft Speed IAS 271 (475 knots ground speed) Simulator setup Speed/Lateral Navigation/Vertical Navigation (SPD/LNAV/VNAV), autopilot engaged, autothrottle engaged Entry waypoint N07.05.7 E103.47.1 Exit waypoint N07.12.7 E103.38.7

Table 2.1A - Data Input for Session 1

To get the ‘aircraft’ to track correctly, a flight path from waypoint IGARI to waypoint BITOD was generated with the entry and exit waypoints entered.

The simulation commenced before IGARI and the ‘aircraft’ turned right on LNAV and tracked to the entry waypoint. Once over the waypoint, the flight management computer (FMC) was directed to fly “direct to” to the exit waypoint. The ‘aircraft’ entered a left turn, with a maximum bank-angle of 26° (maximum bank-angle in LNAV is 25°).

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.

Session 2

Initial conditions (identical to Session 1) Fuel 41,200 kg Gross weight 215,410 kg Height 35,000 ft Speed IAS 271 (475 knots ground speed)

Simulator setup SPD/LNAV/VNAV, autopilot engaged, autothrottle engaged Entry waypoint N07.05.7 E103.47.1 Exit waypoint N07.12.7 E103.38.7 Additional waypoint N05.15.6 E100.27.5

Table 2.1B - Data Input for Session 2

To get the ‘aircraft’ to track correctly, a flight path from waypoint IGARI to waypoint BITOD was generated with the entry and exit waypoint entered. A further waypoint was entered along a track of 244° at the commencement of the right turn south of Penang.

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 bankangle of 26° (maximum bank-angle in LNAV is 25°).

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).

Session 3

Initial conditions Fuel 41,200 kg

Gross weight 215,410 kg Height 35,000 ft Speed IAS 250 (425 knots groundspeed) Simulator setup SPD/LNAV/VNAV, autopilot engaged, autothrottle engaged Entry waypoint N07.05.7 E103.47.1 Exit waypoint N07.12.7 E103.38.7 Additional waypoint N05.15.6 E100.27.5

Table 2.1C - Data Input for Session 3 Following discussions, it was decided to reduce the speed in the turn to see if the rate of turn would increase. In this session, the speed was reduced to 250 knots IAS (ground speed of 425 knots). Similar set up as Session 2.

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 bankangle 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.

Session 4

Following further discussions, it was decided to further reduce the speed in the turn.

The simulation commenced before IGARI and the ‘aircraft’ turned right on 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 bankangle of 23° (maximum bank-angle in LNAV is 25°).

Initial conditions Fuel 41,200 kg Gross weight 215,410 kg Height 35,000 ft Speed IAS 220 (400 knots groundspeed) Simulator setup SPD/LNAV/VNAV, autopilot engaged, autothrottle engaged Entry waypoint N07.05.7 E103.47.1 Exit waypoint N07.12.7 E103.38.7 Additional waypoint N05.15.6 E100.27.5 Table 2.1D - Data Input for Session 4

The ‘aircraft’ made the exit waypoint. However, it took 3 minutes and 30 seconds to achieve it.

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.

Initial conditions Fuel 41,200 kg Gross weight 215,410 kg Height 35,000 ft Speed IAS 271 (475 knots ground speed) Simulator setup SPD/LNAV/VNAV, autopilot engaged, then autothrottle engaged Entry waypoint N07.05.7 E103.47.1 Exit waypoint N07.12.7 E103.38.7 Additional waypoint N05.15.6 E100.27.5

Table 2.1E - Data Input for Session 5 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 disconnected and the ‘aircraft’ manually turned to the left. Bank-angles around 30°-32° were used. As the entry and exit waypoints were displaced slightly laterally (i.e. not exactly aligned 180° apart), the ‘aircraft’s wings were rolled level

when aligned to intercept the exit waypoint. This was at 2 minutes and 10 seconds. The ‘aircraft’ then intercepted the exit waypoint at 2 minutes and 40 seconds.

Session 6 (Manual Flying)

Finally, it was agreed that the same turn should be executed manually but at a lower speed of 250 knots with the autopilot disengaged and the ‘aircraft’ manually flown, with the autothrottle managing the speed. Same set-up as Session 2.

Initial conditions Fuel 41,200 kg Gross weight 215,410 kg Height 35,000 ft

Speed IAS 250 (425 knots ground speed) Simulator setup SPD/LNAV/VNAV, then autopilot disengaged, autothrottle engaged Entry waypoint N07.05.7 E103.47.1

Exit waypoint N07.12.7 E103.38.7 Additional waypoint N05.15.6 E100.27.5 Table 2.1F - Data Input for Session 6

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 stickshaker activated. The ‘aircraft’ intercepted the exit waypoint at 2 minutes and 28 seconds.

Analysis on Re-enactment Sessions (Sessions 1 - 6)

From the various re-enactment sessions tested, it is apparent that the ‘aircraft’ could make the turn in LNAV, but took a longer time due to bank-angle limitations (25°) and also required the need to reduce speed (Session 3 was the closest at 3 minutes and 3 seconds) in the turn.
However, there were issues with the entry waypoint being off the direct track IGARI to BITOD (to the south-east) and this resulted in the ‘aircraft’ being in a slight right bank when overflying the waypoint and then starting the left turn. This would have increased the time to make the left turn as the ‘aircraft’ had to roll through level, before rolling west.
The ‘aircraft’ could also make the turn and achieve a closer time to the recorded radar data with the autopilot disengaged and manually flown (Session 5 was closest with 2 minutes 10 seconds to wings-level and 2 minutes and 40 seconds to the exit waypoint).
Again, there were issues with the positioning of the entry and exit waypoints as they were not aligned (i.e. not 180° apart) leaving a short straight segment before the ‘aircraft’ intersected the exit waypoint.
Summary of 6 Simulator Re-enactment Sessions and Common Factors

Based on the six simulator re-enactment sessions conducted as summarised in (below) and on Table 2.1G the common factors in (below), the Team Table 2.1H concluded the following:

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).

Re-enactment Session 1 2 3 4 5 6 Ground Speed 475 475 425 400 475 425 (in knots) Autopilot     x X Engaged Additional x x X N05.15.6   Waypoint E100.27.5 26o 26o 28o 23o 30-32o 35o Bank angle (in degrees) Exit Waypoint Over- 2 min 3 min 3 min 2 min 2 min Time Shooting 45 sec 3 sec 30 sec 40 sec 28 sec

Table 2.1G - Re-enactment Sessions

Common Factors 1. Fuel 41,200 kg 2. Gross Weight 215,410 kg 3. Height 35,000 ft N07.05.7o E103.47.1o 4. Entry Point N07.12.7o E103.38.7o Exit Point 5. Autothrottle Engaged Table 2.1H - Common Factors

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.

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.
Without further evidence, the reason for the transponder information from the aircraft ceasing could not be determined;
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
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.

Session 7 – Recreating the Right Turn South of Penang Island

Initial conditions Fuel 36,000 kg Gross weight 210,200 kg Height 35,000 ft Speed IAS294 (525 knots groundspeed) M0.86 Note: A tailwind of 30 knots was needed to achieve this Simulator setup SPD/LNAV/VNAV, autopilot engaged, autothrottle engaged. Entry waypoint N05.15.6 E100.27.5 Exit waypoint N05.12.0 E100.01.5

Table 2.1I - Data Input for Session 7

To get the ‘aircraft’ to track correctly (Table [above]), both 2.1I the entry and exit waypoints were entered, without a track between them in the FMC. The ‘aircraft’ was flown on heading mode to turn gently to intercept the exit waypoint.

The simulation commenced before the entry waypoint. Once crossing the waypoint, a heading change to the right was initiated to achieve a bank-angle of 5°. During the turn, the bank-angle was increased to a maximum of 10°. The exit waypoint was easily intercepted at 3 minutes and 5 seconds (the recorded radar time was 3 minutes). No further simulations were done on this turn.

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. 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.

Reference:

Ho Chi Minh radar data recording, page 33 to 41 and page 51 to 61 of the Direct Line Coordination Communication KL ACC Sector 3+5 Planner (Appendix 1.18G) transcripts between Kuala Lumpur ACC and Ho Chi Minh ACC)

2.2 AIR TRAFFIC SERVICES OPERATIONS

2.2.1 Review of Flight MH370 before its Disappearance

The MH370 from Kuala Lumpur to Beijing was a normal daily scheduled flight. It took off at 1642 UTC [0042 MYT].
There was no indication of any unusual operations prior to departure and during the flight until the last secondary radar position symbol was recorded by ATC at 1721 UTC [0121 MYT] as detailed in Table 2.2A below. Chronological of events before disappearance of MH370
Preparation of the flight was in order from the time the Filed Flight Plan29 (FPL) message was filed and transmitted 12 hours before the flight.
The flight crew reported on time for duty and there was no delay in the departure of the flight (Figure [below] message). 2.2C - Departure
There was also no report of any significant or unusual health-related issues for the flight and cabin crew.
The radiotelephony speech segments from the cockpit with KL ACC were determined from the voice analysis of the ATC radiotelephony communications recording to be that of the FO before take-off and the PIC after take-off.
The transfer of control was effected three minutes before the estimate for IGARI. There was no recording of transmission (voice or in written form) of KL ACC informing HCM ACC (via direct land line) when MH370 was transferred 3 minutes earlier than the estimate for the Transfer of Control Point (TCP).

Note:

Based on reconstruction of the flight profile conducted on the (Section 2.1) B777 simulator, the flight would be at waypoint IGARI one minute earlier than the original estimate of 1722 UTC [0122 MYT].

29 Filed Flight Plan – The flight plan as filed with an ATS unit by the pilot or his designated representative, without any subsequent changes. 285

2.2.2 Chronology of ATC Events before the Disappearance of Flight MH370 No. Time Event Remarks 1. 0444 UTC Filed Flight Plan (FPL) of As required under [1244 MYT] scheduled flight of MH370 Annex 10, Volume II. transmitted at 070444 UTC [071244 MYT], about 12 hours earlier over the Aeronautical Fixed Telecommunications Network (AFTN). Flight planned on ATS/RNAV Filed Flight Plan (Figure 2.2A) Routes R208 IGARI M765 BITOD L637 TSN… ZBAA. 2. 1450 UTC PIC of MH370 signed in for duty. [2250 MYT] 3. 1515 UTC FO of MH370 signed in for duty. [2315 MYT] MAS Operations Despatch Centre (ODC) released flight. As per operational 4. 1625:52 UTC Airway clearance request to requirements. Lumpur Airways Clearance [0025:52 MYT] Delivery. 5. 1625:52 UTC Airway clearance request to Lumpur Airways Clearance [0025:52 MYT] . Delivery.

1627:31 UTC Pushback and start-up [0027:31 MYT] clearance request to Lumpur Ground. As per operational 7. 1640:31 UTC Lumpur Tower cleared MH370 requirements. [0040:31 MYT] for take-off. 8. 1642 UTC MH370 departed from Runway Departure message [0042 MYT] Three Two Right KLIA. (Figure 2.2C)
1642:53 UTC Lumpur Departure cleared Normal ATC practice for [0042:53 MYT] MH370 to climb to FL180 and to track shortening. cancel the Standard Instrument Departure (SID) clearance by tracking direct to waypoint (Figure 2.2A) IGARI.

Table 2.2A - Chronology of ATC Events before the Disappearance of Flight MH370 cont…

2.2.2 Chronology of ATC Events before the Disappearance of Flight MH370 (cont.) No. Time Event Remarks 10. 1643:31 UTC KL ACC Sector 3+5 coordinated As per Letter of [0043:31 MYT] with HCM ACC via direct land Agreement between line the estimate of MH370 for Malaysia and Viet Nam. waypoint IGARI at 1722 UTC on (Appendix 1.1A) [0122 MYT], request flight level 350 and the assigned SSR Code 2157. 11. 1646:39 UTC MH370 transferred to Lumpur As per operational [0046:39 MYT] Radar (Sector 3+5). requirement. 12. 1646:58 UTC Lumpur Radar (Sector 3+5) [0046:58 MYT] cleared MH370 to climb to FL250. As per operational requirement. 13. 1650:08 UTC Lumpur Radar (Sector 3+5) [0050:08 MYT] cleared MH370 to climb to FL350. 14. 1701:17 UTC MH370 reported maintainin g It was noticed that the [0101:17 MYT] FL350. PIC made the same statement of “maintaining flight level twice at three five zero’ 1701:17 UTC [0101.17 MYT] and at 1707:56 UTC [0107:56 MYT]. 15. 1707:56 UTC- MH370 reported maintaining • However, the Team [0107:56 MYT] FL350. did not find any significance of that statement spoken twice by PIC in a short interval of 6.39 minutes.

Table 2.2A - Chronology of ATC Events before the Disappearance of Flight MH370

cont…

2.2.2 Chronology of ATC Events before the Disappearance of Flight MH370

No. Time Event Remarks 15. 1707:56 UTC- MH370 reported maintaining Also refer • para. 2.2.9 [0107:56 MYT] FL350. on cont. para 1) a) (1-6) Radiotelephony Readback on frequency changes for more details.

1719:26 UTC The KL ACC radar Controller • Transfer of control was effected 3 minutes [0119:26 MYT] transferred MH370 to HCM ACC before the estimate for by instructing MH370 to contact IGARI. Ho Chi Minh on the VHF radio frequency 120.9 MHz. • KL ACC passed to HCM ACC estimate for IGARI as 1722 UTC. • Transfer of control to HCM ACC was effected at 1719 UTC before MH370 was over IGARI.

There was no arrangement between KL ACC and HCM ACC for an “electronic handoff” or other methods to hand over the radar picture.

1719:30 UTC MH370 responded with: “Good Thereafter there was no [0119:30 MYT] further voice night Malaysian Three Seven communication. Zero”.

Table 2.2A - Chronology of ATC Events before the Disappearance of Flight MH370

2.2.3 Filed Flight Plan of MH370

Source: DCA Malaysia Figure 2.2A - Filed Flight Plan of MH370

Message Code of FPL of MH370 and Meaning Message Code Meaning KLA297 070444 KL KLIA message A Series 297 Sequence Number 070444 Date-time-group or the transmission time of the filed flight plan message at 070444UTC

FF WMKKZQZX WMKKZRZX FF Priority Indicator for the message category WMKKZQZX 8-letter addressee for Lumpur “Area Control Centre”. WMKKZRZX 8-letter addressee for Lumpur “Approach Radar Office”.

070441 WMKKYOYX 070441 Message Filling Time (in UTC) WMKKYOYX 8-letter Message Originator for KLIA Aeronautical Information Office

Field Type 3 - Message type, number and reference data (FPL Filed Flight Plan Message WMKKYOYX Message Originator Indicator i.e. KLIA Aeronautical Information Service Office.

- Field Type 7- Aircraft Identification and SSR mode and code

-MAS370 Aircraft identification Malaysian 370

-Field Type 8 - Flight rules and type of flight -I Instrument Flight Rules -S Status: - Scheduled Air Transport

Field Type 9 - Number and type of aircraft and wake turbulence category -B772/H Boeing 777-200/wake turbulence category/Heavy Figure 2.2B - Message Code of Filed Flight Plan of MH370 and Meaning

cont…

Message Code of FPL of MH370 and Meaning (cont...) Message Code Meaning

Field Type 10 - Equipment and capabilities (a) Radio communication, navigation and approach aid equipment and capabilities -SDFGHIJ3J5M1RWXY/LB1D1

-S Equipped with: Standard COM/NAV/approach aid equipment for the route is carried and serviceable. Standard equipment is considered to be VHF RTF, VOR and ILS. D DME F ADF G GNSS H HF RTF I Inertial Navigation J3 CPDLC FANS 1/A VDL Mode 4 J5 CPDLC FANS 1/A SATCOM (INMARSAT) M1 ATC RTF SATCOM (INMARSAT) R PBN approved. W RVSM approved X MNPS approved Y VHF with 8.33 kHz. channel spacing capability/

(b) Surveillance equipment and capabilities

L Transponder Mode S, including aircraft identification, pressurealtitude, extended squitter (ADS-B) and enhanced surveillance capability B1 ADS-B with dedicated 1090 MHz ADS-B “out” capability D1 ADS-C with FANS 1/A capabilities

Field Type 13 - Departure aerodrome and time -WMKK1635 -Departure aerodrome KLIA estimated off-block time 1635 UTC

Figure 2.2B - Message Code of Filed Flight Plan of MH370 and Meaning

cont…

Message Code of FPL of MH370 and Meaning (cont...) Message Code Meaning Field Type 15 – Route -N0470F290 DCT PIBOS R208 IKUKO/M081F330 R208 IGARI M765 BITOD/N0480F330 L637 TSN/N0480F350 W1 BMT W12 PCA G221 BUNTA/N0480F370 A1 IKELA/N0480F370 P901 IDOSI/N0480F390 DCT CH DCT BEKOL/K0900S1160 A461 YIN/K0890S1130 A461 VYK

-airspeed 470 knots requested flight level 290 - the flight will proceed direct to waypoint PIBOS joining Airway R208 and to waypoint IKUKO, thence the airspeed will be Mach 0.81 flight level 330 on Airway R208 to waypoint IGARI joining Airway M765 thence to waypoint BITOD. Thence the airspeed will be 480 knots and flight level 330 on Airways L637 and proceed to TSN (Tansonnhat), thence the airspeed will be 480 knots and flight level 350. Thence on Airway W1 to BMT (Buon Ma Thout), thence Airway W12 to PCA (Phu Cat), thence on Airway G221 to waypoint BUNTA, thence airspeed will be 480 knots and flight level 370, thence proceed via Airway A1 to waypoint IKELA, thence airspeed will be 480 knots and flight level 370, thence via Airway P901 to waypoint ISODI, airspeed 480 knots and flight level 390. Thence track direct to CH (Cheung Chau), and direct to waypoint BEKOL. Thence the airspeed will be 900 kilometres per hour and level 11600 meters on Airway A461, thence to YIN (Yingde). Thence, the airspeed will be 890 kilometres per hour and level 11300 metres on Airway A461 to VYK (Dawangzhuang).

Field Type 16 - Destination aerodrome and total estimated elapsed time, destination alternate aerodrome(s)

-ZBAA0534 ZBTJ ZBSJ

-Destination aerodrome ZBAA - Beijing Capital International Airport and total estimated elapsed time 5 hours and 34 minutes Destination alternate aerodrome(s) Tianjin Binhai International Airport, and ZBTJ Shijiazhuang Zhengding International Airport ZBSJ -

Figure 2.2B - Message Code of Filed Flight Plan of MH370 and Meaning

cont...

Message Code of FPL of MH370 and Meaning (cont...) Message Code Meaning Field Type 18 – Other information

PBN/A1B1C1D1L1O1S2 DOF/140307 REG/9MMRO EET/WSJC0032 VVTS0042 ZJSA0210 VHHK0233 ZGZU0304 ZHWH0356 ZBPE0450 SEL/QRC RMK/ACASII EQUIPPED) PBN Performance Based Navigation/Indication of RNAV and or RNP capabilities. RNAV Specifications A1 RNAV 10 (RNP 10) B1 RNAV 5 all permitted sensors C1 RNAV 2 all permitted sensors D1 RNAV 1 all permitted sensors RNP Specifications L1 RNP 4 O1 Basic RNP 1 all permitted sensors S2 RNP APCH with BARCO-VNAV DOF/140307 7th Date of flight/2014 March REG/9MMRO Aircraft registration 9MMRO EET FIR boundary designators and accumulated estimated elapsed times from take-off to such FIR boundaries. Singapore FIR 32 minutes Ho Chi Minh FIR 42 minutes Sanya FIR 2 hours 10 minutes Hong Kong FIR 2 hours 33 minutes Guangzhou FIR 3 hours 4 minutes Wuhan FIR 3 hours 56 minutes Beijing FIR 4 hours 50 minutes SEL/QRC Selective Calling code/QRC RMK/ACAS II Equipped with ACAS II) EQUIPPED

Figure 2.2B - Message Code of Filed Flight Plan of MH370 and Meaning

2.2.4 Departure Message of MH370

Source : Dca Malaysia

Figure 2.2C - Departure Message of MH370

Message Code of Departure Message of MH370 and Meaning Message Code Meaning (DEP (Departure -MAS370/A2157 -Aircraft identification MH370/Secondary Surveillance Radar Code A2157 -WMKK1642 -KLIA1642 (UTC) -ZBAA -destination aerodrome: Beijing/Capital -DOF140307) -Date of flight 2014March07) Figure 2.2D - Message Code of Departure Message of MH370 and Meaning

2.2.5 Waypoints - Geographical Coordinates (LAT/LONG) of MH370 Filed Flight Plan

No. WAYPOINT LAT LONG AIRWAY 1. PIBOS N0320.5 E10203.1 R208 2. IKUKO N0545.2 E10313.4 R208 3. IGARI N0656.2 E10335.1 R208

BITOD N0715.4 E10407.1 M765 5. TSN N1049.0 E10638.7 L637 6. BMT N1240.0 E10807.4 W1 7. PCA N1357.4 E10902.5 W12 8. BUNTA N1650.0 E10923.7 G221
IKELA N1839.7 E11214.7 A1 10. IDOSI N1900.0 E11230.0 P901 11. CH N2213.2 E11401.8 DCT 12. BEKOL N2232.5 E11408.0 DCT 13. YIN N2411.4 E11324.9 A461
VYK N3911.7 E11634.3 A461

Table 2.2B - Waypoints of MH370 FPL

2.2.6 Analysis on FPL Message of MH370

The MH370 FPL had been filed in accordance with the Doc 4444 ATM/501, Procedures for Air Navigation Services - Air Traffic Management (PANS-ATM).
However, there are two airways designated as A1/P901 within Hong Kong Flight Information Region (FIR) which required examination. Both airways (A1 and P901) are within the Hong Kong FIR, and have the same alignment and share the same waypoints. The waypoints are IKELA, IDOSI and CH (CHEUNG CHAU). The differences between the two airways are the lower limits and upper limits. The lower limit of A1 is 8,000 ft, and the upper limit is FL285 whereas the lower limit of P901 is FL285 and upper limit unlimited.

Note:

Refer to the following for details:

 (below) Figure 2.2E - Route Segment of ATS Route A1 and and Performance Based Navigation (PBN) Route P901;

 (below) Figure 2.2F - Longitudinal Cross Section of ATS Route A1 and PBN Route P901

It is observed that the fifth group of alphabet/number, written as ZPE0450, in line 13th of the FPL message of MH370 should read ZBPE0450. However, the missing alphabet B from the original text message does not invalidate the FPL.

