Safety Investigation Report 2018:2 Analysis
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
SECTION
TITLE
2
ANALYSIS
2.1
2.1.1
2.1.2
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
2.2.7
2.2.8
ATS Operational Issues after Last Radio Communication with MH370 and subsequent ATS Activities/Actions
- 1) Analysis of ATS Operational Issues after Last Radio Communication with MH370 and subsequent Activities/Actions
- a) Transfer of Control Point at Waypoint IGARI
- b) Responsibilities of Accepting Air Traffic Control Service Unit on Establishment of Communications
- c) Marking on MH370 Flight Progress Strip
- d) Responsibilities of Air Traffic Controllers
- e) Recognising Emergency Situations and Air Traffic Control Actions
- f) Information to be passed to other Radar Units – Civil and Military
- g) Provision of Alerting Service for Flight operating through more than one FIRs and ATC actions
- h) Actions taken by Air Traffic Service Centre Duty Watch Supervisor
- i) Flight-Following System of Malaysia Airlines
- j) Communication Exchanges between KL ACC and HCM ACC and KL ACC and MAS Operations Despatch Centre on MH370
- k) Delegation of Airspace by Singapore Area Control Centre to KL ACC
- l) ATC Actions on Strayed/Unidentified Aircraft (Primary Radar Target) within the Area of Responsibility
- m) KL ATSC Duty Shift System for Air Traffic Controllers
- n) Roles played by the Duty ATSC Watch Supervisor
- o) Activation of Aeronautical Rescue Coordination Centre
- p) Play-back of Radar and Radiotelephony Recordings by ATSC Duty Watch Supervisor
- q) Entries in ATS Logbooks of ATSC Watch Supervisor and Sector 3 Controller Working Position
- r) Distress Message
- s) Issues with Manual of Air Traffic Services (MATS)
2.3
2.3.1
2.3.2
2.3.3
2.3.4
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
- 1) Air-conditioning, Pressurisation and Oxygen
- 2) Autoflight
- 3) Electrical Power
- 4) Flight Control and Hydraulics
- 5) Instrumentation
- 6) Navigation
- 7) Engines
- 8) Fuel Systems
- 9) Auxiliary Power Unit
- 10) Communications
- 11) Airplane Information Management System
2.4.5
Summary
2.5
2.5.1
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
- 1) Introduction
- 2) Department of Civil Aviation Organisation Structure
- 3) Air Traffic Management Sector
- 4) Air Traffic Inspectorate Division
- 5) Search and Rescue
- 6) Kuala Lumpur Air Traffic Service Centre
- 7) Airworthiness Sector
- 8) Flight Operations Sector
2.7.2
Malaysia Airlines
- 1) Engineering & Maintenance
- 2) Flight Operations Management
- 3) In-flight Services
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
- 1) Li-ion Batteries
- 2) Mangosteen Fruits
2.8.6
Effects of Close Proximity of Li-ion Batteries and Mangosteens in Cargo Consignment
- 1) Location of Cargo
- 2) Results of Tests