Safety Investigation Report 2018:1 Factual Information/1.17

SAFETY INVESTIGATION REPORT MH370 (9M-MRO)

1.17 Organisational and Management Information

1.17.1

Department of Civil Aviation Malaysia

1) Introduction
2) Functions and Responsibilities of Department of Civil Aviation
3) Sectors and Divisions of Department of Civil Aviation
4) Areas of Focus
5) Air Traffic Management Sector

a) Air Traffic Inspectorate Division

6) Airworthiness Sector
7) Flight Operations Sector

1.17.2

Malaysia Airlines

1) Introduction
2) Engineering & Maintenance

a) Organisation Structure
b) Maintenance and Design Approval
c) Training
d) Base Maintenance
e) Line Maintenance
f) Maintenance Authorisation
g) Safety Management System

3) Operations

a) Flight Operations

i) Flight Operations Management
ii) Organisation and Management related to
B777 Operations
iii) Technical Crew
iv) Technical Crew of MH370
v) Working Schedule/Roster Schedule and Management
vi) Safety Management System
vii) Confidential Human Factors Incident Report
viii) Flight Operations Quality Assurance
ix) Line Operations Safety Audit
x) Crew Resources Management
xi) Training and Standards
xii) MAS B777 Training and Standards
xiii) Multi-Crew Operation MH370
xiv) Safety and Emergency Procedures
xv) Technical and Development
xvi) Fuel Policy
xvii) Flight Plan Routing
xviii) Hijack and Sabotage Security Procedures

b) In-flight Services

i) Cabin Crew Training
ii) Crew Performance Appraisal
iii) In-flight Operation
iv) Flight and Duty Time Limitations Scheme for Cabin Crew
v) Safety Report

SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
SECTION 1 – FACTUAL INFORMATION
1.17 ORGANISATIONAL AND MANAGEMENT INFORMATION
1.17.1 Department of Civil Aviation Malaysia
1) Introduction
The Department of Civil Aviation (DCA) is an agency under the purview of the Ministry of Transport (MOT) with the authority to regulate and oversee all technical-operational aspects of the civil aviation industry in Malaysia.
As a Contracting State of the International Civil Aviation Organization (ICAO) since 1958 Malaysia through DCA is responsible to ensure that the safety and security of flights are consistently maintained at the highest level possible, and at the same time, to ensure the safety of the Malaysian airspace for aircraft operations in conformity to the requirements of ICAO in all aspect of polices, regulations and Standards and Recommended Practices (SARPs).
Malaysia’s civil aviation system is based on the Federal Constitution as the supreme law. The legal framework in place consists of the following legislations enacted by Parliament:
• Civil Aviation Act 1969 (Act 3), last amended 01 June 2003 • Aviation Offences Act 1984 (Act 307);
• Airport and Aviation Services (Operating Company) Act 1991 (Act 467); and
• Carriage by Air Act 1974 (Act 148).
Specifically, Section 3 of the Civil Aviation Act 1969 empowers the Minister of Transport “to give effect to the Chicago Convention and regulate civil aviation.’’ Under the authority conferred by the same provision, the Minister of Transport also enacted the Civil Aviation Regulations 1996 (CAR) [P.U. (A) 139/96].
CAR 201 stipulates the use of ‘ipso facto’ to address ICAO Annexes 1 to 19, including the application of not only ICAO Standards, but also the recommended practices, provided that a regulation has not already been established in CAR and that a difference has not been notified to ICAO. In
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particular, DCA relies completely on CAR 201 for the implementation of Annexes 3, 4, 5 and 12.
The Civil Aviation Act 1969 or Act 3 also empowers the Minister of Transport to make rules providing for “the investigation in such manner as may be prescribed, including by means of a tribunal established for the purpose, of any accident either occurring in Malaysia or occurring to Malaysian aircraft.” In addition, this Act provides the Minister of Transport, the Chief Inspector of Air Accidents Investigation Bureau (AAIB) with the proper authority and legal tools to conduct investigations effectively, and in compliance with Annex 13.
CAR defines which accidents and incidents shall be reported and empowers the Minister of Transport to appoint a Chief Inspector of Air Accidents and Incidents. CAR provides for the Chief Inspector to “determine whether or not an investigation shall be car ried out in respect of any accident to which these regulations apply and the form of the investigation”. The Chief Inspector may carry out, or may cause another Inspector to carry out, an investigation of any such accident. CAR also makes provision for the mandatory submission of a report to the Director- General of Civil Aviation (DGCA) in respect of any reportable occurrence. No provision is however made for a voluntary non-punitive reporting system.
2) Functions and Responsibilities of Department of Civil Aviation
The functions and responsibilities of DCA are, as follows:
• To exercise regulatory functions in respect of civil aviation and airport and aviation services including the establishment of standards and their enforcement;
• To represent the Government in respect of civil aviation matters and to do all things necessary for this purpose;
• To ensure the safe and orderly growth of civil aviation throughout Malaysia;
• To encourage the development of airways, airport and air navigation facilities for civil aviation;
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• To promote the provision of efficient airport and aviation services by the licensed Company; and
• To promote the interests of users of airport and aviation services in Malaysia in respect of the prices charged for, and the quality and variety of, services provided by the licensed Company.
3) Sectors and Divisions of Department of Civil Aviation
Sectors and Divisions of DCA
1. Flight Operations Sector Grouped under a broader 2. Airworthiness Sector
unit called Engineering and 3. Flight Calibration Division
Flight Operations 4. Air Traffic Management Sector
5. Air Traffic Management Inspectorate Division
6. Aviation Security Division
7. Airport Standards Division
8. Malaysian Aviation Academy Division
2.
4) Areas of Focus
Section 1.17.1 will focus on three Sectors of DCA, as below:
a) Air Traffic Management Sector,
b) Airworthiness Sector, and
c) Flight Operations Sector.
5) Air Traffic Management Sector
The Director of the Air Traffic Management (ATM) Sector is responsible to the DGCA for the planning, implementation and operation of the air traffic services systems in the two Malaysian Flight Information Regions (FIRs), i.e. Kuala Lumpur and Kota Kinabalu FIRs respectively, in accordance with the ICAO Standards and Recommended Practices (SARPs).
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The function of the ATM Sector is responsible for the provision of air traffic service for the safe and efficient conduct of flight within Malaysian airspace pursuant to the Chicago Convention 1944.
The Malaysian airspace is divided into the Kuala Lumpur and Kota Kinabalu FIRs, where operations are associated with air traffic control units. There are two Air Traffic Control Centres; in Kuala Lumpur and Kota Kinabalu, a sub-centre in Kuching as well as 12 Control Towers in Peninsular Malaysia, 4 in Sabah and 8 in Sarawak.
The Director of ATM Sector is supported by Regional Director I (Peninsular Malaysia), Regional Director II (Sabah), Regional Director III (Sarawak), Director KLIA and Director of KL ATSC in the functionality of the Sector.
Supporting the Regional Directors/Directors are ATSC Chiefs, Supervisors, DCA Managers, Unit Chiefs, Operational Controllers and support staff. Other entities, including Aeronautical Information Service (AIS), Procedures for Air Navigation Services and Operations (PANS- OPS), Cartography and SAR are under the direct responsibility of the Director of ATM Sector. The ICAO SARPs associated with the responsibility of ATM Sector are those contained in:
• Annex 1 - Personnel licensing;
• Annex 2 - Rules of the Air;
• Annex 3 - Meteorological Service for International Air Navigation; • Annex 4 - Aeronautical Charts;
• Annex 5 - Units of Measurement to be used in Air and Ground
Operations
• Annex 10 - Aeronautical Telecommunications Volume I & II;
• Annex 11 - Air Traffic Services;
• Annex 12 - Search and Rescue;
• Annex 14 - Aerodromes; and
• Annex 15 - Aeronautical Information Services.
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Other relevant documents are:
• DOC 4444 - Procedures for Air Navigation Services - Air Traffic
Management (PANS-ATM);
• DOC 9859 - Safety Management System Manual;
• CIR 314 - Threat and Error Management (TEM);
• DOC 9910 - Normal Operations Survey (NOSS);
• DOC 9426 - Air Traffic Services Planning Manual; and • DOC 9683 - Human Factors Training Manual.
a) Air Traffic Inspectorate Division
The Air Traffic Inspectorate (ATI) Division is the regulatory body that oversees the provision of Air Navigation Services (ANS) by the ANS providers to ensure compliance with the national legislations, namely the Civil Aviation Act 1969 and the Civil Aviation Regulations 1996, and ANS-related ICAO Annexes to the Chicago Convention.
The ATI Division develops and establishes the ANS safety standards and performs safety oversight and surveillance activities with the sole aim of regulating the ANS providers. The regulatory Manual of ANS Inspectorate contains the requirements and procedures pertaining to the provision of the ANS, based on the SARPs of ICAO Annexes to the Chicago Convention, other ICAO documents and best practices, as may be determined by the ATI Division which develops and establishes the ANS safety standards and performs safety oversight to be applicable in Malaysia. From time to time the ATI Division develops and establishes the ANS safety standards and performs safety oversight and may supplement these ANS safety standards in the form of safety publications such as Air Traffic Inspectorate Directives (ATIDS) or Aeronautical Information Circulars (AIC). Where appropriate, these safety publications will be incorporated into the Manual by amendments.
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i) Audits/Inspections
The audits/inspections utilise protocols questions and compliance checklists to evaluate the level of adherence to stipulated national legislations, and ANS-related ICAO Annexes to the Chicago Convention and ICAO documents, including best practices. The ATI Division also conducts oversight of the ANS provider’s safety management system (SMS) to ensure its formal and systematic implementation by all ATSUs, including compliance with stipulated requirements. Currently, the ANS providers that are regulated by the ATI Division include Air Traffic Management Sector of DCA, Malaysian Meteorology Department, Royal Malaysian Air Force (RMAF) and the Malaysian Army.