2.2.7 Chronology of ATC Events following the Disappearance of MH370 (Table 2.2C, below) No. Time Event 1. 1720:31 UTC Radar recording showed MH370 passed over waypoint [0120:31 MYT] IGARI. 2. 1720:36 UTC Mode S radar symbol of MH370 dropped off from radar [0120:36 MYT] display. 3. 1721:13 UTC 3.2 nm after passing IGARI, SSR radar position symbol of [0121:13 MYT] MH370 dropped off from radar display.

Two radar sources, from Viet Nam and Thailand respectively, captured the disappearance of the radar position symbol of MH370 vis-à-vis Bangkok radar target drop at 1721:13 UTC [0121:13 MYT] and Viet Nam’s at 1720:59 UTC [0120:59 MYT]. 4. 1739:03 UTC HCM ACC queried KL ACC on whereabouts of MH370 and [0139:03 MYT] informed KL ACC that verbal contact with MH370 was not established and the radar target was last seen at waypoint BITOD.

Note: MH370 did not arrive over waypoint BITOD (Refer to above). Item 3 5. 1741:22 UTC HCM ACC enquired for information on MH370. [0141:22 MYT] KL ACC informed HCM ACC that after waypoint IGARI, MH370 did not return to Lumpur radar frequency. transmission’30 6. 1741:23 UTC KL ACC Radar Controller made a ‘blind to [0141:23 MYT] MH370. 7. 1746:47 UTC HCM ACC queried on MH370 again, stating that radar [0146:47 MYT] contact was established at IGARI but there was no verbal contact. HCM ACC advised that the observed radar blip disappeared at waypoint BITOD. HCM ACC also stated that efforts had been made to establish communications by calling MH370 several times for more than twenty minutes.

Table 2.2C Chronology of ATC Events following the Disappearance of MH370

cont...

30 Blind transmission - A transmission from one station to another station in circumstances where two-way communications cannot be established but where it is believed that the called station is able to receive the transmission. 298

2.2.7 Chronology of ATC Events following the Disappearance of MH370 (Table 2.2C, below) No. Time Event 8. 1750:28 UTC KL ACC queried HCM ACC if there was any contact with [0150:28 MYT] MH370. HCM ACC’s reply was: “Negative”.

1757:49 UTC HCM ACC informed that there was officially no contact with [0157:49 MYT] MH370 until this time. Attempts on many frequencies and aircraft in the vicinity received no response from MH370.
1803:48 UTC KL ACC queried HCM ACC on status of MH370. HCM ACC [0203:48 MYT] confirmed there was no radar contact at this time and no verbal communications was established. KL ACC relayed the information received from Malaysia Airlines Operations that aircraft was in Cambodian airspace.
1807:47 UTC HCM ACC queried for confirmation that MH370 was in [0207:47 MYT] Phnom Penh FIR as Phnom Penh did not have any information on MH370. KL ACC indicated it would check further with the supervisor.
1812:15 UTC KL ACC informed HCM ACC that there was no update on [0212:15 MYT] status of MH370. 13. 1815 UTC Extract from Watch Supervisor Log Book (in written form [0215 MYT] only, no voice recording):

KL ATSC WS queried Malaysia Airlines Operations who informed that MH370 was able to exchange signals with the Flight Explorer.

1818:50 UTC KL ACC queried if flight planned routing of MH370 was [0218:50 MYT] supposed to enter the Cambodian airspace. HCM ACC confirmed that planned route was only through the Vietnamese airspace. HCM ACC had checked and Cambodian had advised that it had no information on or contact with MH370. HCM ACC confirmed earlier information that radar contact was lost after BITOD and radio contact was never established. 15. 1833:59 UTC KL ACC Radar Controller enquired with MAS Operations [0233:59 MYT] Despatch Centre (ODC) on communications status on MH370. Personnel was not sure if the message went through successfully. ODC informed that aircraft was still sending movement message indicating it was somewhere

Table 2.2C - Chronology of ATC Events following the Disappearance of MH370 cont... 299

2.2.7 Chronology of ATC Events following the Disappearance of MH370 (Table 2.2C, below) No. Time Event 15. 1833:59 UTC in Viet Nam, and that its last position was at coordinates cont.. [0233:59 MYT] N14.90000 E109 15500 at 071833 UTC [080233 MYT].

1834:56 UTC HCM ACC queried on the status of MH370 and was advised [0234:56 MYT] that the Watch Supervisor was talking to the Company at this time. 17. 1854:28 UTC Requested MH386, which was then in the HCM FIR, to try [0254:28 MYT] to establish contact with MH370 on emergency frequencies.
1930 UTC Extract from KL ACC Watch Supervisor ATS logbook: [0330 MYT] MAS Operations Centre informed KL ACC that the flight tracker was based on flight projection and not reliable for aircraft positioning. 19. 1930:03 UTC KL ACC queried if HCM ACC had checked with next FIR [0330:03 MYT] HAINAN.
1948:52 UTC KL ACC queried if HCM ACC had checked with the SANYA [0348:52 MYT] FIR. HCM ACC informed KL ACC that there was no response until then.
1956:13 UTC KL ACC queried MAS Operations Centre for any latest [0356:13 MYT] information or contact with MH370.
2025:22 UTC HCM ACC Supervisor queried KL ACC on the last position [0425:22 MYT] that MH370 was in contact with KL ACC.
2109:13 UTC Singapore, on behalf of Hong Kong ACC enquired for [0509:13 MYT] information on MH370.
2118:32 UTC HCM ACC queried for information on MH370, KL ACC [0518:32 MYT] queried if any information had been received from Hong Kong or Beijing.
2120:16 UTC Capt. [name redacted] of MAS requested for xxxx [0520:16 MYT] information on MH370. He opined that based on known information,”MH370 airspace.” never left Malaysian
2130 UTC Duty ATSC Watch Supervisor activated the Kuala Lumpur [0530 MYT] Aeronautical Rescue Coordination Centre (ARCC).

Table 2.2C - Chronology of ATC events following the disappearance of MH370 cont...

2.2.7 Chronology of ATC Events following the Disappearance of MH370 (Table 2.2C, below)

No. Time Event 27. 2214:13 UTC KL ACC queried HCM ACC if SAR was activated. [0614:13 MYT] 28. 2232 UTC KL ARCC issued a message. DETRESFA [0632 MYT] Table 2.2C - Chronology of ATC Events following the Disappearance of MH370

2.2.8 ATS Operational Issues after Last Radio Communication with MH370 and subsequent ATS Activities/Actions

The following analysis are based on the ICAO Doc 4444 ATM/501, Procedures for Air Navigation Services - Air Traffic Management (PANSATM), Annex 11 - Air Traffic Services, Aeronautical Information Publication, MATS and MATS Vol 2 Malaysia. Operation Letter of Agreement between DCA Malaysia and Viet Nam Air Traffic Management (effective 1 November 2011/, Letters of Operational Agreement Malaysia - Singapore dated August 1984 DCA/SAR01-84/Doc 04 (a).

They also include the Chronology of events following the disappearance of MH370, as tabulated above (Table 2.2A), the Team had gathered these operational issues regarding activities/actions taken by KL ACC, HCM ACC and others as follows:

No. Operational Issues 1. Transfer of Control Point31 at Waypoint IGARI

Responsibilities of Accepting Air Traffic Control Service Unit on ‘Establishment of Communications’ 3. Marking of MH370 Flight Progress Strips32
Responsibilities of Air Traffic Controller 5. Recognising Emergency Situations and ATC Actions

31 Transfer 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. 32 Flight Progress Strip - It contains essential flight and control data and is the basic tool which enables Controllers to visualize 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. 301

cont..

No. Operational Issues 6. Information to be passed to other Radar Stations - Civil and Military 7. Provision of Alerting Service by an ATSU for flights operated through more than one FIR and ATC actions 8. Actions taken by Duty ATSC Watch Supervisor

Flight-following System of Malaysia Airlines 10. Communications Exchanges between KL ACC and HCM ACC, and KL ACC and Malaysia Airlines Operations Centre on MH370 11. Delegation of Airspace from Singapore ACC to KL ACC
ATC Actions on Strayed/Unidentified Aircraft (Primary Radar Target) within Area of Responsibility 13. KL ATSC Duty Shift System for Air Traffic Controllers 14. Roles played by the ATSC Duty Watch Supervisor 15. Activation of Aeronautical Rescue Coordination Centre 16. Playback of Radar and Radio Telephony Recordings by Duty ATSC Watch Supervisor 17. Entries in Air Traffic Services Logbooks of ATSC Duty Watch Supervisor and Sector 3 Controller Working Position
Distress Message 19. Issues with the Manual of Air Traffic Services
Analysis of ATS Operational Issues after Last Radio Communication with MH370 and subsequent Activities/Actions taken

Transfer of Control Point at Waypoint IGARI

The MH370 flight from Kuala Lumpur to Beijing was planned on ATS/RNAV Routes R208 IGARI M765 BITOD L637 TSN…ZBAA. About one and a half minutes after MH370 took off at 1642 [0042 MYT], KL ACC conveyed to HCM ACC via the direct land line the estimate for waypoint IGARI as 1722 UTC [0122MYT], and requested Flight Level three five zero and Squawk two one five seven. HCM ACC acknowledged: “two one five seven, three five zero is approved, one seven two two”.
The Transfer of Control Point (TCP) for flights on route R208 IGARI M765 BITOD L637 TSN…ZBAA is IGARI. Aircraft operating on this route shall be transferred by KL ACC to HCM ACC when the Radar Controller observes on the radar display that the aircraft is over IGARI or when the aircraft reports over IGARI.
The transfer of control by KL ACC to HCM ACC is by way of instructing the aircraft concerned on the control VHF (very high frequency) radio frequency 132.5 MHz to contact HCM ACC on VHF radio frequency 120.9 MHz. The ATS infrastructure in KL ACC was not equipped to perform an “electronic handoff” of aircraft or other method to hand over the radar picture to HCM ACC.

References:

MATS Vol. 2, Part 2 KL ATSC - Coordination, para. 3.5.8, page 2-3-53 Coordination between Sector 5 Position and HCM ACC dated 15 March 2013 (Table as shown below. 2.2E)

The LOA (Appendix 1.1A) between DCA Malaysia and Vietnam Air Traffic Management dated 18 July 2001 and effective on 01 November 2001, para Transfer of Control Point (Table 2.2D [below]), page 7, as below:

Table 2.2D - Coordination Procedures

Table 2.2E - Coordination between Sector 5 and Ho Chi Minh ACC

(1) The Transfer of Control Point as stated in the Doc 4444 Chapter 10 - Coordination, paragraph, 10.1.2.2, page 10-3 dated 10/11/16 is as follows:

10.1.2.2.1 The responsibility for the control of an aircraft shall be transferred from the ATC unit to the next unit at the time of crossing the common control area boundary as determined by the unit having control of the aircraft or at such other point or time as has been agreed between the two units.

10.1.2.2.2 Where specified in letters of agreement between the ATC units concerned, and when transferring an aircraft, the transferring unit shall notify the accepting unit that the aircraft is in position to be transferred, and specify that the responsibility for control should be assumed by the accepting unit forthwith at the time of crossing the control boundary or other transfer control point specified in letters of agreement between the ATC units or at such other point or time coordinated between the two units.

10.1.2.2.3 If the transfer of control time or point is other than forthwith, the accepting ATC unit shall not alter the clearance of the aircraft prior to the agreed transfer of control time or point without the approval of the transferring unit.

10.1.2.2.4 If transfer of communication is used to transfer an aircraft to a receiving ATC unit, responsibility for control shall not be assumed until the time of crossing the control area boundary or other transfer of control point specified in letters of agreement between the ATC units.

(2) KL ACC transferred MH370 to HCM ACC by instructing MH370 to contact Ho Chi Minh on the VHF radio frequency 120.9 MHz at 1719:26 UTC [0119:26 MYT].

(3) MATS Vol. 2, Part 2 KL ATSC and Operational Letter of Agreement between DCA Malaysia and Viet Nam Air

Traffic Management do not have provision for KL ACC to effect transfer of communication of an aircraft to HCM ACC. It is noted that MH370 was transferred to HCM ACC three minutes before the Transfer of Control Point.

(4) The recorded landline communications 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].

(5) The following timings were based on recordings vis-à-vis landline/radiotelephony communications and radar recording:

(a) 1643 UTC - KL ACC passed MH370’s estimated time over IGARI at 1722 UTC to Ho Chi Minh ACC.

(b) 1719:26 UTC - MH370 was instructed by KL ACC to contact Ho Chi Minh ACC.

(c) 1719:30 UTC - MH370 acknowledged.

(d) 1720:31 UTC - MH370 passed over IGARI.

From the above timings, it is evident that there was a 3minute lapse from the time MH370 was instructed to estimate.33 HCM ACC and the original

(6) Radiotelephony Readback

(a) Readback Messages

MATS Part 10 - COM, page 10-3-3 para 3.4.4 states that:

Pilots are required to read back in full messages containing any of the following:

Level instructions; b) Heading instructions; c) Speed instructions; d) Airways or route clearances;

33 See – Chronology of ATC Events before the Disappearance of Flight MH370 for detailed timeline Table 2.2A plot. 306

Runway in use; f) Clearance to enter, land on, take-off, backtrack, cross or hold short of an active runway; g) SSR operating instructions;

Altimeter settings;

Frequency Changes

(b) Readback on Frequency Changes

Annex 11 - Air Traffic Services, page 3-7 para 3.7.3 states:

Readback of clearances and safety-related information.

3.7.3.1 The flight crew shall read back to the Air Traffic Controller safety-related parts of ATC clearances and instructions which are transmitted by voice. The following items shall always be read back:

ATC route clearances;

clearances and instructions to enter, land on, take-off from, hold short of, cross and backtrack on any runway; and
runway-in use, altimeter settings, SSR codes, level instructions, heading and speed instructions and, whether issued by the Controller or contained in ATIS broadcasts, transition levels.

3.7.3.1.1 Other clearances or instructions, including conditional clearances, shall be read back or acknowledged in a manner to clearly indicate that they have been understood and will be complied with.

(c) Doc 4444 Air Traffic Management (PANS-ATM) Pages 4-8 para 4.5.7.5 states that:

4.5.7.5.1 The flight crew shall read back to the Air Traffic Controller safety-related parts of ATC clearances and instructions which are

transmitted by voice. The following items shall always be read back:

ATC route clearances;

clearances and instructions to enter, land on, take-off from, hold short of, cross and backtrack on any runway; and
runway-in-use, altimeter settings, SSR codes, level instructions, heading and speed instructions and, whether issued by the Controller or contained in automatic terminal information service (ATIS) broadcasts, transition levels.

4.5.7.5.1.1 Other clearances or instructions, including conditional clearances, shall be read back or acknowledged in a manner to clearly indicate that they have been understood and will be complied with.

(d) Pilot’s Readback on Frequency Changes

MATS clearly stipulates that pilots are required to read back radio frequency changes. Similarly, ICAO Annex 11 and ICAO Doc 4444 also stipulate that:

“other clearances or instructions shall be read back or acknowledged in a manner to clearly indicate that they have been understood and will be complied with”.

At 1719:26 UTC KL ACC had instructed MH370 to contact Ho Chi Minh on radio frequency one two zero decimal nine (120.9). MH370 was therefore required to read back the frequency change as an acknowledgment and thereby had complied with the instruction. There was no readback from MH370.

There were altogether five instances where MH370 had to change radio frequencies when transferred from an ATC unit to another. They are as follows:

- From Airways Clearance Delivery to Lumpur Ground (Note 1, below);

- From Lumpur Ground to Lumpur Tower (Note below); 2

- From Lumpur Tower to Lumpur Approach (Note below); 3

- From Lumpur Approach to Lumpur Radar (Sector 3+5) [Note below]; and 4

- From Lumpur Radar (Sector 3+5) to Ho Chi Minh (Note 5, below).

Note 1

When Airways Clearance Delivery transferred MH370 to Lumpur Ground, the radio frequency of Lumpur Ground was not mentioned by the ATC. MH370 responded by transmitting “Good day sir.”

Note 2

When Lumpur Ground transferred MH370 to Lumpur Tower, the Lumpur Tower radio frequency was transmitted by the Controller even though it was unintelligible in the RT recording, MH370 read back the radio frequency, “One one eight eight Malaysian Three Seven Zero thank you.”

Note 3

When Lumpur Tower transferred MH370 to Lumpur Approach Control, ATC transmitted the take-off clearance, no radio frequency was included in the take-off clearance and the pilot read back the take-off clearance, “Three Two Right clear for take-off Malaysian Three Seven Zero thank you bye.“

Note 4

When Lumpur Approach Control transferred MH370 to Lumpur Radar (Sector 3+5), the Sector 3+5 radio frequency was transmitted by Lumpur Approach Control and MH370 read back the radio frequency, “Night one three two six Malaysian err… Three Seven Zero”.

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 the radio frequency Malaysian Three Seven Zero”, 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 readback at this stage of the flight but noted that it was not consistent with the previous frequency changes.

(e) Maintaining FL350 Transmitted Twice

At 1701:17 UTC [0101:17 MYT] MH370 made a radio transmission: “Maintaining flight level three and again at 1707:56 five zero three seven zero” UTC [0107:56 MYT].

The MAS Standard Operating Procedures (SOPs) for flight crew dictated that the PIC and the FO would have to be on-seat during the following phrases of flight:

Take-off; • Climbing and descending; and • Approach and landing.

However, one of the flight crew could leave the cockpit for a break once the aircraft had maintained the assigned cruising level.

The voice recognition process (para 1.5.11) has established that the PIC made the radio transmission of maintaining flight level three five at 1701:17 UTC [0101:17 MYT] and again at zero 1707:56 UTC [0107:56 MYT].

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.

Responsibilities of Accepting Air Traffic Control Service Unit on Establishment of Communications

3rd i) The paragraph of page 11 of the LOA between DCA Malaysia and Viet Nam Air Traffic Management (Appendix 1.1A), titled Establishment of Communication states that:

“The a. accepting unit shall notify the transferring unit if two-way communication is not established within five (5) minutes of the estimated time for the TCP”.

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].

The direct line coordination between KL ATCC Sector 3+5 Planner states that, at 1747:09 UTC [0147 MYT]. HCM ATCC informed KL ATCC that: “we call him many This shows that times until na…more than 20 minutes.” HCM ATCC had commenced communication search for MH370 FROM 1727 UTC [0127 MYT].
At 1757:51 [0157:51 MYT], HCM ATCC again informed KL ATCC: “Yes sir, we officially no contact from Malaysian Three Seven Zero until now and we try on many frequencies and all the aircraft calling, no response from Malaysian Three Seven Zero.”
The 12 minutes lapse on the part of HCM ACC to notify KL ATCC could have come about by their actions to carry out

communication search and thereby had resulted in their failure to notify KL ATCC by 1727 UTC [0127 MYT.

Note

The 12 minutes interval is derived from the timings of the two-way radio communication recording between HCM ACC and KL ACC above for details. (para 2.2.9 para. b) i)

Marking on MH370 Flight Progress Strip

Two markings have been left out on the flight progress strip (FPS), (below) of MH370: Figure 2.2G,

(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.

Source: DCA Malaysia

Figure 2.2G - Flight Progress Strip on MH370 from KL ACC

(3) Strip Marking on Flight Progress Strips

MATS Vol 2, Part 2 KL ATSC - General, page 2-1-8 para 1.4 dated 15 March 2009 and page 2-1-9 dated 15 March 2009 shows example of how the flight progress strip of a flight is marked.

Refer (below): Figure 2.2H - Strip Marking on Flight and Progress Strips generated by FDPS, Figure 2.2I Example on how the PLN strip will appear and Example on how the EXE strip will appear.

Figure 2.2H - Strip Marking on Flight Progress Strips generated by FDPS

MATS Vol 2, Part 2 KL ATSC - General, page 2-10-9 para contd. 1.4 dated 15 March 2009:

Figure 2.2I - Example on how the PLN strip will appear and Example on how the EXE strip will appear

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.

Responsibilities of Air Traffic Controllers

MATS Vol. 1, Part 1 - ADMIN, para 1.2.2, page 1-1-4, which states as below:

responsible: Air Traffic Controller is

for maintaining a continuous watch on their assigned [Refer communications channels or radar displays. para. v) below].

In interviews conducted with the Air Traffic Control Officer (ATCO) who was on duty on the night of the disappearance of MH370, the Sector 3+5 Radar Controller stated that he did not continuously monitor the progress of MH370 because he had to shift his focus to another area, viz. VPK34 (approximately 214 nm south-southwest of IGARI), as there were four other flights over that area that required his attention.
The radiotelephony transcripts of this sector confirmed that there were other four other flights - one at 1723 UTC [0123 MYT] proceeding to VPK and contacting Lumpur Radar and three others at 1726 UTC [0126 MYT], 1742 UTC [0142 MYT] and 1746 UTC [0146 MYT] respectively.
MH370 was operating in the Sector 3+5 Area of Responsibility (AOR) when the Radar Controller transferred the aircraft to HCM ACC. As he had not been monitoring the progress of the flight of MH370, the Sector 3+5 Radar Controller was not aware when MH370 passed the TCP IGARI, and when the MH370 radar display symbol started to “coast” and dropped from the radar display.

34 VPK - Pekan DVOR/DME coordinates 032259N 1032524E. 315

Notwithstanding the fact that he had to shift his focus to another area within his AOR, the Radar Controller was still required to monitor the progress of MH370. The responsibility of the Sector 3+5 Radar Controller for MH370 did not end with the transfer of control to HCM ACC. The process of transfer of control is only with regard to Air Traffic Control Service. Therefore, the Sector 3+5 Radar Controller was still responsible for the provision of alerting service to MH370 as it was still operating within his AOR. The responsibility of the provision of alerting service would end when MH370 had a two-way radio communication with HCM ACC.

The Radar Controller was not aware when MH370 radar position symbol dropped off from the radar display.

Recognising Emergency Situations and Air Traffic Control Actions

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.
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 had existed. By then, the Radar Uncertainty Phase Controller should have commenced full overdue action (not later than 30 minutes after the declaration of an Phase), i.e. notify the KL ARCC that an Uncertainty Alert existed. Phase
Manual of Air Traffic Services, Part 9 - Emergencies, page 9-6-5, para. 6.7.2 dated 15/3/2009 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.

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 coordinating 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 airground 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:

if the aircraft was not equipped with suitable two-way radio communication, or
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 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:

if the aircraft was not equipped with suitable two-way radio communication, or
was not under obligations to transmit position reports.

The responsibility for the provision of alerting service for MH370 therefore rested on KL ACC.

Following the Phase, the should be Alert Distress Phase declared by the Radar Controller after further unsuccessful attempts to establish communication with the aircraft and more widespread unsuccessful inquiries pointed to the probability that the aircraft was in distress.