ii) Personnel Licensing
Personnel Licensing for ATCOs provisions was promulgated in the Malaysia Civil Aviation Regulations (MCAR) 1996. The ATI Division is the authority for issuance, renewal, endorsement and validation of an ATC Licence and an ATC Trainee Licence (implemented since 01 April 2011), in accordance with ICAO Annex 1 to the Chicago Convention.
(1) Air Traffic Control Examination activities include all ATC
courses at ATC organisations that are approved by the
DGCA and operational ATC examinations at ATS units that
control civil air traffic. However, some functions are
delegated to designated ATC Check Officers who are
appointed on a two-year basis by the DGCA.
(2) Air Traffic Control Licensing provisions were promulgated in
the MCAR 1996. The ATI Division is the authority for
issuance, renewal, endorsement and validation of an ATC
Licence and an ATC Trainee Licence in accordance with
ICAO Annex 1 to the Chicago Convention, as follows:
(3) Class 3 Medical Assessment for ATCOs, as part of the pre-
requisite for an ATC Licence and an ATC Trainee Licence,
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shall only be issued by a Designated Aviation Medical Examiner (DAME). The ATI Division develops and establishes the ANS safety standards and performs safety oversight and maintains a comprehensive database of licensing information for all licensed holders, and
(4) English Language Proficiency (ELP) Assessment is
required for ATCOs and aeronautical station operators, and
they must meet the minimum required proficiency level for
radiotelephony communications i.e. Level 4 in accordance
with ICAO Annex 1 to the Chicago Convention.
iii) Certification and Audit of ATC Approved Training
Organisation
The Certification and Audit of ATC Approved Training Organisation (ATC-ATO) is responsible for the training of ATCOs. It provides ATC training by holding ATC-ATO approval certificate that is issued by the DGCA. The ATI Division conducts a regular oversight programme on the approved ATC- ATO to ensure continuing compliance with the approval requirements.
iv) Air Traffic Control Incident Investigations
Air Traffic Control Incident Investigations are carried out for ATC safety-related occurrences to evaluate the effectiveness of the ATC system and its components, as well as recommending mitigation actions towards enhancements. The investigative process includes the Incident Review Panel (IRP), The Board of Inquiry (BOI) and the Safety Review Boards (SRB).
In addition to the licensing and validation of ATCOs, the ATI Division develops and establishes the ANS safety standards and performs safety oversight and is responsible for regulating the checks and standards units at various ATS facilities. It also conducts safety oversight of military ATCOs who are charged with the responsibility of providing air traffic services to civil flights in selected portions of the airspace.
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The ATI Division develops and establishes the ANS safety standards and performs safety oversight and has also developed appropriate processes and procedures to enable the division to carry out its safety oversight functions in accordance with established requirements and in a standardised manner. The Division has the necessary facilities and equipment to enable the personnel to carry out their safety oversight functions in an effective manner. All necessary procedures, including guidance material, have been developed.
v) Search and Rescue
With respect to Search and Rescue (SAR), no legislation specifically addresses the provision of assistance to aircraft in distress. However, in Malaysia, aeronautical SAR (A-SAR) is provided in accordance with Annex 12 to the Convention of ICAO and International Aeronautical and Maritime Search and Rescue (IAMSAR) Manual Vol. I to IV.
As a signatory to the Chicago Convention, Malaysia is obligated to provide A-SAR services on a 24-hour basis, within the Malaysian Aeronautical Search and Rescue Regions (SRR), (defined within the Kuala Lumpur and Kota Kinabalu FIRs).
With the implementation of National Security Council (NSC) Directive No. 20 effective 11 May 1977, A-SAR Operational procedures have been amended to harmonise with inter-agency actions during an aeronautical incident.
vi) Primary Aeronautical and Maritime Search and Rescue
Agencies
(1) National Security Council
The National Security Council (NSC) is the body responsible for establishing, developing and maintaining Aeronautical and Maritime SAR Organisation in Malaysia. The Cabinet, through the Secretary of the National Security Council, directs the NSC on policy, international agreements, conventions and operational matter. The
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NSC is responsible to the Cabinet on all matters pertaining to Aeronautical and Maritime SAR.
Note:
The National Security Council Act 2016 was enacted by the Parliament of Malaysia and published in the Gazette on 07 June 2016.
(2) Department of Civil Aviation
DCA is the SAR Authority for aeronautical incidents and shall be responsible for the provision of Aeronautical SAR service within Malaysia’s Aeronautical Search and Rescue Regions (SRRs). As such DCA shall co-ordinate, liaise, train, equip, staff, maintain, develop procedures and operations and conduct exercises for A-SAR. DCA shall also assist the Maritime SAR Authority, when requested.
(3) Malaysian Maritime Enforcement Agency
The Malaysia Maritime Enforcement Agency (MMEA) is the SAR Authority for maritime incidents and shall be responsible for the provision of Maritime SAR service within Malaysia’s Maritime SRRs. As such MMEA shall co-ordinate, liaise, train, equip, staff, maintain, develop procedures and operations and conduct exercises for maritime SAR. MMEA shall also assist the Aeronautical SAR Authority, when required.
vii) Aeronautical Search and Rescue Plan of Operation
The purpose of this plan is to provide a set of specific Aeronautical SAR Operation Procedures in all SAR missions within the Malaysian SRRs, for which DCA is the SAR Authority for aeronautical incidents and, acts as Chairman to the Aeronautical SAR Working Group. However, this plan is, by no means, exhaustive in nature, and is to be used in conjunction with IAMSAR MANUAL VOLUMES I, II, and III and as well as other departmental documents issued from time to time. Operational Letters of Agreements have also been signed with
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neighbouring States/SAR Regions. The preparedness and training of all entities is ensured through regular exercise and training.
viii)
International Search and Rescue Treaties, Conventions and Agreements
DCA Malaysia had participated in a number of international organisations such as ICAO, and in accordance with the Convention on international Civil Aviation has adopted search and rescue (SAR) standards and practices. Additionally, there are SAR bilateral agreements between Malaysia and the ASEAN countries (Indonesia, Singapore, Thailand, Brunei and the Philippines) SAR agencies to enhance coordination, cooperation and mutual support for operations along commons borders.
(1) Search and Rescue Agreements:
(a) Multilateral
As a member state of the Association of South East Asia Nations (ASEAN), and in line with the Declaration of ASEAN Concord for Cooperation between the member states of Indonesia, Philippines, Singapore and Thailand, Malaysia has formalised the following on aeronautical and maritime SAR:
ASEAN Agreements for the facilitations of search for aircraft in distress and rescue of survivors of aircraft accidents, signed in Singapore on 14 April 1972; and
ASEAN Agreements for the facilitations of search for ships in distress and rescue of survivors of accidents, signed in Kuala Lumpur on May 1975.
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(b) Bilateral
Malaysia has also signed Bilateral Aeronautical SAR Agreements with the following countries:
1. 2. 3. 4. 5.
Singapore Thailand Indonesia Philippines Brunei Darussalam
11 August 1984 09 August 1985 29 August 1985 09 December 1985 16 December 1998
(c) Other Arrangements
Special operational procedures for border SAR Malaysia/Indonesia by the General Border Committee, resulting from the special arrangements between the Malaysia/Indonesia SAR Working Group of both countries.
Under the Operational Letter of Agreements between Singapore and Malaysia pertaining to aeronautical SAR service in the South China Sea Corridor Area12, Kuala Lumpur ACC shall take alerting actions while Singapore RCC shall conduct the aeronautical SAR mission (AIP Malaysia Volume I ENR 2.2-3).
It is noted that the SAR responsibilities over the high seas/Malaysia Exclusive Economic Zone (EEZ) within the KL FIR/ASRR over Malaysia Maritime SAR Region (MSRR) shall be under the jurisdiction of Malaysia SAR authorities.