References

(1) MATS, PART 9 - EMERGENCIES, para 1.3.1 a) and b) page 9-1-2 Ver.01 stipulates that:

Controller may suspect that an aircraft is experiencing an emergency situation or that an emergency situation exists if one of the following situations becomes apparent:

when radio contact is not established at the time it is expected to be established;

radio or radar contact is lost;
pilot reports a malfunction or unusual behaviour of person(s) on board; d) pilot reports of unlawful interference; e) aircraft is observed or reported to be behaving erratically;
aircraft is overdue at an aerodrome; and g) an ELT signal is heard or is reported.

(2) MATS PART 9 - EMERGENCIES, SECTION 2 OVERDUE AIRCRAFT, para. 2.1.1, page 9-2-1, No.1, dated 15/03/2009 stipulates that:

ATC action with respect to an aircraft that is overdue should not be considered in isolation, and the emergency actions described in other sections, in particular radio failure procedures, should be applied if they are appropriate. For example, if a radio-equipped aircraft fails to make an expected report, continuous attempts should be made to re-establish communications while at the same time initiating overdue action.

(3) MATS PART 9 - EMERGENCIES, SECTION 2 OVERDUE AIRCRAFT, para. 2.1.3, page 9-2-1, also stipulates that:

Overdue action must be commenced not later than the times stipulated in the procedure herein. Controllers may at their own discretion consider initiating actions before the times stated. The following consideration will assist Controllers in making a decision: Route - The need for prompt action if the route is over sparsely populated area, mountainous country, and long stretches of water.

(4) MATS PART 9 - EMERGENCIES, Table 9-2-2, page 9-2-3 OVERDUE ACTION - RADIO EQUIPPED AIRCRAFT

ATSC Procedures

Preliminary action

When an aircraft fails to make a position report when it is expected, commence action not later than the ETA for the reporting point plus 3 minutes:

Confirm ATD and time of last contact with preceding ATS unit if appropriate;

Request information from other ATS units and likely aerodromes;

Notify the RCC that the Uncertainty Phase exists; and

Ensure that RQS message is sent.

Full overdue Action

Commence full overdue action not later than 30 minutes after the declaration of the Uncertainty Phase or when advised by the Aerodrome that the aircraft is fully overdue:

Notify the RCC that the Alert Phase exists; Notify the RCC that the Distress Phase exists if: i) 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.

(5) ATC actions on the declaration of emergency phases should be taken as shown below:

MATS PART 9 - EMERGENCIES, page 9-6-2 – para

9-6-4, para 6.4 and Annex 11, page 5-1, para 5.2.1 states:

when: a) Uncertainty Phase

no communication has been received from an aircraft within a period of thirty minutes after the time a communication should have been received, or from the time an unsuccessful attempt to establish communication with such aircraft was first made, whichever is the earlier, or when an aircraft fails to arrive within thirty minutes of the estimated time of arrival last notified to or estimated by air traffic units, whichever is the earlier, except when no doubt exits as to the safety of the aircraft and its occupants.

Alert Phase when:

following the uncertainty phase, subsequent attempts to establish communication with the aircraft or inquiries to other relevant sources have failed to reveal any news of the aircraft, or when
an aircraft has been cleared to land and fails to land within five minutes of the estimated time of landing and communication has not been reestablished with the aircraft, or when
information has been received which indicates that the operating efficiency of the aircraft has been impaired, but not to the extent that a forced landing is likely, except when evidence exists that would allay apprehension as to the safety of the aircraft and its occupants, or when
an aircraft is known or believed to be the subject of unlawful interference.

Distress Phase when:

following the alert phase, further unsuccessful attempts to establish communication with the aircraft and more widespread unsuccessful inquiries point to the probability that the aircraft is in distress, or when
the fuel on board is considered to be exhausted, or to be insufficient to enable the aircraft to reach safety, or when
information is received which indicate that the operating efficiency of the aircraft has been impaired to the extent that a forced landing is likely, or when
information is received or it is reasonably certain that the aircraft is about to make or has made a forced landing except when there is reasonable certainty that the aircraft and its occupants are not threatened by grave and imminent danger and do not require immediate assistance.

Information to be passed to other Radar Units - Civil and Military

The Sector 3+5 Radar Controller did not inform other radar units, civil and military, of the circumstances surrounding MH370. MATS PART 9 - EMERGENCIES, para 6.2.3, page 9-6-2, stipulates that:

If Controllers have reason to believe that an aircraft is lost, overdue or experiencing a communication failure, they shall:

inform appropriate radar units (civil and military) of the circumstances.

request the units to watch out for emergency SSR code display or the triangular radio failure pattern.
notify these units when their services is no longer required.
Provision of Alerting Service for Flight operating through more than one FIRs and ATC Actions

MH370 was operating within the Singapore FIR, in that portion of the airspace which has been delegated to Malaysia (refer to Malaysia) for the Figure 2.2K - Singapore Airspace delegated to provision of air traffic services when the last air-ground radio contact was made at 1719 UTC [0119 MYT]. As such, KL ACC should be responsible for the alerting service which would mean that KL ACC would have to declare the Distress Phase at 1827 UTC [0227 MYT] when HCM ACC informed that there had been no two-way radio communications with MH370.

Reference

Manual of Air Traffic Services, Part 9 - Emergencies, page 9-65, 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:

if the aircraft was not equipped with suitable two-way radio communication, or
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 within which the aircraft was flying at the time of last air-ground radio contact:

that the aircraft was about to enter when last airground 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:

if the aircraft was not equipped with suitable twoway radio communication, or
was not under obligations to transmit position reports.

The responsibility for the provision of alerting service for MH370 therefore rested on KL ACC.

Actions taken by Air Traffic Service Centre Duty Watch Supervisor

In interviews conducted with the Duty Air Traffic Controllers on that night, the Team recorded the following:

At about 1800 UTC [0200 MYT], the Sector 3+5 Radar Controller had instructed a junior Controller to inform the ATSC Duty Watch Supervisor - who was then in the rest area35 - on HCM ACC’s query on the status of MH370;

The ATSC Duty Watch Supervisor stated that he subsequently left the rest area and returned to the ATSC. He contacted MAS Operations Despatch Centre (ODC) by telephone (albeit not tape-recorded) to inform that HCM ACC had not been able to establish radio and radar contact with MH370. In response ODC informed that the Flightfollowing System (FFS) or of MAS showed Flight Explorer that: “aircraft airspace” and added that he in Cambodian

35 Rest area - It is located in the same building adjacent to ATSC and is furnished with 3 x double-decker beds for the night shift Controllers to rest/sleep during break in between shift. 324

(ODC) would try to use the ACARS to contact MH370 and also to request the aircraft to contact HCM ACC. The ATSC Duty Watch Supervisor stated that he was satisfied with the information that MH370 was still flying and therefore did not take any further actions.

The junior Controller (who had earlier informed the ATSC Duty Watch Supervisor in the rest area) stated that the ATSC Duty Watch Supervisor then returned to the rest area at around 1830 UTC [0230 MYT] until about 2130 UTC [0530 MYT].

At 2130 UTC [0530 MYT], the ATSC Duty Watch Supervisor initiated the alerting action by instructing the SAR-trained Controller to activate the KL ARCC.
At 2232 UTC [0632 MYT], the message was DETRESFA disseminated
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 training”. The Team was also informed that all the of 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 actual”. movement and not

Even with this admission, MAS ODC continued to provide information to KL ACC that the aircraft was “still sending messages”, and stated that: movement

“It was somewhere in Vietnam and coordinates of its position as N14.90000 E109 15500 at time 1833 UTC [0233 MYT]”.

(2) KL ACC then relayed the position information to HCM ACC at 1837:41 UTC [0237:41 MYT] informing HCM ACC that MH370 was still flying.

understand how the works, the Team Flight Explorer (3) To requested for a copy of the and Flight Explorer User Manual was informed that there was none in the office. Later, a copy of the was provided to the Team. Flight Explorer User Manual

Note:

is a computer-based system which is also Flight Explorer 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.

(4) Whilst air traffic Controllers’ communication with airline operators to obtain flight information is a normal occurrence, however information provided ought to be evaluated and assessed with due diligence as to its accuracy and relevancy. The information of the FFS on MH370 was derived from the which did not provide real-time tracking. The Flight Explorer was neither a part of the ATS system nor Flight Explorer documented in the Manual of ATS (MATS), International Aeronautical and Maritime Search and Rescue (IAMSAR) Manual Volume IV, Standard Operating Procedure for SAR, Supplementary Operations Instructions (SOIs) or other documents. 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.

Communication Exchanges between KL ACC and HCM ACC and KL ACC and MAS Operations Despatch Centre on MH370

(1) The period between 1739 UTC [0139 MYT] and 2120 UTC [0520 MYT] revolved with ATC communications activities between HCM ACC and KL ACC, and. between KL ACC and ODC, for information on MH370. It also included KL ACC requesting HCM ACC to check with the adjacent FIRs namely SANYA, HONG KONG and BEIJING.

Figure 2.2J - Planning Controller Direct Telephone Line Communication Exchanges between KL ACC and HCM ACC, KL ACC and Singapore ACC from 0119 to 0632 [MYT]

(2) The time and the Planning Controller’s direct line communications exchanges with HCM ACC, and Singapore ACC, from 1719 to 2232 UTC [0119 to 0632 MYT], is illustrated in concentric circles when (Figure 2.2J above) MH370 went missing. The illustrations at 0100 (MYT) begins with the innermost concentric circle followed by 0200 [MYT] on the next concentric circle with 0700 [MYT] on the outermost concentric circle (it depicts the timeline for 08 March 2014 on the KL ACC Planning Controller’s direct line

communication exchanges with HCM ACC and with Singapore ACC from 0119 to 0632 [MYT] when MH370 was missing).

(3) Direct line communication exchanges (time in MYT) between KL ACC Planning Controller and HCM ACC.

No. Time [MYT] Direct-Line Communication Exchanges 1. 0139:03 - HCM ACC initiated the call to enquire about MH370 and notified 0139:36 KL ACC verbal contact was not established with MH370 and the radar target was last seen at BITOD. 2. 0141:10 - KL ACC initiated the call to inform HCM ACC that MH370 did 0141:37 not contact KL ACC after IGARI. HCM ACC informed KL ACC that “we have radar contact but not verbal contact until BITOD, we are no ADS-B identity and no radar contact.” 3. 0146:47 - HCM ACC initiated the call /query about MH370 and stated that 0147:26 “we have radar contact over IGARI not verbal contact and after BITOD we have no radar ident also ADS-B identity. And we call him many times until more than 20 minutes”. KL ACC responded: “Okay, I will try...give a call and then.” 4. 0157:49 - HCM ACC initiated the call/query and stated: “we officially no 0158:40 contact from MH370 until now, and we tried on many frequencies and all the aircraft - calling no response from HCM ACC added and requested by saying: MH370.” “Could you check back for your side?”

KL ACC responded: “Okay we will do that and the first at IGARI did you ever in contact with the aircraft or not first place.” HCM ACC replied: “Negative sir, we have radar contact only but not verbal contact.” KL ACC responded: “But no when passed IGARI, did the aircraft call you?” HCM ACC replied: “Negative sir.”

KL ACC responded: “Negative. Why you didn’t tell me first within five minutes you should be called me?”

KL ACC, before ending the conversation, indicated that he would try to call the Company.

Table 2.2F - Direct Line Communication Exchanges between KL ACC and HCM ACC cont…

(3) Direct line communication exchanges (time in MYT) between KL ACC Planning Controller and HCM ACC (cont…)

No. Time [MYT] Direct-Line Communication Exchanges 5. 0207:47 - HCM ACC initiated the call query to KL ACC for confirmation 0208:28 that MH370 was in Phnom Penh FIR as Phnom Penh did not have any information on MH370.KL ACC responded that he would check with his supervisor again.

0212:15 - KL ACC while coordinating with HCM ACC on another traffic 0212:26 informed that there was no update on the status of MH370.
0218:50 - KL ACC initiated the call and queried if the flight plan routing of 0223:05 MH370 was supposed to enter Cambodian airspace. HCM ACC confirmed that the planned route was only through the Vietnamese airspace. HCM ACC also informed that it had checked and also been advised by Cambodia that it had no information or contact with MH370. HCM ACC confirmed that earlier information on loss of radar contact after BITOD, and radio contact, was never established. KL ACC queried if HCM ACC was taking Radio Failure action but the query did not seem to be understood by the personnel. HCM ACC suggested KL ACC to call MAS Operations and was advised that it had already been done.
0234:56 - HCM ACC initiated the call and queried about the status of 0235:51 MH370 and was informed by KL ACC that the Watch Supervisor was talking to the Company at that time.
0330:03 - KL ACC initiated the call and enquired on news of MH370 and 0331:14 HCM ACC responded: “not yet.” KL ACC queried whether HCM ACC had checked with the next FIR Hainan.

Table 2.2F - Direct Line Communication Exchanges between KL ACC and HCM ACC

(4) Direct line communication exchange (time in MYT) relating to MH370 between KL ACC and Singapore ACC (Table below) 2.2G

No Time [MYT] Direct-Line Communications Exchanges 1. 0509:13 - Singapore ACC initiated the call and informed that it was first 0511:27 alerted by Hong Kong ACC who had made enquiries to ascertain the status of MH370. KL ACC confirmed that it was in contact with MH370 until transferred at IGARI and that MAS on the ground had also no contact with MH370.

Table 2.2G - Direct Line Communication Exchanges between KL ACC and Singapore ACC

(5) below illustrates the time and the Radar Figure 2.2K Controller’s direct line communications exchanges relating to the missing MH370 between KL ACC and HCM ACC, and between KL ACC and ODC.

Figure 2.2K - Radar Controller’s Direct Line Communication Exchanges

It begins with 0100 [MYT] at the innermost concentric circle followed by 0200 [MYT] on the next concentric circle with 0700 [MYT] on the outermost concentric circle (it depicts the timeline for 08 March 2014 on the KL ACC Radar Controller direct line communication exchanges with HCM ACC and ODC 0119 to 0632 [MYT] when MH370 went missing).

(6) Direct line communication exchanges between KL ACC Radar Controller and HCM ACC (Table 2.2H, below)

No. Time [MYT] Direct-Line Communications Exchanges 1. 0150:27 - KL ACC initiated the call to enquire about MH370 and HCM 0150:38 ACC replied: “negative contact.”

0203:48 - KL ACC initiated the call query to HCM ACC on the status of 0205:10 MH370.

HCM ACC confirmed there was no radar contact at that time and no verbal communication was established.

KL ACC relayed the information received from MAS Operations that MH370 was in Cambodian airspace.

0237:15 - KL ACC initiated the call and informed HCM ACC that MH370 0238:40 was still flying, and that the aircraft was sending position reports to the airline.

KL ACC then relayed to HCM ACC the position of MH370 in latitude and longitude as advised by MAS Operations Centre.

0348:52 - KL ACC initiated the call and queried HCM ACC for news of 0351:45 MH370. HCM ACC replied: “Until nothing.” now KL ACC suggested checking with the next FIR and HCM ACC advised: “It was SANYA FIR and he had checked with SANYA now.” FIR but no response until
0425:22 - HCM ACC initiated the call and queried to confirm the last 0429:00 position that MH370 was in contact with KL ACC. KL ACC replied: “The last position we contact that was about IGARI.”

Table 2.2H - Direct Line Communication Exchanges between KL ACC Radar Controller and HCM ACC

cont…

(6) Direct line communication exchanges between KL ACC Radar Controller and HCM ACC (Table 2.2H, below)..cont.

No. Time [MYT] Direct-Line Communications Exchanges 6. 0518:32 - HCM ACC initiated the call and queried for information on 0519:04 MH370. KL ACC queried if any information had been received from Hong Kong or Beijing. 7. 0541:20 - HCM ACC initiated the call and queried for any updates. 0541:59 8. 0614:13 - KL ACC initiated the call and queried HCM ACC if SAR was 0615:13 activated.

Table 2.2H - Direct Line Communication Exchanges between KL ACC Radar Controller and HCM ACC

(7) Direct line communication exchanges between KL ACC and ODC (Table below) 2.2I

No. Time [MYT] Direct-Line Communications Exchanges

0233:50 - KL ACC informed MAS that HCM ACC still had no contact 0237:00 with MH370.

MAS informed that the aircraft was still sending movement messages and providing latitude 14.90000 longitude 109.15500 at 1833 UTC [0233 MYT]. 2. 0356:13 - KL ACC initiated the call and enquired about MH370. 0357:39 MAS replied: “Not yet”. 3. 0520:16 - KL ACC initiated the call and queried MAS for news on 0524:59 MH370.

The Technical Captain said: “Whatever we have here suggest that the aircraft had never leave Lumpur airspace because he and suggested to KL ATSC to has failed to call Ho Chi Minh” trace back the record, voice recording and time of the positive handover to Ho Chi Minh.

KL ACC replied: “I wake up my supervisor and ask him to check again to go to the room and check what, what the last contact all this thing.”

Table 2.2I - Direct Line Communications Exchanges between KL ACC and ODC

Investigation revealed that between 0119 and 0632 MYT, the following ATC communications activities on MH370, between HCM ACC and KL ACC, and between KL ACC and ODC, took place:

There were nine instances KL ACC Sector 3+5 planner Controller communicated with HCM ACC and one with Singapore ACC relating to MH370, and
There were eight instances KL ACC Sector 3+5 Radar Controller communicated with HCM ACC and three with ODC relating to MH370,

(below) illustrates the time and the Radar Figure 2.2L Controller’s direct line communications exchanges, though not relating to the missing MH370, with HCM ACC and Singapore ACC, from 0119 to 0632 [MYT].

. Figure 2.2L - Radar Controller direct telephone line communications exchanges between KL ACC and HCM ACC, KL ACC and Bangkok ACC, KL ACC and Singapore ACC from 0119 to 0632 [MYT] not related to MH370 333

(below) illustrates the time and the Planning Figure 2.2M Controller’s direct line communications exchanges not relating to the missing MH370 with HCM ACC, Singapore ACC and Bangkok ACC, from 0119 to 0632 [MYT]. It begins at 0100am at the innermost concentric circle followed by 0200 [MYT] on the next concentric circle with 0700 [MYT] on the outermost concentric circle (it depicts the timeline for 08 March 2014 on KL ACC Planning Controller direct line communications exchanges with between KL ACC and HCM ACC, KL ACC and Bangkok ACC, KL ACC and Singapore ACC from 0119 to 0632 [MYT] when MH370 went missing).

Figure 2.2M - Planning Controller’s direct telephone line communications exchanges between KL ACC and HCM ACC, KL ACC and Bangkok ACC, KL ACC and Singapore ACC from 0119 to 0632 [MYT] not related to MH370

It begins at 0100 [MYT] at the innermost concentric followed by 0200 [MYT] on the next circle with 0700 [MYT] on the outermost concentric circle (it depicts the timeline for 08 March 2014 on KL ACC Radar Controller direct line communications exchanges between KL ACC and HCM ACC, KL ACC and Bangkok ACC, KL ACC and Singapore ACC, from 0119 to 0632 [MYT] when MH370 went missing).

The Team noted that between 0119 and 0632 MYT:

there were two instances KL ACC Sector 3+5 Radar Controller communicated with HCM ACC, one with Bangkok ACC and another with Singapore ACC relating to other flights; and
there were three instances Sector 3+5 planner Controller communicated with HCM ACC, twelve instances with Bangkok ACC and twenty with Singapore ACC relating to other flights.

Delegation of Airspace by Singapore Area Control Centre to KL ACC

The delegated airspace below) is a portion of (Figure 2.2N airspace within the Singapore FIR over the South China Sea. IGARI is a waypoint along airway M765 which is within the delegated airspace. KL ACC is responsible for the provision of air traffic services to flights operating within the delegated airspace and Singapore ACC is responsible for the provision of SAR service.
At 2109:13 UTC [0509:13 MYT] Singapore ACC contacted KL ACC for information on MH370 following an enquiry on the status of the aircraft by Hong Kong ACC four minutes earlier. By then, over three and a half hours had lapsed.
At 0230 UTC 08 March 2014, KL ARCC advised Singapore RCC on the situation relating to MH370. Singapore RCC informed that a Hercules aircraft (C-130) would be launched to the search area with clearance from Ho Chi Minh. The Hercules aircraft (C-130) was assigned the radiotelephony callsign as by Lumpur ARCC. Rescue 71
Although Singapore ACC is responsible for the provision of SAR service within the delegated airspace, KL ACC did not inform Singapore ACC when MH370 was overdue. Nevertheless, Singapore RCC launched a search and rescue 335

aircraft to the search area after KL ARCC advised on the situation relating to MH370.

Figure 2.2N - Singapore Airspace delegated to Malaysia

Source: DCA Malaysia

ATC Actions on Strayed/Unidentified Aircraft (Primary Radar Target) within the Area of Responsibility

At 1730:37 UTC [0130:37 MYT] a strayed/unidentified aircraft (primary radar target) appeared on the Sector 3+5 radar display at approximately 57 nm north east of Kota Bahru and heading to Kota Bahru. This aircraft target dropped off from the radar display at 1737:22 UTC [0137:22 MYT]. It reappeared at 1738:56 UTC [0138:56 MYT], on airway B219 VPG36 heading towards and dropped off at 1744:52 UTC [0144:52 MYT]. The appearances and reappearances of these strayed/unidentified primary targets on Lumpur Sector 3+5 radar display were for a duration of 6 minutes 45 seconds and 5 minutes 56 seconds respectively. The duration of the strayed/unidentified aircraft appearing on the Lumpur Sector 3+5 radar display was 12 minutes and 41 seconds. When the strayed/unidentified aircraft continued its journey towards VPG, it entered into the Lumpur Sector 1 Area of Responsibility.
On the Lumpur Sector 1 radar display, the strayed/ unidentified aircraft (primary radar target) appeared at 1747:02 UTC [0147 MYT] and dropped off at 1748:39 UTC [0148:39 MYT]; and reappeared at 1751:45 UTC [0151:45 MYT] and dropped off at 1752:35 UTC [0152:35 MYT]. The duration of the strayed/ unidentified aircraft appearing on Lumpur Sector 1 radar display was 2 minutes 27 seconds.

Note

Information on strayed/unidentified aircraft (primary radar target) was obtained from radar recording playback.

In interviews with the ATCOs on duty, the Sector 3+5 and Sector 1 Radar Controllers informed that they were unaware of the strayed/unidentified aircraft (primary radar target) transiting their AORs.

The Sector 3+5 Radar Controller acknowledged that he had to shift his attention to four other aircraft in another area, viz. VPK approximately 214 nm south of IGARI). As such, he did

36 VPG – Penang DVOR/DME coordinates 051646.7N 1001537.4E. 337

not observe the strayed/unidentified aircraft (primary radar target).

The Sector 1 Radar Controller stated that he did not observe the strayed/unidentified aircraft (primary radar target) even though he remained at the Controller working position.