12
South China Sea Corridor Area is defined as the area West of 105E at flight level 150 to Ground/Sea Level and East
of 105E at flight level 200 to Ground/Sea Level, within the dimensions of 023600N 1044500E to 020000N 107000E
and along 020000N till the Singapore/Kota Kinabalu FIR boundary - thence along 060000N till the Singapore/ Kuala
Lumpur FIR Boundary - thence along this boundary to 023600N1044500E)
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(d) Area of Responsibility
In accordance with ICAO agreements, the international boundaries for the provision of the search and rescue (SAR) services in Malaysia and adjacent ocean areas are divided into two search and rescue regions (SRRs) for aeronautical coordination.
(e) Search and Rescue Regions of Malaysia
As promulgated in the ICAO’s Regional Air Navigation Plan, the Search and Rescue Regions of Malaysia are defined as the areas coincide with the boundaries of the Kuala Lumpur and Kota Kinabalu Flight Information Regions; airspace as delegated by Aeronautical SAR Region (ASRR) Appendix ICAO under Malaysia’s jurisdiction. The Malaysia ASRR area of responsibility is, as Figure 1.17A (below).
(f) Maritime Search and Rescue Regions
The Malaysia Maritime Search and Rescue Regions (MSSR) - Figure 1.17B (below), include the waters of Malaysia and the areas declared as the Continental Shelf Boundary and also the waters under the FIRs delegated to Malaysia. This information is published in IMO SAR Plan.
(g) Responsibilities of Department of Civil Aviation
on Search and Rescue
The responsibilities of DCA on Search and Rescue are as follows:
• Developing SAR policies;
• Developing A-SAR bilateral agreements with adjacent states;
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• Establishing, staffing, equipment and managing the A-SAR system;
• Conduct training courses in search and rescue at the Civil Aviation Academy and refresher courses at the ARCC;
• Coordinate for SAR training and refresher courses;
• Establishing of ARCCs and ARSC;
• Arranging for SAR facilities; Conduct and coordinate all SAR missions involving civil aircraft within its areas of responsibility.
• Assist in the conduct of all SAR missions involving military aircraft, when requested by RMAF;
• Assist in the conduct of SAR missions involving vessel when requested by MRCC/MRSC;
• Provision and maintenance of the KL ARCC, KK ARCC and Kuching ARSC; and
• Tasking of SAR participating aircraft or vessel for search and rescue operations:
- Provision of survival equipment; and
- Periodically conduct national and international search and rescue exercises (SAREX).
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Source: DCA Malaysia
Figure 1.17A - Malaysia Aeronautical Search and Rescue Region
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Source: International Aeronautical and Maritime Search and Rescue Manual Volume
Figure 1.17B - Malaysia Maritime Search and Rescue Regions
h) Kuala Lumpur Air Traffic Service Centre
The Kuala Lumpur Air Traffic Service Centre (KL ATSC) is headed by a Director and supported by two deputies - Deputy Director for ATSC and Deputy Director for KL TMA - and 243 ATCOs of various grades. The total number of the ATCO posts approved by the Government was 353. As of March 2014, there were 110 vacant posts.
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The KL ATSC’s Controller Working Positions (CWPs):
(i) Approach Control Surveillance
• TMA Supervisor
• Aproach North
• Approach South
• Approach Low
• Approach Radar (Flow Control)
(ii) Area Control Surveilliance
• Sector 1 Area Control Surveilliance
• Sector 2 Area Control Surveilliance
• Sector 3 Area Control Surveillance
• Sector 4 Area Control Surveillance
• Sector 5 Area Control Surveillance
• Sector 6 Area Control Surveillance (Sector 1 Upper)
• Sector 7 Area Control Surveilliance
(iii) Area Control Procedural
• Sector 1 Area Control Procedural
• Sector 2 Area Control Procedural
• Sector 3 Area Control Procedural
• Sector 4 Area Control Procedural
• Sector 5 Area Control Procedural
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(iv) Sector Flight Data Assistant/Clearance
Delivery
• Sector 1 Flight Data Assistant
• Sector 2 Flight Data Assistant
• Sector 3 Flight Data Assistant
• Sector 4 Flight Data Assistant
• Sector 5 Flight Data Assistant
• Sector 6 Flight Data Assistant
• Flight Data Processing
• Clearance Delivery
• Assistant Clearance Delivery
• Assistant Flight Information Services
(v) Working Positions (No Rating required)
• Watch Manager • Controller-Pilot Data Link Communications
• Flight Information Services
• High Frequency/Aeronautical Mobile Services Station (HF/AMSS) South East Asia (SEA)1 and HF/AMSS SEA 2 Aeronautical Fixed Telecommunications Networks (AFTN) 1 and AFTN 2
(vi) Butterworth Terminal Area
To enable the Military to meet its national operational requirements, a number of control zones, training areas and danger areas have been established. Operational
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control of these airspaces and responsibility for the provision of air traffic services within these airspaces have been delegated to the military. Coordination procedures between the civil and military authorities have also been established as follows:
Provision of approach control service within lateral limits of Butterworth Control Zone:
• Ground/Sea - 5,500 ft. altitude - FL245,
• Elsewhere 2,500 ft altitude - FL245 with Butterworth Terminal Area.
Air traffic to/from the civilian Penang International Airport (PIA), Alor Setar Airport and Langkawi International Airport is provided by military ATCOs who have been licensed by the ATI Division, which develops and establishes the ANS safety standards and performs safety oversight and to ensure the provision of services to civil traffic. The rationale for such an arrangement is based on the military activities at Butterworth Military Airport (BMA) which is in close proximity to PIA, and other military activities carried out over the high seas in danger areas WMD 412A and WMD 413A (permanently established). Furthermore, the final approach segments of both the PIA and the BMA intersect. No major incident has been recorded with the present arrangement/delegation of authority.
6) Airworthiness Sector
The Civil Aviation Act of 1969 empowered the DGCA to exercise its statutory powers to regulate the civil aviation and airport services including the establishment of standards and its enforcement.
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The Civil Aviation Regulation (CAR) of 1996 was derived from the United Kingdom Air Navigation Order (ANO) of the mid-nineties and adopted with certain provisions for the Malaysian requirements. The CAR Fifth Schedule - Aircraft Equipment and Sixth Schedule - Radio and Radio Navigation Equipment to be carried in aircraft, and the DGCA issued Airworthiness Notices (ANs) specifically AN. No. 1 - Aircraft Certification, forms the basis for aircraft airworthiness and design standard for acceptance into Malaysian registry.
A comprehensive review of the MCAR 1996 by consultants was carried out in March 2013 and the submission of the final report was completed in January 2014. It was anticipated that the introduction of the CAR 2016 would streamline the DCA regulatory functions on similar approach to the European Aviation Safety Agency (EASA) requirements. This would include the introduction of CASR (Civil Aircraft Safety Requirements, AMC (Acceptable Means of Compliance) and GM (Guidance Materials) as part of the Malaysian regulatory framework, requirements and procedures.
The Director of Airworthiness Sector reports directly to the DGCA and is responsible for the operations of five divisions, namely: Continuing Airworthiness, Engineering, Maintenance Repair and Overhaul (MRO), Licensing and Standards.
The primary functions of the Airworthiness Sector include surveillance oversight of the aircraft maintenance activities on scheduled and non- scheduled air carriers, MROs, and the licensing of Aircraft Maintenance Engineers (AMEs). The sector is also responsible for the management of the aircraft register and joint technical audits with the Flight Operations Sector and Air Transport Sector for the issue or renewal of Air Operating Certificate.
With respect to aircraft accidents or incidents investigation, officers with specific trade and specialisation may be called upon, to assist the Air Accident Investigation Bureau, which is under the Ministry of Transport.
The Airworthiness Sector has established a minimum qualification of a university engineering degree or an Aircraft Maintenance Engineer’s Licence (AMEL) for the posts of Airworthiness Engineers or
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Airworthiness Inspectors respectively, and in addition, a minimum of five to seven years hands-on aviation industry experience. 37 of the 40 posts had been filled to support an 8% annual rate of growth of aircraft increment for the local air transport industry.
The Airworthiness Sector has developed a good working relationship with the local aviation organisations whereby, the newly recruited technical staff have been given the exposure to work closely with industry players. The DCA has made provisions in the AN. No. 1 Aircraft Certification, for the operator to bear the cost of training for DCA officers, specifically for the airworthiness engineers, inspectors and pilots for new aircraft type to be placed on the Malaysian register. This serves to keep them abreast with the latest development on the local airlines or operators fleet expansion programme.
The DCA Airworthiness Division Manual (ADM) provides guidance and procedures to airworthiness inspectors and airworthiness engineers to carry out their duties and function responsibilities.
The Sector emplaces a fairly comprehensive audit plan for the local and international organisations requiring DCA approvals. These approved organisations are subject to an annual audit. The audit includes local and international base maintenance and line stations. These audits may be scheduled on mutual arrangement with the organisation or be carried out on an opportunity basis when the DCA officers are in the vicinity of that organisation during the auditing period.
Any audit findings or deficiencies will be recorded in the NCRs (Non- Conformance Reports) and categorised into the respective levels of Level 1, Level 2 or Level 3. The Level 1 NCR requires urgent and mandatory compliance to a major deficiency in the audit findings. The Sector would review the corrective actions and reschedule an audit of the organisation before closing the finding as acceptable.
The ANs are published on a regular basis in the DCA website and would serve to notify any current changes on airworthiness policies or requirements for the Aircraft Maintenance Engineers and the aviation organisations to comply with as applicable. Some of the Airworthiness Notices issued by the Airworthiness Sector may originate from Original
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Equipment Manufacturers’ (OEMs) service bulletins or in-service difficulties arising from incident or accident reports which may affect aviation safety. The Airworthiness Notices form part of the Malaysian regulatory framework and the expedient means for the aviation industry to comply with at short notice.
The AN. No. 11 - Mandatory Occurrence Reporting, requires Air Operators and Maintenance Organisations to transmit information on faults, malfunctions, defects and other occurrences which cause or might cause adverse effects on the continuing airworthiness of the aircraft to the DCA.
With respect to ICAO Annex 19 - Safety Management, the Airworthiness Sector has implemented the requirement under AN No. 101 - Safety Management Systems (SMS) For Approved Maintenance Organisation (AMO) including Approved Training Organisations (ATOs) in March 2008. The SMS was made effective on 01 January 2009.
The Sector has been actively involved in the audits of 176 local and international Approved Maintenance Organisations (AMOs) that hold the DCA approvals; continuing airworthiness surveillance of 892 aircraft (of which 839 aircraft are active in operations), 12 Approved Training Organisations (ATOs) for Aircraft Maintenance Engineers and Technicians ab-initio training and also aircraft type training programme. There were 4,212 Licensed Aircraft Maintenance Engineers issued with DCA licence, but 2,374 licensed holders remain current. CAR 30 requires that inspection, overhaul, repair, replacement and modification works on a Malaysian-registered aircraft, including the engines, propellers and aircraft components, are carried out by an approved person or organisation, specifically, under the AMO maintenance organisation exposition procedures. The DCA requires the release of an aircraft ‘Certificate of Release to Service’ to be issued by an approved or authorised personnel, type-rated on the aircraft type under a DCA approved AMO procedures. The introduction of the new CARs would also address the training requirements and certification responsibilities of both Aircraft Maintenance Engineers in Category B and Aircraft Maintenance Technicians in Category A in their respective trades. The DCA Malaysia Part 66 engineers and
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technicians licensing system is based on the EASA Part 66 syllabus and training requirements.
7) Flight Operations Sector
The Director of Flight Operations reports directly to the DGCA and is responsible for the operations of five divisions, namely:
• Flight Crew Licensing, • Air Operator Regulatory, • Flight Simulator, • General Aviation, and • Flight Calibration.
The primary functions of the Flight Operations Sector include surveillance oversight on scheduled and non-scheduled air carriers, flight test and simulator training of pilots, flight crew licensing on examinations standards, General Aviation activities, airfields and airways calibration and the conduct of a joint technical audit with the Airworthiness Sector and Air Transport Sector for the issue or renewal of Air Operating Certificate (AOC) for scheduled and non-scheduled air carriers. With respect to aircraft accidents or incidents investigation, pilots from this sector may be called upon, to assist the Air Accident Investigation Bureau, under the Ministry of Transport.
The Sector has established the procedures for Mandatory Occurrence Reporting (MOR) Scheme Guidelines in the Flight Operations Notice for the air operators to comply with in DCA Malaysia website.
With respect to ICAO Annex 19 - Safety Management, the Flight Operations Sector had implemented the requirement under the Aeronautical Information Circular (AIC) No: 06/2008. In conjunction with ICAO Annex 6 Part 1 Chapter 3 paragraphs 3.2.3 and 3.2.4 and Part III Chapter 1 paragraphs 1.2.3 and 1.2.4 with effect from 1 January 2009, it requires all Malaysian AOC Holders to implement an integrated Safety Management Systems (SMS).
To date, 8 of the AOC Scheduled Operators have complied with the SMS requirements and approved by the Sector. The implementation of the SMS for the 16 Non-Scheduled Operators is being incorporated in stages.
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The following documents form part of the sector procedure manual in carrying out their surveillance responsibilities:
• Flight Operations Surveillance Inspector Handbook, • Flight Crew Licensing Handbook,
• Flight Operations Policy, and
• Procedure Manual and Ramp Inspection Handbook.
As stated in the authorised Flight Examiner Handbook, each flight examiner is required to conduct at least six instrument flight checks and two type rating checks over the three-year period of their authorisation. In addition, they have to submit a quarterly activity report. In accordance with the Handbook, the authorised examiner has to pass an initial test upon appointment and a renewal test, to be conducted six months prior to the expiration of the authorisation. In between the tests, the examiner will also be the subject of one observation session to be conducted by the inspector.
The present activities of the Flight Operations Sector for surveillance oversight includes 8 Scheduled Operators, 21 Non-Scheduled Operators 8 Approved Flying Training Organisations, 16 new AOC applicants, 12 Flying Clubs, international flight en-route Inspections, domestic and international Station Facility Inspections and Ramp Inspections.
The frequency for Station Facility is once in every 2 years, the RAMP Inspection is 4 inspections at every originating en-route or destination stops, 4 inspections annually at every location but may depend on the safety performance of the operator while Base Inspection for Scheduled Operations and Non-Schedule Operations to be carried out on annual basis.
The Sector has a total establishment of 28 pilot posts to manage the various divisions, and of which only 16 posts had been filled. The need for experienced pilots to fill up the various posts had been an issue for most authority bodies worldwide, unless better incentives are offered.
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1.17.2 Malaysia Airlines
1) Introduction
Malaysia Airlines (MAS) began in 1937, when the Straits Steamship Company and Imperial Airways formed Malayan Airways Limited (MAL) in Malaya. MAL evolved through many changes to Malaysia-Singapore Airlines (MSA) until Singapore gained its independence in 1965, where its Malaysian part became Malaysian Airline System (MAS) Berhad. In 1987 the Company took the commercial name of ‘Malaysia Airlines’ in line with the international promotion of the country.
MAS held an Air Service Licence (ASL) and Air Operators Certificate (AOC) for scheduled and non-scheduled operations. It was public-listed in 1985 with the Government holding a golden share. At its peak, MAS had an extensive network of operations with more than 100 destinations spanning over 5 continents around the world. The recession in 1994 affected the airline’s business significantly when its operations were drastically scaled down.
The airline’s performance for the past years had been a subject of great interest as it had suffered financial losses. Competition from emerging low-cost operators significantly contributed to the negative performance of the Company. MAS had in its fleet the A380, A330, B747-400, B777- 200ER, B737-400 and B737-800. Its subsidiaries Firefly & MASWings operated the ATR-72 plying most of the domestic network in Peninsular and East Malaysia.
In spite of its scaled-down operations it was still a fairly large organisation (Figure 1.17C [below] shows the Organisation Structure of MAS), with a staff strength of more than 20,000 employees. It was headed by a Group Chief Executive Officer (CEO) who reported to the Board. Eight Directors reported to him, each heading a Division. The Divisions were, as follows:
• Group CEO Office • Commercial • Operations
• Corporate Services • Customer Services
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• Finance
• Human Resources
• MAS Aerospace Engineering (Engineering & Maintenance Division)
2) Engineering & Maintenance
a) Organisation Structure
The Engineering & Maintenance Department (EMD), also known as MAS Aerospace Engineering, was headed by a Chief Executive Officer (CEO), assisted by a Deputy CEO (Airlines Operations) and Senior Vice President (SVP) MRO Operations. The Finance, Engineering Materials, Business Support, Business Development, Legal and Warranty departments of the EMD reported direct to the CEO of the EMD. Heavy Maintenance, Engineering, Commercial, Training, Special Project, Engineering Facility and Workshop departments reported to the SVP (MRO Operations). The Technical Services, Maintenance Operations, Aircraft & Engine Maintenance Planning, Quality Assurance, Aircraft Project, Lease Planning, End- of-Lease (EOL)/Airline Engineering Group (AEG) Special Project and EOL Project Departments reported to the Deputy CEO (Airlines Operations). The organisation’s management structure encompassed all the relevant areas befitting a maintenance management and maintenance organisation and was manned by suitable and experienced personnel. Key positions (post holders) as required for the Air Operators Certificate (AOC) holder and maintenance organisation were nominated by MAS and approved by DCA Malaysia. These key positions were further supported downstream by departmental managers and their executives.
b)Maintenance and Design Approval
The EMD was responsible to manage and carry out the maintenance of the MAS fleet of aircraft, which consisted of B747- 400, B777-200ER, B737-400, B737-800, A330 and A380. The Maintenance and Management approval was issued by the DCA Malaysia in 1971. The approval was based on the approved quality
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OFFICE OF GROUP CHIEF EXECUTIVE OFFICER
Director of Commercial
Director of Operations
Director of Corporate Services
Marketing & Products
Flight Operations
Secretarial, Risk, Legal
& Governance
Sales & Distribution
In-Flight Services
Network & Revenue
Mgm t
Operations
Control
Centre
Commercial
Systems
Operations System & Support
Strategic Procurement & Insurance
Govt & Int’l
Affairs
Security
Commercial
Finance
Emergency Response & Business Continuity
GROUP BOARD
Group CEO
Director of Customer Services
Director of Finance
Director of Human Resources
Airport Services
Group Finance
Operations &
Industrial Relations
IT
Inflight Operations
Investor Relations
Organization Development
Property
Customer
Care
Funding
Performance & Remuneration
Golden Boutique
Merger & Acquisition Execution
MAS Academy
Service &
Quality Assurance
Subsidiaries Oversight
Figure 1.17C - Organisation structure of MAS
CEO MAS Aerospace Engineering
Group CEO
Office
Strategy &
PMO
Strategic Communications
Internal Audit
Fleet Management
Corporate
Safety Oversight
Firefly
MASkargo
MASwings
Source: MAS
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system laid out in the Maintenance Management Organisation Exposition (MMOE). The quality management system as detailed in the MMOE was under the responsibility of the Head of the Quality Assurance, who had direct access to the CEO of the EMD.
In the quest to undertake third party maintenance business the EMD also carried out maintenance of foreign registered aircraft under their respective National Aviation Maintenance Organisation Approvals. These approvals are from the European Aviation Safety Agency (EASA), the Federal Aviation Administration (FAA) of the United States of America (USA), the Civil Aviation and Safety Authority (CASA) of Australia and others. All these approvals had their independent approval process of initial approval, revalidation and surveillance.
The oversight of these maintenance activities was by regular audits and surveillance by the internal auditors of the Quality Assurance department and by DCA Malaysia, as well as the National Aviation Authorities of the various countries whose aircraft were maintained by MAS. In some cases, the audits were also carried out by the respective customers. There have not been any findings significant enough for any regulatory actions to be taken against the EMD for issues arising out of aircraft maintenance.
The EMD was also issued with Design Organisation Approval by DCA Malaysia. This allows the EMD to make minor design changes on the MAS fleet. To administer this, a team of engineers in the Technical Services Department of the EMD were qualified and approved in the various aviation disciplines such as Structures, Systems and Avionics.
c) Training
The EMD had its own Training school which provided ab-initio training to qualify selected candidates to obtain the DCA Malaysia Maintenance Engineers’ licenses in the Mechanical or Avionics category. There were also training programmes for
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aircraft and workshop technicians as well as approval holders. The Training School also provided continuation training which was required for all staff working on aircraft and in workshops, and in addition, aircraft type training and training for external parties. The training requirements were laid down in the DCA Part 66, which is similar to the EASA Part 66 requirements.
d)Base Maintenance
The EMD had two main bases for base maintenance: KLIA in Sepang and Subang Airport (SZB) in Subang.
The Kota Kinabalu (BKI) base in Sabah was an extension of the KLIA base. These bases were equipped with the hangars and facilities as required in the scope of the approval. The SZB base had 4 hangars to accommodate all aircraft in the MAS fleet. The SZB facility also accommodated all the support workshops for the required maintenance. The KLIA base had 2 hangars, one of which could accommodate the A380-800. The KLIA base had some limited support workshops for maintenance activity under the scope of approval. The BKI, extension of KLIA, had one smaller hangar only capable to accommodate B737 series aircraft or its equivalent.
e) Line Maintenance
Other than the main bases, there were also line stations according to the regions around the world. These were, as follows:
• Peninsular Malaysia,
• Sabah and Sarawak,
• South East Asian,
• Far Eastern,
• America and Pacific,
• Australian and New Zealand, • Indo-Pakistan/Mideast and African, and • European.
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Line maintenance of aircraft at international line stations was contracted out to the local maintenance organisations. These line maintenance organisations were approved by DCA Malaysia before they took over the task. The organisations were also subjected to regular audits by MAS and DCA Malaysia.
f)Maintenance Authorisation