MATS Vol 1, Part 1 - ADMIN page 1-1-4 para 1.2.2 which stipulates that:

responsible: Air Traffic Controller is

for maintaining a continuous watch on their assigned (Point communications channels or radar displays. No. 5)

MATS PART 9 - EMERGENCIES, SECTION 15, page 9-151 (and ICAO Annex 11 - Air Traffic Services Chapter 2, para. 2.24.1, page 2-14) on states: Strayed or unidentified aircraft

1.5.2 The terms “strayed aircraft” and “unidentified aircraft” have the following meanings:

Strayed aircraft - An aircraft that has deviated significantly from its intended track or which reports that it is lost.

Unidentified aircraft - An aircraft that has been observed or reported to be operating in a given area but whose identity has not been established.

ATS PART 9 – EMERGENCIES, SECTION 15, para 15.4, page 9–15–2 (also ICAO Annex 11 - Air Traffic Services Chapter 2, para. 2.24.1.2, page 2-15) stipulates:

15.4 As soon as Controllers become aware of an unidentified aircraft operating in their area of responsibility, they shall endeavour to establish the identity of the aircraft for the provision of air traffic services or as required by the appropriate military authorities in accordance with local instructions. Towards this end, Controllers shall take such action as appropriate to establish two-way communication with the aircraft:

inquire of other ATS units within the FIR about the flight and request their assistance to establish twoway communication with the aircraft; b) inquire of ATS units in adjacent FIRs about the flight and request their assistance to establish two-way communication with the aircraft;

attempt to obtain information from other aircraft in the area; and
notify the appropriate military unit as soon as the identity of the aircraft has been established.
KL ATSC Duty Shift System for Air Traffic Controllers

4-cycle Shift System

The 4-cycle shift system (Table below) for the KL ATSC 2.2J was, as follows:

Day Shift Start End 1 Afternoon 0500 UTC [1300 MYT] 1100 UTC [1900 MYT] 2 Morning 2300 UTC [0700 MYT] 0500 UTC [1300 MYT] Night 1100 UTC [1900 MYT] 1600 UTC [2400 MYT] 3 Morning 1600 UTC [0000 MYT] 2400 UTC [0700 MYT] 4 Off Duty

Table 2.2J - 4-cycle Shift System of KL ATSC

Operations in Restricted/Collapsed Mode

(1) From 1600 UTC [0000 MYT] until 2200 UTC [0600 MYT] the number of Controllers in the KL ATSC was scaled down by half to enable the Controllers to take a scheduled break from duty:

the first group from 1600 UTC [0000 MYT] to 1900 UTC [0300 MYT] and
the second group from 1900 UTC [0300 MYT] to 2200 UTC [0600 MYT].

This practice had been approved by DCA. According to DCA, the scale-down of personnel during lean hours is a norm in air traffic control centres all around

the world where air traffic services can continue safely.

(2) MATS 1 Part 2 Section 2 para. 2.3.6, page 2-2-3 stipulates that:

The Supervisor may give periods of relief during a shift to personnel:

by arranging for relief personnel if possible; or by combining operating positions provided current and anticipated workload permits and the personnel on relief can be recalled quickly; or
by rotating personnel to less active positions.

(3) DCA Unit Administrative Instruction UAI 7/2010 details on how shift duty Air Traffic Controllers have their breaks during night shift work where the number of traffic movements is substantially reduced during the early morning period between 0000-0600 hours. Between the hours of 1600-1900 UTC [0000-0300 MYT] and 1900-2200 UTC [0300-0600 MYT], the shift is undertaken by two teams by combining the six working positions into four. However, though combined, they still would cover all the working positions.

(4) The ‘Shift Break Time’ in below illustrated Table 2.2K the manner the Controller working positions was managed. Based on this table, the Controller working positions on the 07 March 2014 is tabulated as shown in the two tables below:

Table 2.2L - Controller Working Positions between 1600-1900 UTC [0000-0300 MYT], and
Table 2.2M - Controller Working Position between 1900-2200 UTC [0300-0600 MYT].

From 1600 to 1900 UTC [0000-0600 MYT] Sectors 3 and 5 were combined while Sectors 1, 2 and 4 remained status quo.

Legends FS ATSC BA Sector 1 Radar CA Sector 1 Area FB CPDLC Supervisor Proc AA TMA BB Sector 2 Radar CB Sector 2 Area EG Clearance Supervisor Proc Delivery AN Approach BC Sector 3 Radar CC Sector 3 Area RC Relief North Proc AS Approach BD Sector 4 Radar CD Sector 4 Area P Check Officer/ South Proc Candidate AL Approach BE Sector 5 Radar CE Sector 5 Area T Training Low Proc AF Flow BF Sector 6 Radar CR Area Proc FAM Familiarisation Control (Sec 1 Upper) Relief AR APC BG Sector 7 Radar F Extra ADAR Controller Relief BH Area Radar Relief Table 2.2K - Shift Break Time

No. Position Position To Be Covered Time (MYT) 1. Sector 1 Planner Sector 1 Planner

Sector 4 Planner Sector 4 Planner and Sector 2 AFD 3. Sector 3 Radar Sector 1 Radar 4. Sector 4 Radar Sector 2 Planner and Radar 5. Sector 5 Radar Sector 3 + 5 Radar 0000 - 0300 6. Sector 6 Radar Sector 3 + 5 Planner (working position not covered by Sector 6 Radar) 7. Sector 4 AFD Sector 4 AFD 8. Sector 5 AFD Sector 3 + 5 AFD and also cover as Sector 3 + 5 Planner 9. Sector 1 AFD Sector 1 AFD 10. AFD/FDP 1 Assist FIS & AFD/FDP
Assist Clearance Assist Clearance Delivery Delivery 1 12. FIS 3 AFD (0000-0200 UTC)

Table 2.2L - Controller Working Positions between 0000-0300 MYT

No. Position Position To Be Covered Time (MYT) 1. Sector 2 Radar Sector 1 Radar

Sector 2 Planner Sector 4 Planner 3. Sector 1 Radar Sector 2 Radar 4. Sector 5 Planner Sector 3+5 Planner and Sector 3+5 Radar. 0300 - 0600 5. Sector 3 Planner Sector 1 Planner 6. Sector 2 AFD Sector 4 AFD
AFD/FDP Sector 3+5 AFD and also cover as 3+5 Planner 8. Assist FIS Assist FIS & AFD/FDP
Assist Clearance Assist Clearance Delivery Delivery 10. Sector 3 AFD Sector 2 AFD

Table 2.2M - Controller Working Positions between 0300-0600 MYT

(5) This analysis is based on the Air Traffic Controller Duty Roster for the month of March 2014, DCA Unit Administrative Instruction UAI 7/2010 and the entry recorded by the WS in the WS ATS logbook on 07 March 2014. From 1500 UTC [2300 MYT] until 1900 UTC [0300 MYT] and 1900 UTC [0300 MYT] until 2200 UTC [0600 MYT] the Sector 3+5 radar working position was manned by a radar-rated Controller. The Controller working positions (CWPs) between 0000 - 0300 MYT on the night of 07 March 2014, as shown in item 6 of Table above revealed that the Sector 6 Radar Controller 2.2K who was supposed to cover the Sector 3+5 planner position was not rostered by the ATSC Duty Watch Supervisor (the Radar Controller was rostered to work between 0300 - 0600 MYT). Consequently, the CWP for Sector 3 which was combined with Sector 5 at 1500 UTC [2300 MYT] was manned by a Radar Controller and an assistant flight data (AFD) Controller. Since the CWP planner was not covered (item 8 of Table 2.2G above), the AFD Controller stepped in as Sector 3+5 planner (albeit untrained for the planner position). From 1900-2200 UTC [0300 - 0600 MYT], a Radar Controller had to cover the Sector 3+5 radar and planner position (refer item 4 of 2.2H, above with an AFD Table Controller (refer to item 7 of 2.2M) who also Table stepped in as Sector 3+5 planner.

(6) In interviews with the ATCOs, the Team noted that when the planner positions were not covered, the AFD Controllers would step in as planners to assist the Radar Controllers as this had been the practice.

Shift personnel during scheduled break are allowed to rest in the rest area adjacent to the ATSC. The ATSC Duty Watch Supervisor maintains his/her watch at the Operational Centre until 1730 UTC [0130 MYT]. He/she takes his/her break until 2130 UTC [0530 MYT]. During his/her absence, a shift leader (usually the most senior Controller) is appointed to take charge but the ATSC Duty Watch Supervisor can be recalled at a moment’s notice should the need arises.

(7) On the night of 07 March 2014, at 1500 UTC [2300 MYT] the Subang ATSC radar maintenance contractor at KL ATSC received a request from the Sector 5 Air Traffic Controller to absorb functions of control for Sector 5 into Sector 3. The request was successfully executed by the Site Maintenance Engineer (SME).

(8) In interviews with the ATCOs and on listening from the play-back of the direct telephone line recording on the Planning Controller working position, it is confirmed that, from 1600 UTC [0000 MYT] till 2200 UTC [0600 MYT], the Planning Controller working position (Table [below]) was manned by unrated Air Traffic 2.2N, Controllers as follows:

No. Time Sector 3 + 5 Planner Position 1 1600 UTC [0000 MYT] until Manned by an 1730 UTC [0130 MYT] unrated ATCO 2. 1730 UTC [0130 MYT] until 1900 UTC [0300 MYT] Manned by AFD Controller - untrained 3. 1900 UTC [0300 MYT] until and unrated. 2200 UTC [0600 MYT]

Table 2.2N - Planning Controller Position between 1600-2200 UTC

The Team noted that during the operations in restricted/collapsed mode between 1600 UTC [0000 MYT] and 2200 UTC [0600 MYT], untrained and unrated Air Traffic Controller were manning the Planning Controller working position

Roles played by the Duty ATSC Watch Supervisor

Refer to b) MATS PART 1 - ADMIN, para. 2.2.2 para. l) (5). para 1.2.2, page 1-1-3 stipulates that:

- responsible for: Watch Supervisor

ensuring that the operating positions are manned adequately by personnel qualified and current in (Point No. 3). practice. • ensuring that staff are operationally proficient (Point No. 4). 344

In interviews with the ATCOs on shift duty on the day of the disappearance of MH370, the AFD Controllers confirmed that they were performing the functions as Planning Controller for Sector 3+5 from 1600 UTC [0000 MYT] to 2200 UTC [0600 MYT].
Based on transcripts of the planner’s direct telephone line (refer 1-164), Factual Information, Appendix 1.18G, pages from 1620 UTC [0020 MYT] to 2200 UTC [0600 MYT], a total of forty-one (Table below) Planning Controller’s direct 2.2O telephone line exchanges took place - thirty-eight by three ATCOs (one trainee and two AFD Controllers performing the functions of Planning Controller) and the remaining three by a Radar Controller.

ATCO No. REMARKS Radar Planning Trainee (3+5) & AFD 1. 2 8 - Relating to MH370 2. 1 25 5 Not relating to MH370 (mainly Sub-Total 3 33 5 coordination with Total 41 BKK, HCM and SIN

Table 2.2O - Planner Direct Line Telephone Exchanges

Activation of Aeronautical Rescue Coordination Centre

In interviews conducted with the SAR-trained Controller, the Team noted that the Aeronautical Rescue Coordination Centre (ARCC) was activated (Figure below) at 2.2O - ARCC Activation Form, 2130 UTC [0530 MYT]. After the activation, the Search and Rescue Mission Coordinator (SARMC) did not have sufficient details to act upon before the distress message was disseminated at 2232 UTC [0632 MYT]. The SARMC also informed the Team that the ARCC did not receive any alerting message from Ho Chi Minh via the Aeronautical Fixed Telecommunication Network (AFTN).

Figure 2.2O - Aircraft Incident and ARCC Activation Form

The Team noted that the distress message was disseminated an hour and two minutes after KL ARCC was activated. There was no alerting message from Ho Chi Minh RCC.

Play-back of Radar and Radiotelephony Recordings by ATSC Duty Watch Supervisor

At 2145 UTC [0545 MYT], the ATSC Duty Watch Supervisor requested from the radar maintenance personnel to carry out radar data play-back (with permission granted by KL ATSC’s Chief Assistant Director). The SME successfully restored the desired file from the recording play-back back-up hard disc. At 2200 UTC [0600 MYT] the ATSC Duty Watch Supervisor performed radar data and voice recording play-back at the D40 Controller Working Position (D40 CWP).

Entries in ATS Logbooks of ATSC Watch Supervisor and Sector 3 Controller Working Position

MATS Part 1 - Admin, page 1-1-7 para 1.7 on recording of entries in the logbook states, as follows:

The time of entries shall be based on UTC and events recorded in a chronological order;

Entries shall give sufficient details to give readers a full understanding of all actions taken;
The time an incident occurred and the time at which each action was initiated shall be stated.

MATS PART 1 - ADMIN, para 1.7, page 1-1-7 further states that:

The ATS logbook serves to record all significant occurrences and actions relating to operations, facilities, equipment and staff at an ATS unit. It is an official document and, unless otherwise authorised, its content shall be restricted to those personnel requiring access to the information. All personnel should read those log entries of concern to them, which were made during the period since their last tour of duty before accepting responsibility for an operating position.

1.7.2 Where there is more than one unit within a facility, a logbook shall be maintained for each unit.

1.7.3 The Supervisor or the senior Controller on duty shall be responsible for opening, closing and maintaining the log as applicable. Any Controller may make an entry but all entries shall be made in an indelible manner and no erasure is permitted. Incorrect information shall be struck out and the correct information inserted and initiated.

1.7.4 Information to be recorded in the ATS log should, as appropriate to the facility, include such matters as:

Incidents, accidents, non-compliance with regulations or air traffic control clearance, regardless of whether an additional separate report is required;

Aerodrome inspection reports, details of work in progress, aerodrome closures, and other essential aerodrome information;
Changes in the status of facilities, service or procedure including communications difficulties and tests;
Time of receipt of significant meteorological reports, e.g. SIGMET;
Any occurrence of a significant nature;
Configuration and reconfiguration of operation positions;
Any dispensation against the regulations, or special authorisation given by the Director General;
Details of approval for Special VFR operations; and

Opening and closing of shift or watch.

1.7.5 Controllers should follow the following procedures for recording of entries in the log:

Each entry should be accompanied by the signature or the authorised initials of the Controller making the entry.

The time of entries shall be based on UTC and events recorded in a chronological order;
Entries shall give sufficient details to give readers a full understanding of all actions taken;
The time and incident occurred and the times at which each action was initiate shall be stated; and
An entry needs to be brought to the attention of the unit chief shall be so annotated to enable him to take follow up action.

1.7.6 If during an emergency or busy period, it is not possible to make detailed entries in the log at the time of occurrence, Controllers are permitted to keep rough notes with exact times. As soon as possible thereafter, a detailed entry shall be made in the log.

Extract from the Watch Supervisor Logbook

Entry 11 at 1600 - Restricted watch

1st: named “2nd” 12 names for the half)

“1st” ii. Entry redacted (12 names for the half) and 2nd named redacted (12 at 1800:

At 1800UTC, I was informed by S3 radar (name redacted) Controller then Ho Chi Minh is enquiring the position of MAS370 B777 reg. 9MMRO estimate for IGARI 1720, with a cleared level 35,000 ft. MAS370 is from KLIA to Beijing (ZBBB) with 239 POB. The fact is at time 1719 UTC, Mr. xxxx (name redacted) made a transfer of comm. instruction to MAS370 (MAS370 contact HO Chi Minh 120.9) and the pilot acknowledged by reading its callsign (MAS370). (*The radar label as it rosses Igari eastbound was good, but about 4 to 5 miles east of Igari the radar label starts ‘coasting’. *base on radar video recording). 349

Prior to opening up the *replay, Ho Chi Minh indicated the Mr. xxxx (name redacted) that they saw the target until Bitod. At 1815, I check with MAS OPS Centre in KLIA Mr. xxxx, (name redacted) and he mentioned that MAS370 is on their flight tracker and he was able to exchange signals with the flight.

At 1930 UTC Mr. xxxx (name redacted) MAS OPS Centre call in and spoke to Mr. xxxx (name redacted), admitting that the ‘flight tracker’ is based on projection and could not be relied for actual positioning or search.

At 2130 I activated RCC by instructing Pn. xxxx (name redacted) to handle this case.

Until 2245 still no cospas sarsat signal receive at ATCC Subang and ATCC Singapore. I spoke to Mr xxxx (name redacted) - watch supervisor Singapore (night shift), he confirmed that the was no cospas sarsat signal pickup on aviation target, only maritime hits was observed.

At 2250 I spoke to Ho Chi Minh W/sup, and advise him that based of video recording, the target starts to coast out about 4 to 5 miles east of Igari.

L/E at 2200, PTU Mr. xxxx (name redacted) who is in xxxx (name of place redacted) was informed, PP En. xxxx (name redacted) was informed by xxxx (name redacted).

Late entry - note - at 1840 Mr. xxxx (name redacted) (MAS OPS) confirmed that MAS370 download from acft giving a coordinate of N14.9000 1091500E timed 1833.

Conclusion - Our response to this incident is based on input by Ho Chi Minh and MAS Operations Centre using their ‘flight tracker’. MAS370 was well transferred comms to Ho Chi Minh and acknowledged the instruction by pilot. And lastly the

radar label started to coast about 5 NM. east of IGARI. Lumpur RCC responsibility is to assist Ho Chi Minh to locating the acft posn.

Distress Message

The distress message (DETRESFA) is intended to convey pertinent information to the recipients that there is 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.
The message with a date-time-group (DTG) DETRESFA 072232 UTC was transmitted at 2232 UTC [0632 MYT].
The contents of the message, as shown in DETRESFA below was not composed in accordance with Figure 2.2P the standard specified in ICAO DOC 4444, Air Traffic Management (PANS-ATM) Chapter 11, Air Traffic Services Messages, Appendix 3 (Figure below). The errors are, 2.2Q as below:

(1) Appendix 3, page A3-9 (Figure below) 2.2P

Field type 7 - Aircraft identification and SSR mode and code FPL–MAS370–IS should be “MAS370/A2157”

(2) Appendix 3, page A3-14 (Figure below) 2.2P

Field type 13 - Departure aerodrome and time WMKK1635 should be “WMKK1642”

(3) Appendix 3, page A3-29 & A3-30 (Figure below) 2.2P

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.

(4) Spelling of DESTRESFA should read DETRESFA (Figure below) 2.2P

Source: DCA Malaysia

Figure 2.2P - DETRESFA Message sent over AFTN

Excerpt from ICAO DOC 4444, Air Traffic Management (PANS-ATM) Chapter 10, Air Traffic Services Messages, Appendix 3, Field Type 7

Figure 2.2Q - ATS Messages

Excerpt from ICAO DOC 4444, Air Traffic Management (PANS-ATM) Chapter 10, Air Traffic Services Messages, Appendix 3, Field Type 13 below

Figure 2.2R - ATS Messages

Excerpt from ICAO DOC 4444, Air Traffic Management (PANS-ATM) Chapter 10, Air Traffic Services Messages, Appendix 3, Field Type 20

Figure 2.2S - ATS Messages cont…

Figure 2.2T - ATS Messages

Issues with Manual of Air Traffic Services (MATS)

MATS 1 PART 2 - GEN, page 2-2-1 stipulates that:

2.1.2 Controllers and other operational staff shall:

apply as appropriate the rules, procedures, separation minima and guidance material contained in this manual in the control of air traffic and in the provision of other air traffic service; and

additionally comply with directive detailed in SOIs, ROIs, and UOIs and in Operational Letters of Agreement.

2.1.3 Controllers shall not deviate from a rule or separation minima, but may however deviate from a procedure if in the opinion of the Controller the situation warrants.

2.1.4 if a situation that is not covered in this Manual arises, Controllers shall use their best judgement as to the procedure to be applied to handle the situation.

In any uneventful situations, there are specific actions that require ATC personnel to maintain a continuous watch in their respective working positions and not to rely on information from MAS ODC.

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, psychosocial events, and other relevant factors.

The analysis was done based on the following sources gathered from:

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;
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;
Medical records from private health care facility and from MAS Medical Centre; and
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

The flight-crew’s medical background and recent activities were examined. All medical files reviewed showed no significant healthrelated 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.
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.
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.

All cabin crew were adequately rested before the flight based on the flying records.
There is no evidence that members of the cabin crew had received any flight training, based on the ‘Basic Training’ Flying and ‘Aircraft (B777) records of the Type Conversion Training’ Company and records of DCA.

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.
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.
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.

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.

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.

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.

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.

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.

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 overthe-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.

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.

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

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 4th 5th Tower) were those of the FO before take-off and the and 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 was spoken by the PIC at Night Malaysian Three Seven Zero” 1719:30 UTC [0119:30 MYT].

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.

2.4 AIRWORTHINESS & MAINTENANCE AND AIRCRAFT SYSTEMS

2.4.1 Airworthiness & Maintenance

The review of the aircraft Airworthiness and Maintenance records revealed the following:

No current airworthiness issues were noted. There was no evidence of any pre-existing aircraft defects that would affect the safety of the flight.
An assessment of the Aircraft Log Book since the original issue of the Certificate of Airworthiness by the Department of Civil Aviation, Malaysia on 03 June 2002 indicated that the aircraft maintenance was carried out in accordance with the approved manufacturer’s Maintenance Planning Document and in compliance with the Department of Civil Aviation Malaysia Approved Maintenance Schedule requirements. The Certificate of Airworthiness was valid at the time of the occurrence and the next Certificate of Airworthiness was due on 02 June 2014.
The last A1 Check was carried out on 23 February 2014 at 53,301:17 hours and 7,494 cycles. It was also noted that the last A4 Check was carried out at Malaysia Airlines Base Maintenance at KLIA, Sepang from 14 to 16 January 2014 at 52,785:37 airframe hours and 7,422 cycles respectively.
The right wing tip which was damaged during taxi at Pudong, Shanghai Airport on 09 August 2012 was assessed and repaired by Boeing AOG Team at Pudong, Boeing Shanghai facility from 22 September to 03 October 2012 as per MAS-RE-1209619 instructions. The Boeing repair scheme was approved under DCAM Statement of Compliance Reference Number SC/2012/081. There was no evidence of structural anomaly in the repair scheme. The repair had no bearing on the observed events on the event flight, i.e. it would not have affected any of the on-board equipment. There was a requirement, however, for damage tolerance information to be incorporated in the aircraft maintenance programme within 24 months from 02 October 2012, as stated in the FAA Form 8100-9 for the approval of the repair by the FAA Organisation Designation Authorization (ODA). This damage

tolerance information was not yet included in the maintenance programme for the aircraft at the time of the occurrence. The due date for the incorporation would be by 02 October 2014. Incorporation of the information in the maintenance programme would address any maintenance that becomes necessary as a result of the damage tolerance assessment. However, the investigation assessed that this had no effect on the occurrence flight.