The EMD had approximately 4000 staff; distributed among the SZB base, KLIA base and the BKI extension base. There were approximately 1240 certifying staff at both SZB and KLIA bases and 41 certifying staff in BKI. The certifying staff consisted of the following:
• Licenced Aircraft Maintenance Engineers, • Workshop approval holders,
• Certifying mechanics,
• Stores Inspectors,
• Non Destructive Testing (NDT) approval holders, • Welders.
Authorisation of certifying staff for aircraft and component maintenance was carried out by the EMD’s Quality Assurance department. This was strictly in accordance with the requirements laid down in the MMOE. These requirements, which were in line with the EASA requirements, were approved by DCA Malaysia. This process of authorisation was subjected to internal audit by independent quality auditors within the organisation, as well as by the DCA and other National Aviation authorities.
The Head of Quality Assurance (QA) was responsible for the administration and control of the Certifying staff.
g)Safety Management System
The EMD had implemented the Safety Management System as documented in the Safety Management Manual and as required by DCA Malaysia Airworthiness Notice No. 101. This safety
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management was a part of the Company-wide Corporate Safety Management led by the Corporate Safety Oversight department which reports to the Group CEO’s office. There was an internal reporting system in place for occurrences and hazards which encompassed provisions for confidential reporting. Regular safety meetings were conducted within the organisation as well as representing the division within the overall corporate system. Safety Management was supported by Occupational Safety, as required by the Occupational Safety and Health Act 1994. Safety actions were deliberated during these meetings and mitigating actions were discussed and followed up.
3) Operations
This division was headed by the Director of Operations and supported by Flight Operations, In-flight Services, Operations Control Centre, Operations System & Support, Security, and Director of Operations Office.
a) Flight Operations
The structure consisted of 6 Senior Managerial positions namely Quality Assurance & Regulatory Affairs, Training & Standards, Flight Safety & Human Factors, Technical & Development, Crew Planning & Deployment and Line Operations.
i) Flight Operations Management
The Flight Operations Management Structure (Figure 1.17D below) met the Air Operators Certificate (AOC) requirement as stipulated in the MCAR 1996. The key post holder positions in MAS were manned by captains who possessed outstanding credentials, senior in rank and had held several aircraft type rating in the airline’s fleet. Their extensive exposure was therefore an asset to the airline’s operations.
MAS Operations Manual A, Part 1.4.11 defined the guidelines for management pilots’ office coverage and flying duties. As an example, the guideline stipulated that a Flight Operation
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Manager (FOM) would be rostered 9 days flying duties (excluding weekend) and 13 days on office duties.
HEAD FLIGHT OPERATIONS
FLIGHT OPERATIONS
MANAGER QUALITY ASSURANCE &
REGULATORY AFFAIRS
CHIEF
PILOT
LINE OPERATIONS
CHIEF PILOT TRAINING & STANDARDS
CHIEF
PILOT TECHNICAL & DEVELOPMENT
CHIEF PILOT FLIGHT SAFETY
& HUMAN
FACTORS
SENIOR MANAGER CREW PLANNING & EMPLOYMENT TECHNICAL & DEVELOPMENT
Source: MAS
Figure 1.17D - Organisation of Flight Operations Management
ii) Organisation and Management related to B777
Operations
All the fleets in the Company were under the purview of Chief Pilot Line Operations. The fleet was headed by a Fleet Manager B777 who would report to the Chief Pilot Line Operations. The Fleet Manager B777 had been with the Company for the past 17 years and until March 2014 the fleet comprised of 17 aircraft. The Fleet Manager (with more than 10 years Command experience on the B777) was supported by non-flying staff in the day-to-day management of the fleet co-ordinated by Flight Operations Controllers (Figure 1.17E
[below]).
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CHIEF LINE OPERATIONS
FLIGHT OPERATIONS
CONTROLLER
Source: MAS
Figure 1.17E - Line Operations, Administration & Support (as of January 2014)
iii) Technical Crew
The airline technical crew were pioneered by pilots who crossed over to MAS when the then Malaysia-Singapore Airlines (MSA) split in 1972 to become MAS and SIA respectively. In the early days of MAS up to the mid-1980s a majority of MAS pilots came from MAS-sponsored cadets. These trainee pilots were normally sent to reputed Flying Colleges/Academies, mainly in Australia, Philippines, Scotland and Indonesia. These candidates were put through stringent pre-hire recruitment processes which included aptitude tests, psychomotor skills, as well as interviews by a panel comprising of Management Pilots and Human Resource Managers and/or Executives. In later years, the process became even more stringent with the inclusion of simulator evaluation and psychological tests.
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After the mid-1980s, the emergence of local flying schools had resulted in most of the sponsored cadets undergoing their basic training in Malacca at the Malaysian Flying Academy (MFA). The MFA had also provided training for foreign students from Singapore, Indonesia, Bangladesh and India. This had benefited MAS in terms of costs and the ability to graduate ab initio qualified pilots in a shorter time compared to overseas flying schools.
In the last ten years, more flying colleges or academies were set up, such as in Kota Bahru and Langkawi. MAS- sponsored cadets were eventually trained at these places in tandem and then absorbed as trainee pilots into MAS, including a small number of self-sponsored students who made the grade. These cadets would pass out with a Frozen ATPL (Air Transport Pilot Licence) and by the time they had accumulated a total of 1,500 hours or more, the full authorisation of the licence would take effect giving the holder the privilege of its full coverage.
From the early days of operations, MAS started with domestic and regional services. Thus, the fleet of aircraft had always included small propeller aircraft to service remote towns that were equipped with short field aerodromes and short-haul twin engine jets. Generally, a career of a pilot in MAS began as a co-pilot on the smallest Turbo Props, or sometimes when the demand and the promotion was rapid, suitable candidates would be posted direct to the B737 upon entry into the airline. Aco-pilot would need to serve for at least 5 to 7 years in the Company on the lower fleet before one could be considered for promotion to the B777. Before the arrival of the new generation aircraft, the career progression would start with the F27/50, then the 737 classics as their first jet aircraft experience, then to either A300B4 or the DC10/B747-200. After the introduction of the new generation aircraft, they were normally promoted from the B737/200/400/800 to the A330 or B777 fleet then the B747-400/A380 depending on the Company’s individual
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fleet requirement.
The pilot promotion policy had since changed to include individual pilot’s bidding for promotion to larger aircraft, which was not the case in the past.
The pre-hire test also applied to those joining the airline with previous flying experience from other flying organisations. A significant percentage of MAS pilots came from the Royal Malaysian Air Force (RMAF), mainly those who had served the Air Force as short-commissioned officers. After about seven to ten years of service in the RMAF, they were able to join MAS with recognised flying hours and experience to be accepted as First Officers in the lowest fleet. After accumulating sufficient airline flying hours, they would be ready for promotion to Captain on the lowest fleet, e.g. F27/50, or direct to the B737 jet. A small percentage of pilots came from a general aviation background and needed to go through the similar stringent pre-hire process before commencing their training to the appropriate fleet.
On the average it would take at least 15 years of flying in the Company before a pilot could be promoted to command the B777. Among the factors for career progression is eligibility in terms of total command hours, base check and line check competencies, seniority in the pilot ranking and the airlines expansion plan. In Malaysia Airlines, no young fresh ab-initio pilot would be posted direct to the big wide-body jet (i.e. B777) without the smaller twin jets experience. By the time a captain was ready for the B777, he would have at least flown F50, B737 or A330 or combination of all the 3 aircraft with at least a total of 5,500 hours, part of which had to be a minimum of 1,500 command hours and 2 years operational on the MAS B737.
By normal career progression, the Captain that was flying on this aircraft would have met the full pre-requisites to be on the elite fleet of the B747-400 or the A380. However, it was his choice that he preferred to remain on the B777 fleet
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as he did not bid for position on the two higher fleets.