The cabin re-configuration was approved under the FAA STC and DCAM SOC and there is no evidence of any documented deviation from stipulated design changes.
A review of aircraft concessions during the last year of operation revealed that Malaysia Airlines Quality Assurance Department had requested from the Department of Civil Aviation, Malaysia for a 10-day or 100-hour extension for a C1 check from 22 August to 01 September 2013. This request was approved. There were no other concessions recorded in the Aircraft Log Book.
A review of Malaysia Airlines Airworthiness Directives indicated that all the applicable Airworthiness Directives for mandatory compliance were complied with.
A review of the recent Technical Log Book entries by the flight and ground crew did not reveal any significant defects or trends.
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.
According to maintenance records, the SSFDR 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. There is some extra margin in the design to account for battery life variability and ensure that the unit will meet the minimum requirement. However, once beyond the expiry date, the ULB effectiveness decreases so it may operate, for a reduced time period until it finally discharges. While there is a definite possibility that a ULB will operate past the expiry date on the device, it is not guaranteed that it will work or that it would meet the 30-day minimum requirement.

There is also limited assurance that the nature of the signal (characteristics such as frequency and power) will remain within specification when battery voltage drops below the nominal 30-day level.

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 the aircraft the expiry date for the battery was December 2012.

Interviews were held with the MAS Engineering Technical records staff to determine why the ULB battery was not replaced before the expiry. It was revealed that the Engineering Maintenance System (EMS, a computer system used to track and call out maintenance) was not updated correctly when the SSFDR was replaced on 29 February 2008. The update involves ‘removal’ of the old unit in the system followed by ‘installation’ of the new unit. In this particular instance, although the old unit was ‘removed’, the new unit was inadvertently not recorded as ‘installed’ in the system. If the system was updated correctly on the installation, the next due date for removal would have been for the replacement of the ULB battery. Since the system was not updated it did not trigger the removal of the SSFDR for replacement of the ULB battery when it was due. ULB battery replacement is normally done in the workshop by routing the removed SSFDR, together with the ULB, to the workshop. This oversight was not noted until after the disappearance of MH370 when details of the ULBs were requested.

Subsequently, MAS Engineering Technical records staff carried out a fleet-wide record inspection for the ULBs to ensure all records for other aircraft were updated accordingly.

2.4.2 Emergency Locator Transmitters

The aircraft was fitted with four Emergency Locator Transmitters (ELTs) meeting the current ICAO and regulatory requirements at the time. All four ELT battery lives were within the required expiry dates. No ELT signal from 9M-MRO was reported by the responsible Search and Rescue agencies or any other aircraft. There have been reported difficulties with

the transmission of ELT signals if an aircraft enters the water, such as in the case of Air France flight AF447. In these instances, the ELT does not activate, or the transmission is ineffective as a result of being submerged under water. Furthermore, the ELT itself could be damaged or, very commonly in the case of fixed ELTs, the antenna or antenna cables become disconnected or broken. This significantly hampers any search and rescue effort and may mean the aircraft location remains undetected for a considerable time. A review of ICAO accident records (refer to 1.6D) over the last 30 years indicates that of 173 accidents Appendix involving aircraft fitted with ELTs, only 39 cases recorded effective ELT activation.

Following the disappearance of MH370 and in line with Global Aeronautical Distress and Safety System (GADSS) recommendation an amendment to ICAO Annex 6, Part 1 has been proposed for an Automatic Deployable Flight Recorder (ADFR). The ADFR is a combination recorder fitted into a crash-protected container that would deploy from an aircraft during significant deformation of the aircraft in an accident scenario. Considering the design and deployment features of a deployable recorder, the recorder is usually fitted externally, flush with the outer skin towards the tail of the aircraft. To find a deployed ADFR, an Emergency Locator Transmitter (ELT) is integrated in the ADFR. This ELT has the added advantage to assist in locating the accident site and facilitate search and rescue efforts. In the case of a new generation ELT being fitted, the ELT will provide emergency tracking data before the impact. Furthermore, if the wreckage becomes submerged in water, the traditional ELT signal will be undetectable, but with the deployable recorder being floatable, the ELT signal would still be detectable, and the deployable recorder would be recovered quicker. As the ADFR is floatable, there is no requirement for an underwater locating device.

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. Depending on the type of failure, failure of the ACARS itself can be reported by the system. However, no such reports were received for the flight. The traffic log of maintenance messages transmitted for the last 10 flights for the aircraft indicated that the CMCS was functioning appropriately before the event flight. On an average, 11 maintenance messages, of various systems, were transmitted on each flight. A review of the maintenance history showed no evidence of a defect trend on the CMCS.

2.4.4 Aircraft Systems Analysis

The aircraft systems analysis is severely limited by the lack of available evidence. The information in this section is primarily inferred from SATCOM transmissions, aircraft system characteristics, radar data, and the absence of other communications from the aircraft for the majority of the flight.

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. Refer to the aircraft performance section in 1.6.9. Section

There is no evidence from the limited data available on the status of the aircraft air-conditioning and pressurisation systems during the flight. There was no Mandatory Occurrence report raised for this aircraft on pressurisation issues. A review of the Technical Log entries since the last D check in June 2010 did not reveal any defect trends in the air conditioning or the pressurisation systems. There were also no such defects reported prior to the event flight. There was an FAA Airworthiness Directive (AD) issued which made mandatory the accomplishment of Boeing Service Bulletin 777-53A0068 which addresses a crack in the fuselage skin under the SATCOM antenna adapter. This Service Bulletin was issued on 12 June 2013. A crack in the fuselage skin could lead to rapid decompression and loss of structural integrity of the aircraft. However, this AD or the Service Bulletin was not applicable to 9M-MRO due to a different configuration and location of the SATCOM antennas.

In the event of a complete pressurisation failure, however, oxygen would be available for the flight crew through the flight crew oxygen system and masks. Two cylinders located in the left side of the main equipment centre, each of 115 cubic feet (3256 litres), would be able to supply oxygen to a single person for a duration of 27 hours, or for 2 persons for a duration of 13 hours.

For the passengers, oxygen could be supplied by chemical oxygen generators located in passenger service units (PSUs). A door with an electrically operated latch keeps the masks in a box until the oxygen

deployment circuit operates. The deployment circuit would operate, and the masks automatically drop from the PSUs if cabin altitude were to exceed approximately 13,500 ft. Oxygen would flow when any mask hanging from that PSU was pulled. Oxygen would be available for approximately 22 minutes. The passenger masks can be manually deployed from the cockpit by pushing the overhead panel PASSENGER OXYGEN switch to the ON position. The electrical power to the latch is supplied through a circuit breaker located in the Main Equipment Centre. It is not possible to deactivate automatic deployment of the masks from the cockpit.

There are also portable oxygen cylinders located throughout the cabin which let the flight attendants move in the aircraft when oxygen is in use. It is also a gaseous oxygen supply for medical emergencies. The cylinders are fitted with a disposable mask. 15 cylinders are located throughout the passenger cabin. Each cylinder is of 11 cubic feet (310 litres) capacity. The flow of oxygen can be controlled by an ‘Off-On’ knob which can be rotated to control the flow from 0 to 20 liters per minute.

A review was carried out of whether there could have been an oxygen leak in the crew oxygen system. A leak of oxygen is a potential source for fire to break-out. A review of the Technical Log entries since the last D check in June 2010 did not reveal any oxygen leak in the system. There had been the usual servicing of the oxygen system when the pressure had dropped from the nominal level. The Stayover check, which is carried out whenever the aircraft planned ground time exceeds 6 hours, calls for the crew oxygen pressure to be checked. It has been the practice of the airline to service the oxygen system whenever time permits, even if the pressure is above the minimum required for dispatch (310 psi at 35°C). Tech Log entries showed that the system was serviced when the pressure dropped to, on an average, 1100 psi. On 07 March 2014, prior to the last flight, the pressure was noted to be 1120 psi and serviced to 1800 psi. However, it was not possible to eliminate the possibility of an oxygen leak on the event flight.

Another potential source of fire fed by oxygen is the issue highlighted in FAA AD 2012-13-05 which made mandatory the accomplishment of Boeing Service Bulletin 777-35A0027, as highlighted in Section 1.6.4 5). An electrical fault or short circuit can result in electrical para. heating of the low pressure oxygen hoses in the flight crew oxygen system and can cause the low pressure oxygen hose to melt or burn.

This can result in smoke and/or fire in the flight compartment. This service bulletin was already accomplished on 9M-MRO on 17 January 2014 by replacing the low pressure oxygen hoses with non-conductive low pressure oxygen hoses, reducing the likelihood of this potential source of fire.

Autoflight

The turn after IGARI was made from a heading of about 060° to a final heading of about 240° (a change of 180°) based on recorded radar data. Simulator sessions indicated that a bank angle of at least 30° is required to accomplish a half rate turn, of 180° in 2 minutes with a Ground speed of about 470 knots. Such a turn is not possible using autopilot as the bank angle is limited up to a maximum of 25° in any of the autopilot modes, such as LNAV or HDG SEL. Using LNAV mode, the time taken to make the turn is greater than 3 minutes. At an Indicated airspeed (IAS) of 250 knots (groundspeed – GS, of 425 knots) it took 3 minutes 3 seconds while at an IAS of 220 knots (GS of 400 knots) it took 3 minutes 30 seconds. Both manoeuvres were at 35,000 ft. Refer to on a discussion on this. From the Section 2.1 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.

Electrical Power

As the aircraft SATCOM system was providing log-on information to the INMARSAT satellites it can be deduced that at least part of the SATCOM system had electrical power. The SATCOM system components including the Satellite Data Unit (SDU), Radio Frequency Unit (RFU), High Power Amplifier (HPA), Low Noise Amplifier/Diplexer (LNA/DIP) and the Beam Steering Unit (BSO) are powered by the 115V AC, Left Main AC bus. This bus is normally powered by the Left Engine Generator, however a failure of the generator or the power feed to it will cause the Bus Tie Breakers to close and automatically let the Right Engine Generator power the bus.

This bus can also be powered by the Auxiliary Power Unit (APU) Generator, if the APU is started manually or automatically (such as a loss of power to both engines).

The above suggests that at least one generator was operating and providing the power to the SATCOM system after power was restored at 1825 UTC following the interrupt of between 22 to 78 minutes.

SATCOM operation, especially the electronic steering of the Radio Frequency signals through the antenna to the satellite, requires the Air Data Inertial Reference Unit (ADIRU) to be functioning. The ADIRU, which is a single unit on this aircraft, is an integrated unit having internal redundancy and provides the air data and inertial reference functions. It is powered either by the Right 28 Volt DC bus, the Left 28 Volt DC bus or the hot battery bus (a direct connection to the aircraft battery). The DC busses can be powered by the respective Main AC busses (after being rectified to DC) or by automatic switching (in case of failure of the respective AC bus) by the opposite Main AC bus. The battery itself can only supply power for a short duration, so it is highly likely that the source of power for the ADIRU was one of the generators as the SATCOM system was powered for many hours.

The operation of the SATCOM not only depends on the supply of power to its own system, it also depends on the supply of power to other systems feeding it, such as the ADIRUs. This inter-dependency of operation suggests that significant parts of the aircraft electrical power system were probably functioning throughout the flight.

Flight Controls and Hydraulics

The primary flight control system is highly redundant, with three operating modes: normal mode, secondary mode, and direct mode. The primary flight controls are powered by redundant hydraulic sources. The hydraulic systems are pressurised from the engines and the electrical actuation systems are similarly highly redundant. The secondary flight controls, high lift devices consisting of flaps and slats, are hydraulically powered with an electrically powered backup system. 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.

Instrumentation

Flight instruments are required only to fly the aircraft manually. The aircraft was equipped with Standby flight instruments which operate independently of the Primary flight instruments. Operation of the autopilot is not dependent on operation of the flight instrument displays.

Due to the lack of available evidence, it was not possible to determine the extent to which the instrumentation was operable throughout the flight. However, the instrumentation system, and the system that feed information to it, are highly redundant and driven from multiple automatically-reconfigurable electrical power sources. Based on the findings that several systems (particularly ADIRS, AIMS and SATCOM) were operable for some or all of the flight, it is very likely that some or all instrumentation was available.

Navigation

The main systems that are relevant for consideration are the Air Data Inertial Reference System (ADIRS), the Flight Management System (FMS) and the Global Positioning System (GPS).

If the autopilot (at least the basic modes) was functional, the ADIRS must have been operating satisfactorily because an essential input to the autopilot is the aircraft attitude which is provided by the ADIRU, the main unit of the ADIRS. In addition, the SATCOM continued to transmit during the flight as evidenced by the handshakes (Section 1.9.5). The SATCOM was using the High Gain Antenna for tuning. This shows that the ADIRU was operable, otherwise the Low Gain Antenna (LGA) would have been used.

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.

The GPS is required for position updates of the FMS. Accurate navigation is dependent on GPS inputs. However, the ADIRU can provide the navigation reference without GPS inputs, although with lesser accuracy.

Engines

The aircraft satellite transmission associated with the 7th arc is most likely associated with power interruptions on board the aircraft caused by fuel exhaustion (Section 9). The time of this 2.4.4 para. transmission is consistent with the maximum flight times expected for the MH370 flight, based on the total weight of fuel remaining during the last ACARS transmission at 1707 UTC. It is highly likely that both the engines were operating for the aircraft to have flown for more than 7 hours with that amount of fuel on board.

The Engine Health Monitoring (EHM) system trend reports over the last 3 months which cover ‘snapshot’ data points gathered at take-off, climb and cruise also showed no evidence of unusual engine behaviour for both engines. Similarly, the last report (Climb report) received at 1652 UTC on 07 March 2014 (0052 MYT on 08 March 2014) and the earlier Take-off report, do not show any unusual engine behaviour. Furthermore, there were no fault messages transmitted by the CMCS to indicate any engine abnormalities, before the ACARS last transmission.

Fuel Systems

The fuel systems were most probably functioning satisfactorily as the performance of the engines was dependent on this. It is unlikely that there were any problems in these based on the premise that the aircraft most likely flew to fuel exhaustion, as explained in Section 9). 2.4.4 para.

Auxiliary Power Unit

The operation of the Auxiliary Power Unit (APU) during the majority of the flight is uncertain although it is possible that it started up automatically (as it should) after both engines shutdown due to fuel exhaustion at the end of the flight. This start-up and power-up of the 7th electrical buses most likely caused the and last, aircraft initiated SATCOM handshake.

Performance calculations indicate the possibility that the aircraft 7th would have reached fuel exhaustion at, or before the time of the handshake. After a single engine shutdown, automatic switching of the electrical tie breakers would ensure the Left and the Right Main busses and the Left and Right Transfer busses were still powered by the remaining generator driven by the running engine. After the 372

shutdown of the second engine following fuel exhaustion, the Main busses and the Transfer busses would have de-energised as there would be no generators powering these busses. An electronic logic in the APU starting system would automatically start the APU, if the aircraft was in the air, and both the Left and Right Transfer busses were not powered. As the fuel inlet for the APU is below that of the engines (left engine main fuel inlet in the left tank) the APU can start up and run for about 14 minutes even though the aircraft engines themselves are exhausted of fuel from the fuel tanks as the difference in the fuel intake levels would provide about 30 pounds of fuel. It would take about 1 minute for the APU to start up and power the busses and once powered, the Satellite Data Unit (SDU) of the SATCOM would take approximately another 1 minute to initiate the ‘handshake’, which 7th would have been the and last SATCOM handshake. Both the APU start up and the initialisation of the handshake by the SDU would have happened within the 14 minutes of running time available from the 30 pounds of fuel, after which the APU would have shut down due to its own fuel exhaustion.

Communications

The aircraft was fitted with many communication systems, available to the flight crew. Among them were the High Frequency (HF) system, the Very High Frequency (VHF) system, the Air Traffic Control system including the Mode S Transponder, the ACARs and the SATCOM. The SATCOM phone in the cabin was available for the cabin crew. Despite the availability of all these systems no communications were received from the aircraft after the last communication at 1719:30 UTC, 07 March 2014 (0119:30 MYT on 08 March 2014) except for the ‘handshakes’ received from the SATCOM system.

High Frequency System

Communication with ATC after take-off is normally through the VHF. The HF system is for communication with ground stations or other aircraft during long overwater flights. There was no evidence to indicate that the HF systems (Left or Right) were used prior to the aircraft’s last communication at 1719:30 UTC on 07 March 2014. This communication was through VHF. There was no message received from the aircraft to report on a HF system failure or system technical error prior to the last voice or ACARS communication. There was also no recent defect trend on the HF systems.

Very High Frequency System

The aircraft VHF system was operating satisfactorily as evidenced by the communication by the flight crew to ATC up to the last communication at 1719:30 UTC, 07 March 2014 (0119:30 MYT, 08 March 2014). There were three independent VHF communication systems on the aircraft. The crew normal procedure is to use the Left VHF for communications. There was no message received from the aircraft to report on the VHF system failure or system technical error prior to the last voice or ACARS communication. There was also no recent defect trend on the VHF systems.

Air Traffic Control/Mode S Transponder System

The aircraft transponder was operating satisfactorily up to the time it was lost on the ATC radar screen at 1720.36 UTC, 07 March 2014 (0120:36 MYT, 08 March 2014). There was no message received from the aircraft to report a system failure prior to the last voice or ACARS communication. The crew procedure for normal operations is to select the left system on the control panel so the left system was likely in use. Failure of the system will be annunciated in the cockpit so that the crew can select the operating 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.

This system can be deactivated (turned OFF) by pulling the circuit breakers located at the P11 overhead circuit breaker panel in the cockpit or by selecting the Transponder Mode

Selector (Transponder Panel) to “STBY” position. Selecting the Mode Selector to “STBY” will deactivate both the transponders.

Aircraft Communications Addressing and Reporting System

The ACARS communicates through either the VHF or the SATCOM systems. The ACARS datalink connects to the Satellite Data Unit (SDU) of the SATCOM system and the Center and Right VHF Communication Transceivers of the VHF systems. The Center VHF exchanges data with the ACARS modem in the Communications Core Processor Module (CPM/Comm) of the Left AIMS cabinet. The right VHF exchanges data with the ACARS modem in the CPM/Comm of the Right AIMS cabinet. The ACARS does not interface with the Left VHF Transceiver.

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, voice was selected for the Center VHF on the ground which resulted in the ACARS using SATCOM for the data transmissions, as shown in the SATCOM Ground Station Logs (refer to 1.9.4). Section

As the ACARS function is part of the AIMS there is no direct way of removing electrical power from the ACARS. This would require removing power to the AIMS which would disable many other systems as the AIMS manages data for several integrated avionics systems. However, it is possible to deactivate the ACARS downlink function from the ACARS Manager page in the Communications main menu on the selected Multifunction Display (MFD) in the cockpit. However, this will not affect the SATCOM handshakes. The COMM display switch, located on the display select panel, displays the communications main menu on the selected MFD. The 375

ACARS Manager page allows the flight crew to select/deselect VHF or SATCOM transmission of data (Figure below). 2.4A ACARS is set to auto mode (both boxes selected) at power-up or during a manual data communication system reset. Normally, this permits ACARS to automatically use VHF or SATCOM (if VHF is unavailable). If both boxes are deselected, ACARS loses the capability to send downlink messages, but can receive and display uplink messages.

Once deselected, a power interruption, will not cause the ACARS to be set to auto mode (both the VHF and SATCOM boxes selected) again. For the ACARS to be set to auto mode, either a data communication system reset or a power-up is done. The system does an automatic data link system reset 10 minutes after last engine shutdown and first passenger door open. This would explain why the power resumption at 1825 UTC following the interruption (Section 4) did not 1.9.5 para. activate the ACARS downlink again (with the assumption that both the VHF and SATCOM boxes were deselected).

Figure 2.4A - ACARS Manager Page on MFD

The last position report transmitted via ACARS was at 1707:29 UTC, 07 March 2014 (0107:29 MYT, 08 March 2014). Parameters recorded (Table 2.3A) were as follows:

Greenwich Mean Time (GMT) 1706:43 UTC Altitude (ALT) 35004 feet Calibrated Airspeed (CAS) 278.4 knots MACH 0.821 Mach Total Air Temperature (TAT) -13.1° C Static Air Temperature (SAT) -43.8° C Latitude (LAT) 5.299 Longitude (LONG) 102.713 Gross Weight (GWT) 480,600 lb Total Remaining Fuel Weight (TOTFW) 43,800 kg Wind Direction (WINDIR) 70.0 Wind Speed (WINDSP) 17.13 True Heading (THDG) 26.7 Table 2.4A - Last Position Report from ACARS

All programmed communications via ACARS prior to 1707:29 UTC were working satisfactorily.

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.

Satellite Communication System

Refer to for the detailed analysis of SATCOM. Section 2.5

Airplane Information Management System

The Airplane Information Management System (AIMS) is designed with several redundancies to be failure tolerant. The system consists of two cabinets performing almost identical operations. The signal outputs of these cabinets are fed onto common busses which are shared by the various systems. These two cabinets are also isolated in location, the Left AIMs is located in the forward rack of the Main Equipment Centre (MEC) while the Right AIMS is located in the rear rack of the MEC.

The AIMS cabinets also receive electrical power from different busses. The Left AIMS cabinet gets electrical power from the 28V 377

DC Capt Flight Instrument bus and the 28V DC F/O Flight Instrument bus. The Right AIMS cabinet gets electrical power from the 28V DC Left bus and the 28V DC Right bus. Each cabinet receives the power from four 28V DC circuit breakers in the overhead circuit breaker panel. The four 28V DC bus inputs, known as power 1 through power 4 enter the cabinets through different routings. Power 1 and power 2, known as left power, enter the cabinet through a connector on the left side of the cabinet. Power 3 and power 4, known as right power, enter the cabinet through a connector on the right side of the cabinet.

Each AIMS cabinet has four Input/Output modules (IOM) and four Core Processor Modules (CPM). These are Line Replaceable Modules (LRM). The IOM transfers data between the software functions in the AIMS CPMs and external signal sources. The CPMs supply the software and hardware to do the calculations for several avionic systems. The software is called functions. To keep a necessary separation between the functions, each function is partitioned. The partitions permit multiple functions to use the same hardware and be in the same CPM. Each LRM receives power from four sources, two for main power and two for monitor power. The main circuitry uses the main power. Special circuits that monitor the condition of the power supply in the LRM use the monitor power. The two main and two monitor sources of power for each LRM come from different power sources. Each LRM must have at least one main and one monitor power input to operate. The loss of any one of the four power buses to the backplane power bus or to any one LRM has no effect on the function of the LRMs. The loss of two power inputs from the same side of the cabinet, left or right, has no effect on the function of the LRMs. The loss of one power input from the left side and one power input from the right side results in the loss of function in four LRMs. The loss of three or four of the power buses to the cabinet chassis power backplane results in the loss of function of all the LRMs.

Each AIMS cabinet also receives power through one hot battery bus circuit breaker in the standby power management panel. The connection to the hot battery bus keeps the LRMs internal memories active. The hot battery bus also makes the AIMS cabinet less likely to have faults due to power transients.

Given the preceding arrangement of dual and distant location of the AIMS cabinets, independent and multiple power sources and 378

separation of the computing functions the likelihood of failure of the AIMS operation is remote. Furthermore, operation of the SATCOM is reliant on satisfactory operation of the AIMS. Regular SATCOM 7th ‘handshakes’ were present, till the and last handshake at 0019 UTC. This indicates that the AIMS, or at least part of it, was operational.

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 SATELLITE COMMUNICATIONS ANALYSIS

2.5.1 Summary of Key Observations of the SATCOM Ground Station Logs

The key observations of the SATCOM Ground Station Logs, with an assessment, are summarised below:

Prior to take-off, the SATCOM Logged On (normally) a number of times, the last time being at 1600, when it sent a valid Flight ID to the Ground Earth Station (GES). The SATCOM link was available for both voice and data (known as Log-On Class 3).
After take-off, the In-Flight Entertainment System (IFE) Short Messaging System (SMS) e-mail application sent a normal beginning of flight message at 1642 (containing the correct Airborne Earth Station (AES ID), Flight ID “MAS370”, origin airport “WMKK”, and destination airport “ZBAA”), indicating that the IFE was receiving the valid Flight ID, origin airport and destination airport from Airplane Integrated Management System (AIMS) and the ICAO (AES) ID from the Satellite Data Unit (SDU) at this time.
The SATCOM link was available for most of the flight, excluding periods leading up to 1825 on 07 March 2014 and 0019 on 08 March 2014.
When the SATCOM link was re-established at the above times, no Flight ID was present. This implies that a valid Flight ID probably stopped being sent to SATCOM at some time between 1642 (when the IFE reported the correct Flight ID) and 1825 (when the SATCOM Logged On with no Flight ID) on 07 March 2014. The possible reasons for the link losses and the subsequent Log-Ons that took place at 1825 and 0019 have been investigated and are detailed in tables in Section There are many quite complicated scenarios that could have 2.5.2. caused the 1825 Log-On. However, the most likely reason is a lengthy power interrupt to the SATCOM. The most likely reason for the 0019 Log-On was also a power interrupt to the SATCOM.
During the two in-flight Log-Ons at 1825 and 0019, the GES recorded abnormal frequency offsets for four burst transmissions from the SATCOM. After extensive analysis, the following explanations have emerged.

The 1825 Log-On Request had a non-zero BER and could therefore have been logged at the Ground station with a BFO measurement error suggesting that the BFO figure may not be reliable.

1825 Log-On Acknowledge - Most likely due to the power-on drift of the SDU Oven Controlled Crystal Oscillator (OCXO), thus endorsing the belief that the 1825 Log-On was preceded by a lengthy power interrupt.

0019 Log-On Request - Could have been due to uncompensated vertical velocity, indicating that the aircraft was likely to be descending at this time. Alternatively, it could have been due to the OCXO warm up drift, or it could have been due to a combination of uncompensated vertical velocity and OCXO warm up drift.
0019 Log-On Acknowledge - Could have been due to uncompensated vertical velocity, indicating that the aircraft was likely to be descending at this time. Alternatively, it could have been due to the OCXO warm up drift, or it could have been due to a combination of uncompensated vertical velocity and OCXO warm up drift.
It has not been possible to attribute specific correction values to the 1825 Log-On Acknowledge and 0019 Log-on Request and Log-On Acknowledge BFOs, so it was excluded from the Doppler calculations undertaken by the Aircraft Flight Path/Performance Subgroup. In the case of the 1825 Log-On Acknowledge, the following subsequent bursts were used instead, as the frequency is more stable at these times:

1828:05.904 Data-3 R-Channel burst.
1828:14.905 Data-3 R-Channel burst.

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.
No Data-2 Aircraft Communications Addressing and Reporting System (ACARS) traffic was observed after 1707 on 07 March 2014.
The IFE equipment set up two ground connections over SATCOM (for the SMS e-mail application and Built-In Test Equipment (BITE) application) after the SATCOM re-established the link at 1825 on 07 March 2014 (normal), but not after the SATCOM re-established the link at 0019 on 08 March 2014 (abnormal). In the 0019 case, it is possible that the IFE was no longer powered, or failed, or that the IFE and/or the SATCOM became inoperative before the connections could be set up. At no time during the flight was any user data sent over the link by means of the SMS/e-mail application.
Two Ground-to-Air Telephony Calls were placed to the cockpit from the MAS Airline Operations Centre at Airline Operational Communications (AOC) Q10 priority level at 1839 and at 2313 on 07 March 2014. Neither of the calls was answered.
The SATCOM responded normally to a series of roughly hourly Log-On Interrogations from the Perth GES, up to and including a Log-On Interrogation at 0011 on 08 March 2014. The two unanswered ground to air calls at 1839 and 2313 reset the Perth GES inactivity timer and hence the Log-On Interrogations were not always hourly.
The SATCOM transmissions during the two in-flight Log-Ons and five Log-On Interrogations form the seven ‘handshakes’ that have been used by the Flight Path/Performance Subgroup to calculate the seven geographical ‘arcs’.
The last transmission received from the SATCOM occurred at 0019 on 08 March 2014 and the SATCOM failed to respond to a series of three Log-On interrogations starting at 0115 on 08 March 2014. This implies that the SATCOM probably became inoperative at sometime between 0019 and 0115 on 08 March 2014.

2.5.2 Possible Reasons for the 1825 and 0019 Log-On Events and Preceding Link Losses

First In-Flight Log-On at 1825 on 07 March 2014

Flight ID Status Log-On Likelihood Comments Change Reason Description Flight ID stopped Power Medium CBs are not readily accessible, but could being received from Interrupt have been due to power interrupt. AIMS, or being received, Sysfail Very low Sysfail is a very rare event and usually but with the Sign (software fail) results in only a few minutes loss of link. Status Matrix Loss of Not Loss of Minop or link would have resulted (SSM) field not Minop37 or possible in the original Flight ID being sent to the set to Normal Loss of Link GES at Log-On. Operation. Flight ID received Power Low Flight ID would have to have transitioned Interrupt to null value whilst the SDU was not from AIMS, but powered. with null value (zeros) and Sign Sysfail Very low Flight ID would have to have transitioned (software fail) to null value whilst the SDU was in Sysfail Status Matrix (which is a rare event in itself). (SSM) field set to Loss of Low Flight ID would have to have been Normal Operation Minop or cleared whilst the SDU was in loss of Loss of Link Minop or experiencing loss of link (duration at least 22 minutes). Otherwise a Log-On Renewal would have occurred and the GES log shows that a Log-On renewal did not occur. Flight ID Power Not SDU needs to be operational to accept Inter r u p t o r manually possible null Flight ID via an MCDU. Sysfail cleared via the (software fail) MCDU Los s of Low Flight ID would have to have been Minop or manually cleared whilst the SDU was in Loss of Link loss of Minop or experiencing loss of link (duration between 22 and 78 minutes). Otherwise a Log-On Renewal would have occurred and the GES log shows that a Log-On Renewal did not occur. Table 2.5A - Possible Reasons for the 1825 Log-On Events and Preceding Link Losses

From the above table, the most likely reason for the 1825 Log-On is a power interrupt.

37 Loss of Minop - Is the inability of the AES to Log-On, because of one or more missing or failed resources, (e.g. equipment BITE failure). 383

Second In-Flight Log-On at 0019 on 08 March 2014

Log-On Likelihood Comments Reason P ower M edium The SATCOM CBs are not readily Interrupt accessible and are therefore unlikely to have been cycled. However, given that MH370 could have been low on fuel at this time, some form of generator transfer may have occurred, resulting in a SATCOM power interrupt. Sysfail Very low Sysfail is a very rare event. (software ffail) Loss of Low Loss of Minop - Normally a very low Minop likelihood, but given that MH370 could have been low on fuel at this time, some form of generator-related abnormal operation of a peripheral system (e.g. AIMS) may have occurred. Loss of Low Loss of Link would have prompted Link a new Log-On attempt via the Low Gain Antenna (LGA) subsystem. From the GES records, the subsequent Log-On is known to have been via the High Gain Antenna (HGA) subsystem, so for loss of link to be the Log-On reason, both the HGA and LGA subsystems would have had to have failed to close the link for a while. This is only likely in the case of an abnormal aircraft attitude, but given that MH370 could have been low on fuel at this time, this is a plausible reason.

Table 2.5B - Possible Reasons for the 0019 Log-On Events and Preceding Link Losses

From the above table, the most likely reason for the 0019 Log-On is a power interrupt. 384

Note:

The above table does not include the ‘Flight ID Status Change Description’ column that appears in the previous table, as there is no change of Flight ID Status for this second in-flight Log-On.

Preceding Link Losses

Although the link loss that is believed to have preceded the 1825 Log-On is most likely to have been due to a power interrupt, for completeness, other possible reasons for the link loss are considered in the following table (Table 2.5C).

Link Loss Likelihood Comments Reason A utomatic Very low Had the SDU initiated a Satellite/GES handover, a Log-Off Handover Request should have been recorded in the GES log. No such request was recorded.

Manual Log-Off, Very low Had a manual Log-Off via the MCDU been initiated via the MCDU, a Log-Off Request should have been recorded in the GES log. No such request was recorded. Table 2.5C – Other Reasons for the Link Loss

The above table confirms that the link loss that is believed to have preceded the 1825 Log-On was not due to Satellite/GES handover or manual intervention via the MCDU.

2.5.3 Summary Assessment of Doppler for 1825 and 0019 Log-On Events

During each of the two in-flight Log-Ons that occurred during flight MH370, the GES recorded abnormal frequency offsets for the SATCOM transmissions. This is in contrast with the ‘normal’ Log-On behaviour.
in shows the frequencies of these Log-On Table 1.9D Section 1.9.5 bursts, as measured at the GES, plus differences from assumed reference frequencies. The table also shows the very high delta frequencies between the respective Log-On Request and Log-On Acknowledge bursts.
The following graph shows the delta frequencies (Figure 2.5A) between pairs of Log-On Request and Log-On Acknowledge bursts for over one hundred Log-Ons of the SATCOM on-board 9M-MRO, up to and including the two during flight MH370. In every case prior to MH370 the delta frequencies were fairly small. Only the last two pairs of transmissions (the 1825 and 0019 Log-Ons) show significant deltas. Note that for ease of display, only the magnitude is shown for the two MH370 Log-On frequency deltas.

Figure 2.5A – Delta Frequencies between Pairs of Log-On Request and Log-On Acknowledge

From the Perth GES logs, the AES is known to have Logged-On as Class 3 (Voice & Packet Data). In order to have done so, the SDU must have been receiving valid Air Data Inertial Reference Unit (ADIRU) data from AIMS. In this case, the AES would apply open loop Doppler compensation, whereby it uses the ADIRU data in order to calculate the transmit frequency Doppler offset.
An OCXO provides a stable reference frequency for the SDU Radio Frequency (RF) transmit and receive circuits and also for

SDU modem timing. Within the OCXO, a regulated oven keeps the crystal at an almost constant temperature if the ambient temperature in the crown area is between the ranges -550C up to +700C. above The oven also contains extra electrical regulation and isolation to ensure frequency accuracy and stability. The OCXO includes an oven ready flag, which triggers the Log-On initiation when the OCXO reaches its operating temperature. Extensive laboratory testing has revealed that during warm up, the OCXO frequency may vary non-linearly with time, but then settles with almost negligible variation. At power-on, the OCXO can exhibit either a rising or falling frequency gradient, before decaying over time to its normal steady state value. The testing has indicated that reasonable stability (within 2Hz/minute) is typically reached by around five minutes after an initial peak or overshoot. The testing has also shown that there can still be a significant frequency offset at the time that the oven ready flag initiates the Log-On process, so the Log-On request, Log-On Acknowledge and subsequent data bursts can all exhibit significant frequency offsets.

These frequency offsets can be seen in the plot (Figure 2.5B) below, for a 9M-MRO SATCOM Log-On (believed to have taken place after a lengthy power down), at 1250 on 07 March, whilst the aircraft was on the ground at Kuala Lumpur, prior to the departure of MH370. The frequency has stabilised to a value of around 350Hz, within three minutes of the Log-On Request.

Figure 2.5B - SATCOM Log-On Frequency Offsets at 1250, 07 March 2014

These frequency offsets can also be seen in the plot (Figure below for the MH370 1825 Log-On. As with the 1250 Log2.5C) On, the frequency has stabilised within three minutes of the LogOn Request, this time at around 150Hz.

Figure 2.5C - SATCOM Log-On Frequency Offsets at 1825, 07 March 2014

The 1825 Log-On Acknowledge and the subsequent Data-3 transmissions exhibit a frequency offset, which decays to the steady state value. This frequency decay endorses the belief that the SATCOM had been powered down prior to the 1825 Log-On.
The 1825 Log-On Request does not exhibit the frequency offset decay though. However, it is possible that the OCXO frequency was rising at this time, prior to decaying to its steady state value. It is noted that the 1825 Log-On Request was received at the GES with a low Received Carrier/Noise Density Ratio (C/No) and a channel Bit-Error-Rate (BER) of 5 and could therefore have been logged at the Ground station with a BFO measurement error suggesting that the BFO figure may not be reliable. Non-zero channel BER transmissions are not uncommon for a satellite link. The C/No (and hence channel BER) can be impacted by the gain of the SATCOM antenna and also atmospheric effects, as well as interference due to collisions with a (lower power) burst from another aircraft.
In the seven days leading up to flight MH370, 235 out of 6803 (3%) of 9M-MRO SATCOM Class 3 transmissions (via HGA) were received at a GES with a non-zero channel BER and during flight MH370, 5 out of 112 (4%) of transmissions were received at a GES with a non-zero channel BER. So, the MH370 SATCOM performance from a channel BER perspective appears to have been normal.
The plot below shows a series of MH370 Log-On (Figure 2.5D) Interrogation transmissions, which steadily rise in frequency (due to the satellite ephemeris). However, the 0019 Log-On Request and Log-On Acknowledge transmissions diverge from the steady state slope.

Figure 2.5D - Log-On Interrogation Transmissions

For the 0019 BFOs, the following possible error contributions are considered:

GES Measurement Errors - There is only evidence to suggest a significant GES measurement error in the case of a burst that is received at the GES with a non-zero channel BER, as in the case of the 1825 Log-On Request. This was not the case with the 0019 BFOs, so it can be discounted.
SDU OCXO Reference Error – OCXO stability has been measured over both temperature (circa -0.65Hz/deg. C) and time (as described above). The OCXO double

inflection warm up drift could explain at least part of the 0019 Log-On Request and Log-On Acknowledge frequency offsets.

Satellite Doppler Towards SDU and GES - Doppler frequency offset due to the relative movement of the satellite could not account for the >100Hz frequency shift in the <10 seconds between the 0019 Log-On Request and the Log-On Acknowledge bursts.

Doppler Error due to ADIRU Drift - If the aircraft ADIRU is assumed to have a maximum drift of 2kts (1m/s), then the worst case Doppler offset is 16Hz, significantly smaller magnitude than the >100Hz frequency shift in the <10 seconds between the 0019 Log-On Request and the LogOn Acknowledge bursts.
Doppler due to erroneous ADIRU Data - From a SATCOM perspective, the SDU will not use navigation data unless the Sign Status Matrix (SSM) for every one of the required ARINC 429 words (Latitude, Longitude, Groundspeed, Track, Pitch, Roll and Heading) is set to Normal Operation. It is “extremely improbable” that an ADIRU will send erroneous data with the SSM set to normal. In this case, we can conclude that the abnormal frequency offsets are extremely unlikely to be as a result of the SDU receiving or acting upon erroneous navigation data from an ADIRU.
Uncompensated Vertical Velocity - The SATCOM SDU does not consider vertical velocity in its Doppler calculation. It has been calculated that a vertical velocity of +100ft/min causes about a +2Hz change in the Doppler shift. Therefore, under normal circumstances, only a small frequency error results from the uncompensated vertical velocity. For example, an ascent or descent rate of 2000ft/minute would cause a 40Hz offset. In the case of MH370, a significant vertical velocity could explain at least part of the 0019 Log-On Request and Log-On Acknowledge frequency offsets.

In summary, the abnormal BFOs for the 1825 and 0019 LogOns can be explained as follows:

The 1825 Log-On Acknowledge - Most likely due to the power-on drift of the OCXO.
0019 Log-On Request and Log-On Acknowledge - Could have been due to uncompensated vertical velocity, indicating that the aircraft was likely to be descending at this time. Alternatively, it could have been due to the OCXO warm up drift, or it could have been due to a combination of uncompensated vertical velocity and OCXO warm up drift.

It has not been possible to attribute specific correction values to the 1825 Log-On Acknowledge and 0019 Log-on Request and Log-On Acknowledge BFOs, so it was excluded from the Doppler calculations undertaken by the Aircraft Flight Path/Performance Subgroup. In the case of the 1825 Log-On Acknowledge, the following subsequent bursts were used instead, as the frequency is more stable at these times:

1828:05.904 Data-3 R-Channel burst.
1828:14.905 Data-3 R-Channel burst.

2.6 WRECKAGE AND IMPACT INFORMATION

2.6.1 Debris Considered for Detailed Examination

After the completion of the underwater search no wreckage belonging to MH370 was found. However, a number of debris were washed ashore near and onto the coast of south east Africa. Only the right flaperon, part of the right outboard flap and a section of the left outboard flap were confirmed to be from MH370. So far, 7 other pieces were also determined to be almost from MH370. To date, 27 items were considered significant for certain evaluation and the table below lists them and the status.

Ref. Debris Status Item 1 Right Flaperon Confirmed Item 2 Right Wing No. 7 Flap Support Fairing Almost certain Item 3 Right Horizontal Stabiliser panel piece Almost certain Item 4 Engine Nose Cowl Almost certain Item 5 Door R1 Stowage Closet Almost certain Item 6 Right Hand Engine Fan Cowling Almost certain Item 7 Wing Body Fairing Likely Item 8 No. 1 Flap Support Fairing Tail Cone Highly Likely Item 9 Left Wing Trailing Edge Panel Highly Likely Item 10 Left Outboard Aft Flap Section Confirmed Item 11 Seat Back Trim Panel Encasing IFE Monitor Highly Likely Item 12 Bottom Panel of Wing or Horizontal Stabilizer Likely Item 13 Unidentified Part Not ldentifiable Item 14 Unidentified Part Not ldentifiable Item 15 Right Wing Trailing Edge Panel Highly Likely Item 16 Cabin Interior Panel A lmost certain Item 17 Unidentified Part Not ldentifiable Item 18 Right Forward Nose Landing Gear Door Highly Like ly Item 19 Right Outboard Flap Confirmed Item 20 Right Aft Wing to Body Fairing Highly Likely Item 21 Unidentified Part Not ldentifiable Item 22 Right Vertical Stabilizer Panel Almost Certain Item 23 Unidentified Part Not Identifiable Item 24 Unidentified Part Not Identifia ble Item 25 Unidentified Part Not ldentifiable Item 26 Right Aileron Highly Like ly Item 27 Right Wing No. 7 Flap Support Fairing Highly Likely Table 2.6A - List of Debris Found and Considered for Detailed Examination

Examination, analysis and test were conducted by ATSB in Canberra, Australia and MH370 Safety Investigation Team in collaboration with STRIDE of Malaysia.

2.6.2 Location of Debris with respect to Aircraft

(below) shows the locations of the debris with respect to the Figure 2.6A aircraft.

Item 4 (part of the Engine Nose Cowl) is depicted to be from the right engine. 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 the cowling. Similarly, although Item 6 (part of the RH fan cowl) is depicted to be from the right engine in Figure there is a possibility that it could also be from the left engine. As for 2.6A, Item 7 - Wing body fairing - this too could be from either side of the aircraft.

Based on the identification of the parts and debris found, it shows that most of those parts and debris were from the right hand side of the aircraft.

Figure 2.6A - Location of Parts and Debris Found with respect to Aircraft

2.6.3 Damage Analysis of Significant Debris

Damage examination on the recovered part of the right outboard flap (Item 19), together with the damage found on the right flaperon (Item 1) indicates that the right outboard flap was most likely in the retracted position and the right flaperon was probably at, or close to, the neutral position, at the time they separated from the wing. This conclusion is based on the following findings and analysis.

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.

With the flap in the retracted position, alignment of the flap and flaperon rear spar lines, along with the close proximity of the two parts, indicated a probable relationship between two areas of damage around the rear spars of the parts. This was consistent with contact between the two parts during the aircraft breakup sequence, indicating that the flaperon was probably aligned with the flap, at or close to the neutral (faired) position. Refer to ATSB’s report on the Outboard Flap Failure Analysis (Appendix for 2.6C) further details.

It should be noted that the DGA/TA, after examining the flaperon soon after it was found in July 2015, had concluded that the flaperon was likely to be deflected at the time of impact. This was primarily based on the damage observed on the trailing edge of the flaperon. However, this scenario was considered a hypothesis only due to lack of corroborating information, and more importantly, it was done without the benefit of the damage information available from the right outboard flap which was found much later. Additionally, the flaperon being rear of the engine, left some doubt as to its loading during the aircraft impact with the water and the phenomena at issue being highly dynamic and thus difficult to exploit. Refer to Appendix 1.12Afor further details. 2

Two pieces of debris are from the cabin interior suggesting almost certain 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.

Of the pieces tested so far, no traces of explosion were found.

2.6.4 Marine Life Examination

The marine organisms (barnacles) found on the flaperon were examined in detail by marine biologists, under the directive of the French Investigative judge. Below is a summary of the analysis.

The barnacles present on the flaperon belonged to the species Lepas striata. This sub-species is strictly pelagic, always living (Anatifa) anatifera on floating objects. It is a cosmopolitan species, widespread in worldwide oceans at tropical and temperate latitudes, in water temperatures above 1820°C. The size of the biggest specimen indicated that the initial settlement could have occurred 15-16 months prior the discovery of the flaperon at to Reunion Island. The locations of the colony on the flaperon indicated Lepas that the flaperon was floating with its "belly face" up (the lower surface [intrados] was up, the upper surface [extrados] was immersed). Refer to for details. Appendix 2.6A

Temperatures during the growth of the youngest valves and the terminal fringe of the biggest adult valves (25.4 +/- 1°C) were consistent with temperatures observed off the Reunion Island. These results suggest that the barnacles ended up their developments in waters whose thermal characteristics were similar to waters close to Reunion Island, before the discovery of the flaperon.