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v) Working Schedule/Roster Schedule and Management
The working schedule and rest requirement to manage crew fatigue was highly regulated and normally bounded by guidelines stipulated by the CAA UK CAP 371 and the Malaysian Civil Aviation Regulations (MCAR) 1996. The MCAR 1996 adapted the CAA CAP 371. With the formation of the Joint Aviation Requirements (JAR), DCA Malaysia had gradually migrated towards regulations stipulated in the JAR. Duty and Flight Time Limitation (FTL) was strictly guided by these published regulatory documents. In general, MAS has since its inception, adopted a more stringent and restrictive FTL based on the Memorandum of Understanding (MoU) between the Pilots Association and the adequately rested before they were scheduled to any assigned flight duties. The Pilots Association played an important role to ensure compliance to the limits were met.
In the case of MH370, the expected flight and duty time was less than 8 hours, with a single leg of one take-off and one landing. The Regulatory requirement and MAS Operations Manual A, Part 7.1.20 and MoU would only require one set of crew to man the flight. Standard Company’s practice, in compliance with FTL, would call for the whole set of crew to be allocated a stop-over duration of 24 hours (more than the minimum rest period required) in Beijing before returning to Kuala Lumpur. Beijing was a destination that MAS operated with the same aircraft type on a daily basis.
The guidelines for Technical Crew complement requirements based on Maximum Schedule Block Time were as follows:
• Less than 8 hours: 2 crew (1 Captain and 1 Co-pilot);
• Between 8 to 12 hours: 3 crew (2 Captains and 1 Co- pilot); and
• More than 12 hours (3 Captains and 2 Co-pilots).
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The Technical Crew were required to undergo medical check-up by approved aviation doctors for their license renewal. The medical certificate issued forms part of the validity of a pilot flying license.
A summary of the work schedule for the PIC and the FO, three months prior to the eventful flight, is available in Table 1.17A (below).
Rank
Pilot-in- Command
First
Officer
24 72
Hours 0:00:00 7:00:00
7 28 90 SEP
Days
Validity 20:39:00 91:04:00 303:09:00 14 May 2014
0:00:00
0:00:00
28:47:00 51:17:00 158:46:00 26 July 2014
Table 1.17A - 3 Months FTL Data
vi) Safety Management System
MAS Safety Management System (SMS) had been designed to comply with the framework as per ICAO in Annex 6, Appendix 7 (Currently Annex 19), Framework for Safety Management Systems and the expanded guidance found in the ICAO Doc.9859 Safety Management Manual (SMM) and IATA SMS Implementation Guide. In addition, this system was consistent with the requirements of the DCA Malaysia’s Aeronautical Information Circular (AIC) document number 06-2008: SMS. MAS had established these requirements to ensure positive control and continuous improvement for safe and secure operations, including the operations of its subsidiaries, MASWings, Firefly, MAS Aerospace Engineering and MASkargo. This document had formed an integral part of the Corporate Safety Policy Manual.
The SMS encouraged an open reporting policy or commonly referred by industry as non-punitive reporting system. This assured employees that reports of unpremeditated or inadvertent errors would not result in disciplinary or punitive
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action being taken against the reporter or other individuals involved. Employees were assured that the identity, or information leading to the identity, of any employee who reported an error under this policy was never disclosed unless agreed to by the employee or required by law. The Open Reporting Policy encouraged individuals to report hazards and operational deficiencies to management. It also assured personnel that their candid input was highly desired and vital towards safe and secure operations.
The organisation had a proactive reporting system in place. Refer to Figure 1.17F (below):
•The SMS’ guidelines resided in the Corporate Safety Manual. There were various reporting channels for the staff to transmit safety-related reports to account holders or their designates;
•The reporting channels were covered all areas of operations:
well-structured and
- Air Safety Report (ASR)
- Cabin Safety Report (CSR)
- Ground Safety Report (GSR)
- Hazard report (Hazard/HZR)
- Confidential Human Factors Incident Report Programme (CHIRPs); and
- Flight Operations Quality Assurance (FOQA).
vii) Confidential Human Factors Incident Report
The flight crew and cabin crew were constantly being encouraged and reminded to utilise this reporting channel during their CRM and Safety classes (refer SEP Manual; Part 7.15.2). The Confidential Human Factors Incident Report (CHIRP), (refer to Table 1.17B [below]), being a highly confidential report, had become the most appropriate
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tool for identifying potential human factor issues, especially on the behavioural patterns of flight and cabin crew.
Source: MAS
Figure 1.17F - Safety Report Process
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CHIRPS
Sep 4
Year 2013 Year 2014 Oct Nov Dec Jan Feb Mar
- 2 - - - -
10 September 2013
23 September 2013
Communication issues between Tech Crew and Cabin Crew (1 report received)
Cabin Crew to be offloaded by Tech Crew (3 reports received)
15 November 2013
Mis-communication between Technician and Cabin Crew during ground servicing (2 reports received)
Table 1.17B - List of CHIRPs 2013 & 2014
viii) Flight Operations Quality Assurance
The airline had acknowledged the importance of safety as its utmost priority. Like most other airlines, with statistics showing Human Factor as the main contributor to air accidents, the Flight Operations Quality Assurance (FOQA) programme was introduced. This system had contributed tremendously even in non-eventful cases where impending trend towards an unsafe situation could be recorded. With this system in place investigations of events that could lead to an incident would be undertaken and remedial actions and recommendations put into place.
The FOQA programme was introduced in 2010. The objective of FOQA was to promote safety and accident prevention by identifying operational safety trends during normal line operations.
MAS considered FOQA as an important safety reporting culture where safety is enhanced in a non-punitive manner (reference: MAS Operations Manual A, Part 2.2.4.2). FOQA protocol, a written document under the custody of the Flight Safety and Human Factor Department (dated 07 July 2010) stipulated manners at which corrective and timely strategies
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were implemented following a risk or potential hazardous trend.
The statistics of FOQA events in the last 2-year period (April 2012-March 2014) is as in Table 1.17C (below).
ix) Line Operations Safety Audit
The Line Operations Safety Audit (LOSA) was first introduced in 2004 in collaboration with the University of Texas, USA. The results were fruitful, and recommendations were implemented via Safety Change Process (SCP). MAS conducted LOSA every 2 years but not later than 5 years. LOSA was conducted by taking random samplings of all aspects of operations including random audit of normal scheduled commercial flights.
The last LOSA (2nd LOSA) was carried out between March and August 2011. The objective of LOSA was for MAS to diagnose its level of resilience to systemic threats, operational risks, and front-line personnel errors, thus providing a data driven approach to prioritise and implement actions to primarily enhance safety. This was carried out system-wide with no emphasis on any specific fleet.
x) Crew Resources Management
MAS considered Crew Resources Management (CRM) as a critical component of flight safety during operations and introduced it more than 20 years ago. The training programme for the pilots included the Cabin crew & Dispatchers. For new recruits there was a 3-day programme for CRM. Recurrent training was conducted on a yearly basis. The Safety Awareness Programme (SAP) conducted on a yearly basis would include the recurrent for the CRM training/ refresher. This programme had been in the system ever since the release of ICAO Annex 6 Part 1.
It started off with the pilots only to improve the cockpit culture. It was considered essential then as the airline had
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Source: MAS
Table 1.17C - Statistics of FOQA Events in the Last 2-Year Period (April 2012-March 2014)
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significant numbers of expatriate community serving MAS from a diverse culture. Later, the training programme also included Cabin crew& Despatchers. For new recruits there was a 3-day programme for the Initial CRM. Recurrent CRM training (1 day) also known as Safety Awareness Programme (SAP) was conducted regularly to cater for flight crew, cabin crew and flight despatchers. JAR-OPS Subpart N, JAR-OPS 1/3.965 stated that all major CRM topics should be covered every 3 years for technical crew, every 2 years for cabin crew and annually for flight despatchers.
xi) Training and Standards
MAS managed its entire training requirement in-house including the mandatory requirement for the flight crew. MAS had its own Training Centre for pilots as well as engineers. It was equipped with various Full Flight Simulators for all the fleet in the Company with most of the Flight training devices certified to FAA Level D, capable of zero flight time training. This Training Centre had been established for more than 40 years and had been certified by many countries as an approved Type Rating Training Organization (TRTO.)
Type Rating Instructors (TRI) & Type Rating Examiners (TRE) normally came from within the airline and they require stringent training and check before being approved by the DCA Licensing Division. Besides the availability as a TRTO, the Simulators were utilised by neighbouring airlines and smaller organisations within the region to fulfill their training and checking requirements.
Competency of pilots, as per regulatory requirements worldwide, is normally monitored every 6 months. MAS training policy required 2 Simulator sessions every 6 months. The two training sorties every 6 months consisted of 1 review and training followed by proficiency check session.
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xii) MAS B777 Training and Standards
The training package for the B777 conversion training followed the Boeing Training Recommendations. During the introduction period, representatives from the Boeing Flight Training Department oversaw the operations. The first crew trained by Boeing comprised a project team of four pilots from the Company and one representative from DCA, the regulatory authority. The team members were then responsible for managing the introduction of the new aircraft into operation. Part of their responsibility was to ensure that the subsequent training and recurrent requirements were addressed according to the recommendations of the aircraft manufacturer, consistent with the mandatory requirements of the DCA Licensing Authority. When the B777 was introduced, the simulator was also procured, and it arrived at the MAS training premises before the first aircraft entered into commercial service. At the introduction phase of the B777 into MAS, the airline had sought assistance from the Boeing Flight Training Department to kick-start the training of new pilots locally.
In MAS, all aircraft purchased came with a package that included the respective simulator, except the B747- 200/300 and Fokker F27. Like most other established airlines, MAS considered training as vital tool to maintain good pilot skills and standards.
The pilot’s upgrade policy of having to serve on the smaller fleets at point of entry helped in preparing captains and co- pilots to handle larger machines, such as the B777. During the day of the event, the co-pilot was on his last training flight before he was due for a check flight on his next flight duty assignment. The Team had recorded that the FO was assigned to be the flying pilot for Kuala Lumpur/Beijing sector on the ill-fated flight.