At the beginning of their growth, the barnacles were immersed in waters with a temperature close to 28.5 +/- 1°C. Temperature distribution maps in the months preceding the discovery of the flaperon suggest that it has drifted in waters located East-North East of Reunion Island.

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. Refer to for details. Appendix 2.6B

2.7 ORGANISATION AND MANAGEMENT OF DEPARTMENT OF CIVIL AVIATION AND MALAYSIA AIRLINES

2.7.1 Department of Civil Aviation Malaysia

Introduction

In light of the disappearance of MH370 on 08 March 2014 [MYT], Malaysia as the State of Registry, State of Operator and State of Occurrence was obliged to conduct an investigation into the incident. Accordingly, the Minister of Transport had on 25 April 2014, instituted an independent international Investigation Team known as The with Malaysian ICAO Annex 13 Safety Investigation Team for MH370 the sole objective of “prevention of future accidents or incidents and not for the purpose to apportion blame or liability.” The Team, headed by an Investigator-in-Charge, comprised of nineteen Malaysians and seven international Accredited Representatives (AR) of seven safety investigation authorities from seven countries (Australia, China, France, Indonesia, Singapore, the United Kingdom, and the United States of America).

Department of Civil Aviation Organisation Structure

The Department of Civil Aviation (DCA) organisation structure at headquarters and operations resembles a flat or horizontal organisation structure which enables the officers to know what their respective responsibilities are since individual officers are assigned specific roles and functions. It enables the coordination of all activities within the DCA so that there is minimal duplication of effort or conflict and avoids overlapping of functions. As this structure creates fewer management levels, quick decisions and prompt actions can be taken without delay. Fast and clear communication is possible among these few levels of management and subordinates who are free from close and strict supervision and control.
This organisation structure is suitable for DCA at headquarters as the activities are rather routine and standardised. The officers at headquarters are assigned specific roles and functions enabling them to carry out their duty efficiently.
The DCA does not have sufficient technical personnel to effectively carry out all of its safety oversight tasks and functions due to resignations, delays in the filling of existing vacant posts, and difficulty in increasing the number of established posts in response to the growth of the industry. Uncompetitive employment conditions and the current practice of accepting technical personnel on rotational secondment from other government departments and short-term contracts from industry create difficulties in recruiting and retaining qualified and experienced technical personnel.
DCA is looking into the State Safety Programme (SSP) in accordance with Chapter 3, Annex 19 to the Convention on International Civil Aviation which will be applicable on 07 November 2019.

Air Traffic Management Sector

Organisation Structure

The organisation structure of the Air Traffic Manager (ATM) Sector at headquarters and operations resembles a flat or horizontal organisation structure which enables the officers to know what their responsibilities are since individual officers are assigned specific roles and functions. It enables the coordination of all activities within the ATM headquarters so that there is minimal duplication of effort or conflict and avoids overlapping of functions. As this structure creates fewer management levels, quick decisions and prompt actions can be taken without delay. Fast and clear communication is possible among these few levels of management and subordinates are free from close and strict supervision and control.

The ATM Sector at headquarters has a total establishment of 19 posts to manage the ATSUs in Kuala Lumpur and Kota Kinabalu FIRs and all the posts are filled and are sufficiently staffed.

This organisation structure is suitable for ATM headquarters as the activities are rather routine and standardised. The officers in this Sector are assigned specific roles and functions enabling them to carry out their duty efficiently. However, the personnel in ATM headquarters should closely monitor the Air Traffic Services Units (ATSUs) in the Kuala Lumpur and Kota Kinabalu

FIRs to ensure that the rules and established procedures are strictly adhered to. Periodical reminders and surprise visits to the respective ATSUs should be carried out so that the operational personnel would not lose touch with current procedures.

The ATM headquarters’ responsibility with regard to MH370 is through the KL ATSC Director in adherence to and compliance with the rules and established procedures in the MATS Vol. 1 and Vol. 2, ICAO Annexes and Documents, Operational Letter of Agreements and Departmental Directives and Instructions, Supplementary Operations Instructions and Administration Instructions.

Air Traffic Inspectorate Division

The Air Traffic Inspectorate (ATI) Division organisation resembles a flat or horizontal organisation structure which enables the officers to know what their responsibilities are since individual officers are assigned specific roles and functions. It enables the coordination of all activities within the Division so that there is minimal duplication of effort or conflict and avoids overlapping of functions. As this structure has fewer management levels, quick decisions and prompt actions can be taken without delay. Fast and clear communication is possible among these few levels of management and subordinates are free from close and strict supervision and control. This organisation structure is suitable for the ATI Division as the activities are rather routine and standardised.
The ATI Division is headed by a Director and assisted by a Deputy Director. There are three units viz. Safety Oversight of ANS Providers, ATC Examination, ATC Licensing and Safety. There are three Principal Assistant Directors and three Senior Assistant Directors.
The ATI Division has conducted six Safety Oversight Audits on the Kuala Lumpur ATSC (KL ATSC). The last audit was conducted from 22 - 25 April 2013. The objective of the audit is to ensure conformity with ATMS prescribed standards and requirements in the provisions of ATMS by the ATM service provider.
The relevant ICAO Annexes, Documents and Manuals were used to identify differences between KL ATSC practices and those established by the ATM Sector, and ICAO Standard and Recommended Practices (SARPs).
During the on-site audit, the audit team made 6 observations, with only one having a bearing on the ongoing investigation by the Team. The observation was that the “Direct line at Watch facility”. Supervisor console was not connected to recording During the course of the audit, there were 8 Manual of Air Traffic Services’ (MATS) non-compliance reports (NCRs), 21 Annex 4’s NCRs (16 Annex Chapter and 5 Annex Chapter 21), 6 Doc 9426 - ATSC Facilities NCRs and 2 ANS Regulatory NCRs. There was a total of 37 new NCRs’ findings for the audit conducted in 2013. However, for the audit that was conducted in 2010, 9 out of 11 MATS’ NCRs and the entire 8 Doc 9426’s NCRs still remain open. There were a total of 17 NCRs still remaining open. There were 6 NCRs brought forward from 2005/2006. KL ATSC has accumulated altogether a total of 60 NCRs after the audit conducted in April A2013.

Notwithstanding the above, the Team does not find any direct link between the NCRs and the disappearance of MH370.

There has not been any direct link as to the functions of the ATI Division with regard to the disappearance of MH370. The ATI Division has issued ATC licenses to the ATC personnel in accordance with Personnel Licensing under Regulation 92(1) of the Malaysian Civil Aviation Regulations 1996.

Search and Rescue

Although there is no legislation specifically to address the provision of assistance to aircraft in distress, Aeronautical SAR (A-SAR) in Malaysia is provided in accordance with ICAO Annex 12 and the International Aeronautical and Maritime Search and Rescue (IAMSAR) Manual Vol. I – III (ICAO Doc 9731-AN958). It should be noted that CAR 201 stipulates the use of to address ICAO Annexes 1 to 18, including ‘ipso facto’ the application of ICAO Standards and Recommended Practices (SARPs), provided that a regulation has not already been established in CAR and that a difference has not been

notified to ICAO. In particular, DCA relies completely on CAR 201 for the implementation of Annexes 3, 4, 5 and 12.

IAMSAR Vol. IV - The National Aeronautical and Maritime Search and Rescue Manual (Malaysia), prepared under the direction of the National Search and Rescue Committee, National Security Council (NSC) and the Prime Minister’s Department in March 2008, provides guidance to federal agencies concerning the implementation of the National Search and Rescue Plan. This Plan provides specific additional national standards and guidance that build upon the base line established by the International Aeronautical and Maritime Search and Rescue (IAMSAR) Manual. The IAMSAR Manual is a three-volume set published jointly by both the International Civil Aviation Organisation (ICAO) and the International Maritime Organisation (IMO) for use by all countries. This Plan provides guidance to all federal forces, military and civilian, that support civil search and rescue (SAR) operations. It should be noted that the land (populated areas) and military SAR elements, under the portfolio of its respective ministries, are intentionally excluded from this document.

The IAMSAR Vol. IV is a very comprehensive national SAR manual covering areas viz.:

Part One Aeronautical and Maritime SAR Authority and Administration; Part Two Aeronautical and Maritime SAR Policy Part Three Aeronautical and Maritime SAR Resources Part Four Aeronautical and Maritime SAR Communications Part Five Special Procedures Part Six Memoranda of Understanding Plan of Operation Part 1 - Aeronautical Part 2 - Maritime

Over the South China Sea, within the Singapore FIR, there are two distinct areas namely the South China Sea Corridor (SCSC) and the airspace delegated to KL ACC by Singapore ACC known as the “Delegated Airspace”. There are special arrangements whereby the roles and responsibilities of KL

ARCC and Singapore RCC have been defined in terms of alerting service and SAR operations as follows:

South China Sea Corridor

The arrangement for aeronautical search and rescue service by way of the Operational Letter of Agreement between Malaysia and Singapore for the part of the South China Sea (which is within the Singapore FIR) was in force since 1984. The agreement specified the designated area, known as the South China Sea Corridor (SCSC) and stipulates that in the event of an aircraft emergency occurring within the SCSC, the KL ACC shall be responsible to take initial alerting action whilst Singapore RCC shall be responsible for subsequent coordination of all SAR efforts. Whist the responsibility for the provision of search and rescue service within the SCSC rests with the Singapore RCC, the Singapore RCC may delegate responsibility for the overall control of the SAR mission to Kuala Lumpur RCC or Kota Kinabalu RCC, whichever is deemed appropriate.

Letter of Agreement Para 3.2.2 states that:

When a transfer of responsibility for the overall SAR coordination 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:

direct discussions, wherever possible, shall take place between the Search and Rescue Mission Coordinators (SMCs) concerned to determine the course of action,

if it is decided that a transfer of responsibility is appropriate for the whole mission or part thereof, full details of the SAR mission shall be exchanged, the initiating RCC shall continue to retain responsibility until the accepting RCC formally assumes control for the mission. 402
“Delegated Airspace” in Singapore FIR

The “Delegated Airspace” is a defined airspace over the South China Sea within the Singapore FIR that has been delegated by Singapore to Malaysia for the purpose of Air Traffic Services. SAR service is provided by Singapore.

Figure 2.7A - Kuala Lumpur - Aeronautical Rescue Coordination Centre (ARCC)

On 08 March 2014 [MYT], MH370 operated within the “Delegated Airspace”. The radar position symbol dropped from the radar display at 1721:13 UTC [0121:13 MYT]. Though the KL ACC was responsible for the provision of Air Traffic Services, no alerting action was taken. At 2130 UTC [0530 MYT] the KL ATSC Duty Watch Supervisor directed the Search and Rescue Mission Coordinator (SARMC) to activate the ARCC (Figure above and below). 2.7A Figure 2.7B After the ARCC was activated, and due to a lack of details from the KL ATSC Duty Watch Supervisor, the SARMC only managed to disseminate the distress message at 2232 UTC [0632 MYT], an hour and two minutes later.

Figure 2.7B - Kuala Lumpur ARCC Work Stations

Kuala Lumpur Air Traffic Service Centre

Staffing

This analysis on the Organisation Structure of the Kuala Lumpur Air Traffic Service Centre - below - is based Figure 2.7C on information obtained from the Department of Civil Aviation. There are altogether 353 approved ATS posts of various grades in the KL ATSC. As of March 2015, there were 110 vacancies and 64 as of December 2014. The reason cited for the posts not being filled was “considering the opening of klia2, DCA has managed to obtain new posts for KL ACC (Area and Approach) and KLIA on 08 May 2013. But due to the delay of klia2 opening the promotion exercise was also delayed”.

Findings of Safety Oversight Audit

The findings of the Final Report of the Safety Oversight Audit (Follow-up) of KL ATSC in April 2013 state that:

the organisational charts do not reflect the task currently

assigned to and being performed by the ATS staff who are also assigned secondary posts with specific duties.

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.
No internal audit conducted however it is noted that an audit team will be established consisting of personnel who had previously attended audit course.

The reasons cited in the audit report were inadequate staffing and inadequate resources to run the programme.

Figure 2.7C - Overview of Kuala Lumpur Air Traffic Control Centre

Duty Roster for March 2014

This analysis is based on the KL ATSC duty roster for Air Traffic Controllers for the month of March 2014. The Team acknowledges that the duty roster was prepared with the number of Controller working positions (CWPs) in the KL ATSC being filled by qualified Controllers at all CWPs.
On the night of 07 March 2014, at 1500 UTC [2300 MYT] the functions of control for Sector 5 was absorbed into

Sector 3. There was no issue from this time other than that the combination of these two CWPs was carried out an hour earlier than scheduled. From 1600 UTC [0000 MYT] until 1900 UTC [0300 MYT] and 1900 UTC [0300 MYT] to 2200 UTC [0600 MYT] the Sector 3+5 radar working position was manned by radar-rated Controllers. However, it is confirmed that, from 1600 UTC [0000 MYT] till 2200 UTC [0600 MYT], the Sector 3+5 Planning Position was manned by an and an OJT Controller AFD as the qualified Controllers were having their Officer respective breaks.

Area Controlers Working Positions

Watch Supervisor Working Positions

Figure 2.7D - Kuala Lumpur Air Traffic Control Centre – Area Control CWPs 7) Airworthiness Sector

The Airworthiness Sector is not involved in the frontline operations of the aircraft. Organisational weaknesses or shortcomings of the Airworthiness Sector however may contribute to accidents due to weaknesses in the management systems and culture.

Areas Analysed

The following areas were analysed for latent conditions:

Corporate goals • Organisational Structure Communication • • Planning

Control and monitoring • • Procedures • Resources, which include: - Regulations - Safety Management

Corporate Goals

The Airworthiness Sector does not have specific corporate goals. It shares the Vision, Mission and values of the parent DCA. The DCA’s Vision is “to be the world’s authority”. Its Mission is “to leading aviation continuously enhance safety, security and efficiency for sustainable industry”. These Vision and Mission do not aviation specifically relate to the roles and functions of the Airworthiness Sector, which is to carry out “the regulatory function in respect of airworthiness through the establishment of standards recommended practices and guidelines, and their enforcement as required by the Civil The organisational Vision and Aviation Act [CAA] 1969”. Mission are normally related to corporate goals. It is very important to instil values in each staff to achieve the corporate objectives. However, there is no direct evidence that any missing corporate goals in terms of Vision and Mission may contribute to any latent conditions which can lead to the potential failure of the system.

Organisational Structure

The organisational structure of an Airworthiness Organisation is detailed in the ICAO Document 9760. The Airworthiness organisation is divided into the Airworthiness Engineering Division (AED) and Airworthiness Inspection Division (AID), as shown in Figure 2.7E - Setup of the Airworthiness Organisation 9760). (ICAO Document

STATE GOVERNMENT

Civil Aviation Authority

Flight Safety Standards

Personnel Aircraft Operations Airworthiness Licensing

Airworthiness Licensing Airworthiness Aircraft Maintenance Engineering Division Inspection Division

Service Provider and Industry

Figure 2.7E - Setup of the Airworthiness Organisation (ICAO Document 9760)

DIRECTOR OF AIRWORTHINESS

AIRWORTHINESS AIRWORTHINESS AIRWORTHINESS AIRWORTHINESS AIRWORTHINESS LICENSING MAINTENANCE ENGINEERING STANDARDS REPAIR STATION

SC H D U L E D CERTIFICATION AIRCRAFT LICENCING AIRCRAFT F L IG H T REGISTRATION AND MORTGAGE NON SCHDULED MANUFACTURING COMPONENT FLIGHT EXAMINATION STNDARD AND DATA GENERAL ENGINEERING ANALYSIS AVIATION

Figure 2.7F - DCA Airworthiness Sector

The DCA Airworthiness Sector is divided into 5 divisions: Airworthiness Licensing, Airworthiness Maintenance, Airworthiness Engineering, Airworthiness Repair Station, and Airworthiness Standards as in above. Figure 2.7F

The roles and responsibilities of each division are as follows:

Airworthiness Licensing is responsible for examination of engineers, approval of training organisations, and issuance of licensing of aircraft maintenance engineers.
Airworthiness Maintenance is responsible in initial issuance and renewal of Airworthiness Certificates and approval of aircraft maintenance and facilities, continuing airworthiness maintenance and investigation of incidents and defects.
Airworthiness Engineering is responsible for certification of aeronautical products, issue of Airworthiness Directives (AD), approval of modification and repair, and approval of Design Organisations (DOA) and Production Organisations (POA).
Airworthiness Repair Station is responsible for investigation of incidents and defects and approval of maintenance organizations/repair stations (MRO).
Airworthiness Standards is responsible for registration of all civil aircraft and aircraft mortgage, to develop and update standards, requirement and procedures, analyse airworthiness data, including all occurrence reporting, service difficulties reporting, malfunction and defects.

The organisational structure of the DCA Airworthiness Sector does not clearly show the divisions of AED and AID. The licensing of aircraft maintenance is in the Airworthiness Sector. However, the analysis of the current Airworthiness Sector organisation structure indicates there are elements of AED and AID in the organisation. The AID elements are available in 409

Airworthiness Maintenance, and Airworthiness Repair Stations. The Airworthiness Standards cover both the AED and AID. The Airworthiness Licensing should be in the Airworthiness Sector because the DCA has a dedicated division to handle all licensing matters. Based on the organisation structure and the roles and responsibilities of each of the divisions within the Airworthiness Sector, there is no evidence of any aspects or characteristics which may lead to a latent condition.

Communication

The effective external and internal communication is essential because ineffective communication and miscommunication have shown to result in unsafe condition. The Airworthiness Sector external and internal communication have been shown to be effective formally by letter and email. The internal communication is by means of meetings and discussions between the staff. The work process and activities are consistent since the Airworthiness Division Manual (ADM) is used by the airworthiness engineers and inspectors as their procedure manual when carrying out their respective tasks. Therefore, there is no evidence of any unsafe condition with respect to communication.

Planning

The Airworthiness Sector carries out continuing airworthiness and surveillance oversight of aircraft maintenance activities of 8 Scheduled Operators and 21 Non-Scheduled Operators, 176 (local and international) Approved Maintenance Organisations (AMO) and 12 Approved Training Organisations (ATO). MAS was one of the major airline operators. The Airworthiness Sector also provides technical audit support in conjunction with the Flight Operations Sector and Air Transport Division to issue an Air Operating Certificate (AOC). The above activities are adequately planned and conducted, based on the schedule established for each organisation.

For the initial airworthiness certification, airworthiness inspectors and airworthiness engineers carry out new aircraft type design certification or the validation of Aircraft 410

Type Certificate before the aircraft is registered. The Airworthiness Sector also reviews new applications for minor or major modifications and monitoring the applicability of mandatory Airworthiness Directives issued by the State of Design.

The audit and surveillance of the organisation (i.e. MRO, ATO and AOC) and aircraft inspection for Certificate of Airworthiness (C of A) renewal are conducted on a regular basis of at least once a year. The Airworthiness Sector establishes a detailed annual audit and surveillance programme.

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.

Control and Monitoring

The control and monitoring mechanism requires the organisation to have key performance indicators (KPI) of its performance, hazards identification and risk management policies and programme. The aspects of hazards identification and risk management are essential for the organisation in decision making of its functions and responsibilities. The aspect of organisation key performance indicators is clearly discernible.

Procedures

The Airworthiness Sector uses Airworthiness Department Manuals (ADM) as internal documented policies and procedures for the Airworthiness Engineers and Inspectors. The ADM has detailed most of the Airworthiness Sector’s working procedures. However, it has not been reviewed regularly and updated in line with technological advancement. There is no specific unsafe condition, but it could be a latent condition.

Resources

ICAO through Doc 9760 has recommended that inspectors and engineers possess relevant knowledge, experience and competency. The Airworthiness Sector has recruited a number of fresh engineers and inspectors to fill up the relevant posts. These new engineers/inspectors need to undergo training required under ICAO requirements.

Regulation is one aspect of the important resources required by the Airworthiness Sector. All the activities of the Sector were based on the Civil Aviation Act 1969. The Act requires compliance with the ICAO Annexes. The Act also requires the Minister of Transport to make regulations based on ICAO SARPS (Standards and Recommended Practices. The Minister of Transport formulated the Civil Aviation Regulations 1996 under the provisions of the Civil Aviation Act 1969. The analysis on the Malaysian civil aviation laws and regulations indicate that the Civil Aviation Act 1969 and CARs of 1996 may be outdated by present international regulatory standards and practices.

It is anticipated that the future introduction of the Civil Aviation Safety Requirements (CASR), Acceptable Means of Compliance (AMC) and Guidance Materials (GM) would serve to streamline the Malaysian regulatory framework, requirements and procedures, similar to the approach of the European Aviation Safety Agency (EASA) requirements. In the absence of new regulations in CAR 1996, the Airworthiness Sector has adopted and

adapted other countries’ laws and regulations (i.e. United States of America, European Union) and published these regulations either in notices, circulars, directives or information and issued them under section 240 (Publication of Notices) of the Civil Aviation Act 1969.

Flight Operations Sector

Corporate goals

The Flight Operations Sector (FOS) is one of the sectors of DCA Malaysia. It does not have specific corporate goals, vision or mission. It rides on the DCA Vision and Mission, which are not specific to the functions and responsibilities of the FOS. A specific vision and mission would focus the FOS inspectors on common values and practices. There is no evidence of any significant safety issue with the absence of a specific Vision and Mission for the FOS. It has no direct bearing on the disappearance of MH370.

Organisational structure The FOS is divided into 5 divisions namely: Flight Crew Licensing, Air Operator Regulations, Flight Simulator, General Aviation and Flight Calibrations.

The FOS is responsible primarily for ICAO Annex 6 (Aircraft Operation) and ICAO Annex 1 (Personnel Licensing) for the flight crew. There is an operational division in the FOS - Flight Calibration Division - which operates a number of aircraft for calibration of airfields and airways. FOS is considered a mixed mode of authority-cum-operator.

Resources

The FOS lacks the required number of experienced inspectors (pilots). The shortage of personnel may affect the flight safety standard of the Air Operating Certificate (AOC) holders, especially with respect to the frequency of audit involving station facility inspection, RAMP Inspection for en-route and destination stop, annual inspection at every location, and base inspection for Scheduled Operations and Non-Scheduled Operations. Similarly, the shortage of flight examiners may also affect the standard of the training establishments.

The Flight Operations’ Aeronautical Information Circular (AIC) No. 30/2005 November 2015 - Inspections and Investigation of Air Accidents, reiterates the statutory powers of the Minister of Transport to investigate aircraft accidents and serious incidents that occur in Malaysia regardless of nationality of aircraft registration. With respect to aircraft accidents or incidents investigation, the inspectors from the FOS may be called upon to assist the Air Accident Investigation Bureau (AAIB) under the Ministry of Transport. This function would create some constraint to the FOS in view of the shortage of experienced pilots in the Sector. This shortage is potentially a latent condition, which if not addressed, may lead to potential unsafe conditions.

Regulations is another important resource issue with the FOS working within the Civil Aviation Act 1969 and MCAR 1996. The MCAR 1996 is unable to cope with the rapid development in international aviation regulations and practices. Under the provision of section 240 of the Civil Aviation Act 1969, the AICs are published by the DCA. This practice of supplementing the CAR 1996 has been successful. However, it is still unable to cope with the up-to-date rules and regulations in Europe and North America. This condition could not have contributed to the disappearance of MH370. However, this is a latent condition which needs to be appropriately addressed.

Safety management is another important aspect in the organisation. The ICAO Annex 19 (Safety Management) has mandated the aircraft operators to develop their organisations’ SMS by January 2009. To comply with the ICAO requirements, the FOS has developed the AIC No. 06/2008 which was issued under section 240 of the Civil Aviation Act 1969 for all Malaysian Air Operating Certificate (AOC) holders to establish their organisational Safety Management System (SMS). Notably, MAS had implemented the SMS into their procedures manual. The requirement for the operators to establish SMS by the FOS is adequate. However, the FOS has to establish its own safety management programme.

2.7.2 Malaysia Airlines

Engineering & Maintenance

Based on the factual information provided in the Section 1.17.2 para. 2) Engineering & Maintenance Division was well-structured appropriate to a maintenance management and maintenance organisation with key positions manned by persons approved by the Department of Civil Aviation (DCA), Malaysia. The required oversight of the maintenance activities was provided both by internal Quality auditors, as well as by the DCA Malaysia. This was further supported by audits by foreign auditors, such as from the EASA and FAA. There were no significant audit findings suggesting that the organisation was well managed. It is not unusual to have findings during audits; the purpose is to continuously improve by instituting corrective and preventive actions.

Maintenance personnel were appropriately trained and qualified in accordance with approved procedures, as documented in the Maintenance Management and Organisation Exposition (MMOE).

Although recently introduced in the year 2009, Safety Management had been embraced in the organisation and in line with the corporate system.

Flight Operations Management

The Flight Operations Management (FOM) office positions were sufficiently manned by qualified individuals and the working guidelines ensure their effectiveness in carrying out duties in their respective management positions. The fleet manager, being on the B777 for more than 10 years and having held the post of Type Rating Examiner (TRE), attests to his level of competency and seniority.

Technical Crew of Malaysia Airlines

There was no evidence of irregularities in the standards, performance and capability of pilots in Malaysia Airlines (MAS).

Medical Check-up

There was no evidence of irregularities in terms of medical and licensing validity of pilots in MAS.

Roster Schedule & Management

Data collected indicate that the pilots’ roster and rest period are in compliance with MCAR FTL requirements. 415

There is no evidence to suggest that any of the two pilots infringed any of the required MCAR FTL limits.

Confidential Human Factors Incident Report System

In September 2013 to March 2014 over a period of six months, there were a total of six reports submitted, mainly on communications issues between staff.

This suggests that the CHIRPS was capturing adequate data to meet its objective.

There was no evidence to suggest that any of the two pilots were subjected to CHIRP’s surveillance.

Flight Operations Quality Assurance

Sampling of FOQA data over a 2-year period prior to the event was studied. Capture rates were close to 100% and it is evident that the system works and justifies its role in identifying non-normal operations either deliberate or due to environment factors.

The overall rate for B777 has its average figure comparative to the industry standards.

As an example, the highest event of UA (Unstablised Approach) occurred in the month of August 2013 at a rate of 49.26 per 10,000 flight cycles. This is equivalent to 0.49% for the month.

The highest FOQA trigger was the long flare event which occurred in the month of May 2012 at 243.6 per 10,000 flight cycles. This is equivalent to 2.3% for the month.

Based on these findings, enhanced training on the proper corrective measures was introduced during recurrent simulator checks.

Line Operations Safety Audit

The findings were very relevant, and recommendations were implemented via Safety Change Process (SCP). MAS on the average had less findings compared with the other 5 airlines in the Line Operations Safety Audit (LOSA) archive. Safety Change Process was carried out to mitigate the findings. LOSA findings also revealed low prevalence in terms of overall mismanagement rate (unsafe operations) in the B777 fleet as reported in MAS LOSA Report 2011. LOSA was conducted by taking a random sampling

on all fleets including the B777. MAS had met the average safety standards of most international airlines.

Crew Resources Management

The Team’s analysis reveals that the CRM programme had been implemented and had produced positive results over the years. These awareness and regular recurrent training programmes had inculcated good interpersonal relationships between flight crew members and had contributed significantly to the overall safety of the flight operations.

Both the technical and cabin crew were in compliance with CRM requirements.

Safety and Emergency Procedures

Findings have indicated that both the technical and cabin crew were in compliance with SEP validity. The training syllabus had met all the regulatory requirements.

Flight Deck Security Procedures

At the time of flight MH370, there were no requirements for an additional crew member in the cockpit in the event when one of two pilots were to leave the cockpit. However, in response to flight MH370, MAS has, since introduced this requirement into its safety procedures effective 27 March 2014, a procedure subsequently introduced by other airlines following the GermanWings Flight 9525 accident on 24 March 2015.

MAS B777 Training and Standards

The fleet carried sufficient numbers of Type Rating Examiners (TRE) and Type Rating Instructors (TRI) to fulfil the licensing requirements. TRE and TRI were Captains from within the airline, appointed with approval from the Licensing Section of the DCA. They were also tasked with monitoring the overall standards to be maintained by the fleet. This responsibility was under the jurisdiction of the Training and Standards Department, which was headed by a Chief Pilot.

Multi-crew Operation MH370

Flight MH370 was operated on a normal 2-man crew operation with one PIC and one FO. A third pilot was not required as a safety pilot as the trainee’s performance was reported to be above average and deemed safe by the previous Training Captain.

The duration of the scheduled flight with FDP (Flight Duty Period) of less than 8 hours also justified the 2-man crew operations.

Operation Control Centre

During the day of the disappearance of MH370, it was established that the FFS was programmed to receive a download from the aircraft at 30 minute intervals. The last download was transmitted at 1707:29 UTC [0107:29 MYT]. As a result, the track and position shown on the monitor after this time was only the predicted track and position.

Facts gathered during interviews with despatchers on duty during the incident suggested that with the exception of hijack and bomb hoax, there were no quick references to guide the frontline operations staff to react to emergency situations such as a lost aircraft and a crash.

The FFS was observed to be in accordance ICAO Annex 6 Part 1 FOSI38 Chapter 4, AIC 10/2002 dated 25 July 2002 and Handbook, Vol 3, Chapter 4, para 6. Personal interviews with individual despatchers suggested increased workload which could

38 This order is referred to as a handbook and directs the activities of Flight Operations Surveillance Inspectors (FOSI) who are responsible for the certification, technical administration, and surveillance of scheduled air carriers and certain other air operators who conduct their operations in accordance with the Malaysian Civil Aviation Regulations 1996, made under the Civil Aviation Act 1969.

have affected the quality of work. There is evidence that the Supervisor/Despatcher-in-charge oversaw an average of 30 flights on that particular night shift, including monitoring seven to eight different flights at one time on the Orient Sector. This suggests the existence of an element of overworked condition.

The Team’s investigation into the basic capability of the FFS suggested that there are bound to be discrepancies between the actual aircraft position compared to the projected flight path in the FFS once an automatic update stops. This could explain the state of confusion and uncertainties among all parties involved during the incident. These discrepancies suggest two hypotheses:

Data downlink failure from the ACARS communication. • Intentional or unintentional deactivation of ACARS Communications.

The position update on the FFS was programmed at 30 minute intervals on the B777. This interval is the same as the B747-400 but comparatively longer than other aircraft (A380: 10 mins; A330: 10 mins; B737-800: 10 mins).

The displayed aircraft position was erroneous right from the point where the ACARS communication was lost.

Fuel Policy

There is no evidence to suggest that the PIC had ordered or carried any extra amount of fuel beyond the minimum amount recommended by the Computerized Flight Plan. This was in compliance with the Company’s fuel policy.

No irregularities were found in the fuel computation and fuel flight plan.

Flight Plan Routing

There is no evidence in terms of out-of-normal flight planning on the KUL/PEK sector nor any deliberate rerouting to suggest that the PIC might have the intention to carry extra fuel. Nonetheless, it is a captain’s authority to carry additional fuel if he thinks it is justified and to override the despatcher’s decision.

No irregularities were found in the aircraft flight plan.

In-flight Services

Cabin Crew Training

The cabin crew of MH370 were provided with proper training on Safety and First Aid. They were also trained to handle:

Safety and emergency evacuation. ii) Disruptive/difficult passengers. iii) Medical emergency (provision of First Aid).

Crew Resource Management (CRM) is part of the mandatory programme in cabin crew training. It is on record that the IFS did his CRM a day before the departure of the MH370 flight (the most current in the CRM recorded was from the IFS where it was noted that he did his CRM a day before the departure of the MH370 flight).

All the cabin crew of MH370 were trained with Safety procedures and in compliance with regulatory and Company’s requirements.

Crew Performance Appraiser

The Crew Performance Appraiser (CPA) system was an established process in the organisation to monitor crew performance and standards including safety knowledge.

The organisation had a clear system on the CPA monitoring process that, if a crew member had failed to carry out the required CPA, the crew member was reminded by the system or the Ward Leader39 to follow up on the crew member apart from alerting the Crew-in-charge to ensure that the crew member would have to fulfil the requirement within the stipulated cycle in a year.

There is no evidence to indicate that the disappearance of MH370 was attributed to poor crew performance.

Medical Record

The cabin crew of MH370 had undergone a medical check-up as a requirement during the initial crew training. However, medical check-up was never made compulsory as a yearly pre-requisite. There is no evidence to suggest that the disappearance of MH370 was attributed to medical conditions of the cabin crew.

39 Ward Leader – An executive assigned to monitor the performance, discipline and welfare of cabin crew. 420

In-flight Operation

To efficiently carry out the duties that include in-flight customer services including serving passenger meals, MAS had established the need to carry 11 cabin crew members. MH370 however departed with only 10 cabin crew members, 1 less than the normal compliment. It is an established fact that, based on regulation, the minimum crew required are 8, consistent with the number of doors/Emergency Exits available on the B777. It is unlikely that any of the crew were subjected to exhaustion before or while on duty on the ill-fated flight.

MAS was then facing acute shortage of cabin crew resulting in flights departing with under-strength crew complements from the numbers normally required on many of their aircraft operations in the past year.

The flight departed within the legal minimum crew requirement as per the local Civil Aviation Requirement. Shortage of manpower can lead to personnel fatigue even though it is within the legal requirement and acceptable operations.

Nevertheless, there is no evidence to indicate that exposure to stress and overwork had contributed to the disappearance of MH370.

Flight Time Limitation

The Malaysia Airlines Employee Union (MASEU) was the recognised Union Organisation endorsed by MAS to represent the cabin crew. The Flight Time Limitation (FTL) and the working conditions were governed by the Collective Agreement (CA) signed between the Union and MAS in accordance with the Civil Aviation Regulations 1996, whichever was the more limiting.

Another Union - the National Union Flight Attendants Malaysia (NUFAM) - was later formed and sought recognition to represent the crew’s Collective Agreement (CA). A secret ballot was held in July 2013 and NUFAM won the election with a majority of 60% indicating the cabin crew’s preference. However, MAS Management did not recognise the Union. This stalemate had delayed the renewal of the Collective Agreement which expired in August 2013.

There was no infringement of the FTL. The cabin crew were in

compliance with the requirements of the Civil Aviation Regulations 1996.

There is no evidence to indicate that the disappearance of MH370 was attributed to insufficient rest or exceeding permitted working hours.

FTL is not a contributing factor to the disappearance of MH370. However, the crew’s working conditions and FTL were subject to each organisation’s MOU with the approval of the DCA as a regulator. The crew were in compliance with the requirements of the Civil Aviation Regulations 1996.

2.8 AIRCRAFT CARGO CONSIGNMENT

2.8.1 Cargo on Board MH370

The gross weight of the cargo carried on board MH370 was 10806 kg (cargo plus packing materials, pallets and ULDs).
The nett and gross weight of the cargo are as depicted in Table 2.8A (below).

WEIGHT (in kg) CARGO ITEMS NETT GROSS Scholastic Assorted Books 2,250 2,320 Lithium Ion Batteries 221 2,650 Walkie Talkie and Radio Accessories 2,232 and Chargers Electrical Parts (Capacitors) 26* (410 + 394) Vehicle Electronic Chips 6* 804 Electronic Measurements 646* Fresh Mangosteens 4,566 4,926 Courier Materials - Documents 6 6 Total 9,953 10,806 Table 2.8A - Cargo List

shared cargo position

There were 2 items of concern viz. Lithium Ion (Li-ion) batteries and mangosteen fruit. The batteries were speculated to be a fire hazard and the mangosteens were also speculated to be out of season at that time of the year.
A total of 36 shipments of Li-ion batteries and accessories and mangosteens were flown together to China on previous flights (Appendix 2014). There were 1.18J - Airways Bills from January to May no reports of any incidents concerning these cargo shipments.
During the Team’s visit to NNR Logistics, Tianjin, China the forwarding agent for Motorola confirmed that they had reserved cargo space on all MH370 departures out of Kuala Lumpur to Peking for the carriage of Motorola products. NNR Logistics had also highlighted that, in compliance with Motorola’s stringent Standard Operating Procedures

(SOP), any damaged boxes would be rejected during physical inspection and loading.

2.8.2 Li-ion Batteries on Board MH370

Of the total consignment of 2,453 kg from Motorola Solutions Penang, only 221 kg were Li-ion batteries in compliance with Section II of Packing Instruction 965; the rest comprised Radio Accessories and Chargers.
Testing of the Li-ion batteries was carried out by the Company’s Research & Development Department in the United States of America as per Certificate of Compliance, Certificate No. 12GEM0185 with Issue Date: 12-09-2012 for PMNN4081BRC; and Certificate No. 13GEM0300 with Issue Date: 2013.10.25 for PMNN4073AR. Appendix 2.8A - Certificates of Compliance (Rev 14 and 15).
The shipments from Motorola Solutions, transported to the Penang MASkargo Complex by NNR were physically (external visual inspection but did not involve the breaking down of the cargo) inspected by the MASkargo handlers in Penang but not screened by MAS security personnel by means of an x-ray screening machine. At that time there were no available x-ray machines on the landside large enough to screen the consignments. In June 2014, Penang MASkargo had acquired three machines capable of screening large consignments which were fully operational in July 2014.
The security procedures are in accordance with Amendment 13 of ICAO Annex 17 which came into force on 15 July 2013 where all cargo are required to undergo physical security screening as per DCA Director General Directive No. 1A/2013 (AVSEC) Physical Security Screening-Enhanced. There is also a Director General Directive No. 2/2013 (AVSEC) on Air Cargo Transhipment in Malaysia effective 15 July 2013 which allows this procedure (Appendix 2.8B - Director General Directive No. 1A/2013 and Appendix 2.8C - Director General 2/2013). Directives No.

After the physical inspection by MASkargo personnel, the loaded consignments went through Customs inspection and clearance. The truck was then sealed by Customs and MAS Security before being allowed to leave the Penang cargo complex enroute to KLIA under escort. The truck made a routine resting stop at Rest and Recreation

(R n R) Centre, Tapah, Perak on the North-South Highway. The two drivers interviewed revealed that the truck was never left unguarded by them or the security escort. The shipment arrived at KLIA Cargo Complex on the evening of 07 March 2014, before the seals were broken and the cargo loaded onto MH370 without further screening.

The security procedures for the cargo from Motorola Solutions to KLIA, Sepang were reviewed and found in accordance to the standard operating procedures.

2.8.3 Mangosteen Fruits on Board MH370

The Team confirmed that MH370 was carrying mangosteens to China. Contrary to speculations that the fruits were out of season, it was found to be in season in Muar, Johore and neighbouring countries. At the time of writing of this report the fruits are still being exported by the same company to Beijing, China.

2.8.4 Dangerous Goods

The Li-ion batteries carried on board MH370 were not listed as dangerous goods (DG) and as such they were in compliance with Section II of Packing Instruction 965. Hence, there was no requirement for the pilots to be informed. However, the mangosteens were declared in the Special Load Notification to Captain (Doc. DVC-17957 1529 07Mar14 (Appendix 2.8D) and the Letter and Directive by the Director General (Appendices 2.8C) as it is classified as a perishable 2.8B and item.
Both pilots were trained on DG procedures and were periodically updated (once every two years) in their Safety and Emergency Procedures (SEP) training programme. (below) shows the Table 2.8B training programme.

Crew SEP Expiry CRM Date DG Date Attended Cat 10 Pilot 17 August 07 September 24 February 2014 2011 2014 Table 2.8B - Table for Technical Crew SEP/CRM/DG CAT

2.8.5 Laboratory Tests Conducted

After the disappearance of MH370, laboratory tests on Li-ion batteries and mangosteens were conducted by STRIDE, Malaysia to determine their 425

individual and/or combined reactions under certain conditions. Refer to The Appendix 2.8E Laboratory test on Li-ion batteries and mangosteens. test results are as follows:

Li-ion Batteries

High Temperature Tests

175o i) Point of bulging was at C;

187o ii) Point of fuming was at C;

207o iii) Point of eruption was at C;

At peak, release of carbon monoxide (CO) was at 176.5 ppm;

At peak, release of carbon dioxide (CO2) was at 471 ppm.

Functional and Voltage Capacity Tests

All the batteries tested were functioning normally. ii) Average capacity of 60% or about 7.3V from full capacity of 11V.

Drop Tests

The tests were carried out with batteries (window white box in brown box 2.8A, [below]) dropped at a height of 120.92 (Figure cm (48 inches) on to a wooden platform. It was found that the batteries had no observable physical damage and functioned normally.

Short Circuit Tests

The batteries produced sparks when electrodes (Positive and Negative) touched directly.
The batteries did not produce sparks when the electrodes were touched with cardboard soaked in water from sponge or mangosteen extract.

Built-in Voltage and Current Protection Circuit Tests

The batteries also have a built-in voltage and current protection circuit. “…Cell protection features consist of internally trimmed charge and discharge voltage limits,

discharge limit with a delayed shutdown and an ultra-low discharged.” current sleep mode state when the cell is

Figure 2.8A - 2 Batteries in window white box and placed in a brown box

Mangosteen Fruits

pH Value Tests

Water from the sponge used to keep the fruit fresh was tested and found to have a pH value of 6 and the mangosteen juice had a pH value of 3.

Conductivity Tests

When current was passed through distilled water, the current flow indicator did not light up (distilled water was not conductive);
When current was passed through mangosteen extracts, the current flow indicator lit up (mangosteen extract was conductive);
When current was passed through water from the sponge, the current flow indicator lit up (water from the sponge was conductive).

2.8.6 Effects of Close Proximity of Li-ion Batteries and Mangosteens in Cargo Consignment

Location of Cargo

In one of the cargo compartments on MH370 the Motorola Solutions batteries and mangosteens were placed next to each other (No. 1 and ‘A’). Even though they were placed next to each other in the aircraft (Figure [below]), the mangosteens were packed in 2.8B plastic crates and placed in Unit Load Device (ULD) containers. The consignment was also wrapped in a plastic sheet to make it waterproof to a certain extent.

Figure 2.8B - Sample ULD and Batteries placed next to each other

Results of Tests

There were concerns that the mangosteen extracts could have got into contact with the batteries and produced hazardous fumes or in a worst case scenario caused a short circuit and/or fire. These tests were carried out and the results are as follows:

This was highly improbable on board MH370 with a comparatively short flight duration and under controlled conditions.

After carrying out the tests, STRIDE was convinced that the two items tested could not be the cause in the disappearance of MH370. The Team concurs with STRIDE’s findings.

Safety Investigation Report 2018:Section 2

SECTION 2 – ANALYSIS

INTRODUCTION

2.1 DIVERSION FROM FILED FLIGHT PLAN

2.1.1 Seven Simulator Sessions

2.1.2 Ho Chi Minh Air Traffic Services Operations

2.2 AIR TRAFFIC SERVICES OPERATIONS

2.2.1 Review of Flight MH370 before its Disappearance

2.2.2 Chronology of ATC Events before the Disappearance of Flight MH370

2.2.3 Filed Flight Plan of MH370

2.2.4 Departure Message of MH370

2.2.5 Waypoints - Geographical Coordinates (LAT/LONG) of MH370 Filed Flight Plan

2.2.6 Analysis on FPL Message of MH370

2.2.7 Chronology of ATC Events following the Disappearance of MH370 (Table 2.2C, below)

2.2.8 ATS Operational Issues after Last Radio Communication with MH370 and subsequent ATS Activities/Actions

2.3 MEDICAL/HUMAN FACTORS ISSUES

2.3.1 Introduction

2.3.2 General Human Performance Issues

2.3.3 Specific Human Factors Issues

2.3.4 Human Factor Aspects of Air Traffic Control Recordings

2.4 AIRWORTHINESS & MAINTENANCE AND AIRCRAFT SYSTEMS

2.4.1 Airworthiness & Maintenance

2.4.2 Emergency Locator Transmitters

2.4.3 Aircraft Health Monitoring

2.4.4 Aircraft Systems Analysis

2.4.5 Summary

2.5 SATELLITE COMMUNICATIONS ANALYSIS

2.5.1 Summary of Key Observations of the SATCOM Ground Station Logs

2.5.2 Possible Reasons for the 1825 and 0019 Log-On Events and Preceding Link Losses

2.5.3 Summary Assessment of Doppler for 1825 and 0019 Log-On Events

2.6 WRECKAGE AND IMPACT INFORMATION

2.6.1 Debris Considered for Detailed Examination

2.6.2 Location of Debris with respect to Aircraft

2.6.3 Damage Analysis of Significant Debris

2.6.4 Marine Life Examination

2.7 ORGANISATION AND MANAGEMENT OF DEPARTMENT OF CIVIL AVIATION AND MALAYSIA AIRLINES

2.7.1 Department of Civil Aviation Malaysia

2.7.2 Malaysia Airlines

2.8 AIRCRAFT CARGO CONSIGNMENT

2.8.1 Cargo on Board MH370

2.8.2 Li-ion Batteries on Board MH370

2.8.3 Mangosteen Fruits on Board MH370

2.8.4 Dangerous Goods

2.8.5 Laboratory Tests Conducted

2.8.6 Effects of Close Proximity of Li-ion Batteries and Mangosteens in Cargo Consignment

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