Throughout a pilot’s career, should the pilot’s performance during Simulator and Line operational checks fell belowthe minimum standards, the Company would provide adequate retraining to ensure the required regulatory
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competency was maintained.
It is important to note that there were 3 phases of training when a pilot was undergoing conversion training to a new fleet in MAS. The FO’s last fleet was the A330 and he was undergoing the final phase of training to be qualified as a co-pilot on the B777. The three training phases were:
• Ground School & Computer Base Training (CBT); • Simulator Training; and
• Initial Operation Experience (IOE) Phase 1 and Phase 2.
The IOE was for the trainee to be trained during line operations on a passenger scheduled flight commanded by a TRE or TRI-qualified Captain.
During the initial part of the IOE, it was the Company’s policy that the flight had to be accompanied by an additional experienced co-pilot or captain to support the flight in case the trainee needed any supervision and, most importantly, if the TRE or TRI was incapacitated. This policy guaranteed that in such an untoward incident, there would always be a qualified Pilot to take over command of the aircraft and proceed with the next safe course of action.
As the training progressed, and if the trainee’s performance was above average, and deemed safe, the carriage of the third pilot would not be necessary beyond this stage of training, based on the recommendation of the earlier trainer (TRI/TRE) in accordance with the training policy.
In such a case, a trainee pilot under IOE would not need a third pilot to accompany the flight, even though he was effectively still in the training phase. This was the case on the day of the eventful flight.
On the B777 a pilot under training normally would require to operate a certain number of minimum sectors before he could be certified to be fully functional as a line operational pilot (end-of-training). Depending on the
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previous aircraft flown, the minimum and maximum number of required training sectors were, as follows:
• Last aircraft flown B737: Minimum 10 sectors, Maximum 14 sectors; and
• Last aircraft flown A330: Minimum 8 sectors, Maximum 14 sectors.
xiii) Multi-crew Operation MH370
During the day of the eventful flight, the FO was on his last training flight before he was due for a check flight on his next flight duty assignment. Record shows that he was assigned to be the flying pilot during that first leg from Kuala Lumpur to Beijing. The airline encouraged Captain to allow First Officer a fair share of flying and handling of the aircraft. Under normal practice, if the duty pattern involves more than 1 sectors, it is quite common that the additional sector will be flown by the First Officer. The decision of who to carry out the take-off and landing was solely at the discretion of the Captain. The assignment of duty regarding who was going to be the flying pilot for the first flight out normally decided during the pre-flight briefing at the despatch office.
If the decision was made that the First Officer was going to be the Pilot Flying, the MAS Flight Operations policy required that the Captain would start and taxi the aircraft up to the take-off point on the runway, after which control of the aircraft would be handed over to the co-pilot to perform the take-off and eventually the landing at the destination. Up to the take-off position at the beginning of the runway, radio communications with the ATC would be the responsibility of the co-pilot. It was a MAS’ written procedure during this phase of the flight that the throttle would be handled by the Captain as PIC, a policy to ease and expedite the rejected take-off manoeuvre if so required. The First Officer would control the rudder and control column as the pilot flying.
As soon as control was handed over to the co-pilot at the take-off point, the ATC communication became the
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responsibility of the Captain. Evidence from the KL ATSC’s voice recording indicated clearly (in interviews with the Captain’s colleagues, friends and son), that the voice recorded was that of the Captain after the aircraft took off.
xiv) Safety and Emergency Procedures
Proficiency in Safety and Emergency Procedures (SEP) was also a part of the mandatory training requirement which was conducted every 12 months. It was based on the Aircraft Type that the pilot was rated on. This recurrent training required a minimum of 3 days which covered all aspects of emergencies including medical and first aid knowledge. This section of Training fell under the purview of Flight Safety and Human Factor.
(1) Operation Control Centre
The Operation Control Centre (OCC) was where the briefing of flight crew and cabin crew took place. A team of Licensed Aircraft Despatchers were stationed in this Department.
Besides the crew formalities required prior to departure, the flight crew would be working in tandem with the assigned despatcher to review all documentations related to the assigned flight which influenced the decision on the finalised routing and fuel ordered by the Captain of the flight.
(2) Flight-Following System
In MAS, the FFS was an integrated approach which enabled flight operations Controllers to easily monitor the status of flights and gain a better view of impending operational problems, and making the process of resolving them much more efficient. A 24-hour OCC maintained operational control of all fleets in MAS by providing support for the pilots before and during flights. The FFS played the foundational role in OCC. The system is a product from Sabre and utilises position input to update the aircraft’s geographical position. Position updates come from two sources namely:
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• ASDI (Aircraft Situation Display Information) sourced from the FAA for aircraft flying in the United States, and
• ACARS update from individual Company aircraft flying anywhere in the world.
The information was available on a monitor mounted in the ODC and was also available on all Despatchers’ positions via selections to be displayed on individual monitors.
• Projected flight plan against hazardous weather and published prohibited or restricted areas en- route;
• Actual flight data; and
• Pertinent data related to the flight, and allows direct communications with aircraft via satellite phone or ACARS communications.
xv) Technical and Development
Technical data and aircraft performance were under the control of the Operations Engineering Department. This Department worked closely with the Technical Services Department of the Engineering Division and Aircraft Manufacturers on Performance Engineering matters. The Technical and Development Department participated in the evaluation of new Aircraft Type and Aircraft Equipment.
xvi) Fuel Policy
The fuel policy defined in the MAS Operations Manual A (Part 8.1.7) met the minimum required for aircraft despatch. A Captain has the privilege of carrying extra fuel if he feels that there is justification to do so, based on expected weather forecast enroute and at the destination. Extra Fuel carriage can also be due to aircraft performance penalty as required by MEL or specific ATC requirement at some destination airports.
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xvii) Flight Plan Routing
The Company’s policy required the despatcher to evaluate the flight routing for the best economy routes to Beijing based on the OCC Flight Management System. As there was no known enroute weather forecast that could pose a threat for MH370, the usual standard routing was chosen. This was normally done by the computer system to give the despatcher the recommended routing unless otherwise modified.
xviii) Hijack and Sabotage Security Procedures
The Hijack and Sabotage Security Procedures and Guidelines in MAS’s SEP Manual (Part 4.3) were recommended by the world’s aviation security authorities based on in-depth studies of actual hijack and sabotage incidents. These authorities included ICAO Annex 17, IATA, TSA, FAA, Malaysia Airlines Security Programme and the Aviation Offences Act 1984 (Act 307).
The procedures stipulated that security precautions against both hijack and sabotage cannot be maintained at maximum level at all times without disrupting operational functions and public goodwill.
b)In-flight Services
i) Cabin Crew Training
Cabin crew were required to be present on public transport flights to perform duties in the interest of passengers’ safety. They must be well-informed about safety and Policies of the Company. Each cabin crew member shall:
• Be well-prepared and fit for the flight;
• Ensure adherence of “Fasten Seat Belt” and “No Smoking” signs;
• Ensure the comfort and safety of all passengers; and
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• Ensure passengers safely escape in an emergency evacuation.
A cabin crew member is a person employed to facilitate the safety of passengers whose duties are detailed by the Company or the aircraft Commander. Cabin crew will not act as a member of the flight crew.
At the point of recruitment, the candidate would have to undergo through a thorough interview and medical check- up. Once selected, a comprehensive training of safety and service procedures would be provided by the airline for the duration of 3 months and he/she would graduate and leave the academy as a qualified cabin crew assigned to the selected fleet that he/she was trained for.
MAS had the policy of fleet grouping for cabin crew in the following order:
• Narrow Body • Wide Body
- -
B737
A330, B777 & B747/A380
Upon graduation, the cabin crew would be given a flight duty roster on a monthly basis. The roster was managed by the Crew Planning & Deployment Section.
Initially, a cabin crew was required to operate the domestic and the regional flights known as the Narrow Body Fleet for a minimum of 2 years. With sufficient experience gained on the narrow body fleet he/she might be eligible for promotion to the wide-body fleets. These new wide-body may include long-haul flights to international destinations. The selection of cabin crew for promotion normally depends on merit, track record and seniority.
A cabin crew would be provided with proper training on Safety and First Aid. He/she would be trained to handle:
• Safety and emergency evacuation • Disruptive/Difficult passengers
• Medical emergency (Provide First Aid)
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On a yearly basis, the cabin crew was required to go through a safety recurrent training on their Safety Emergency Procedures (SEP) at the academy in order to keep his/her licence and training validated by certified instructors. It was mandatory for the crew to achieve the required minimum safety and emergency procedures and knowledge which were assessed through examinations. This recurrent training included first aid training and examination, to get the certificate renewed. There were also “Safety Awareness Programme” and “Crew Resources Management” classes that were compulsory for the cabin crew to attend every 2 years. These two programmes were basically similar, and they were incorporated within the 3 days of training.
The cabin crew would be issued with a Safety Card endorsed by the Safety and Human Factors Department of MAS as well as a Crew Performance Card issued by the Cabin Crew Line Operation and Performance Department. The crew would be expected to carry these two documents at all times for flight duty.
Excellent service awards won by the Company’s cabin staff for several years stood as a testimony for the quality of the training and the service standards acquired. MAS’ reputation had attracted foreign established top-rated airlines for secondment of cabin crew.
ii) Crew Performance Appraisal
The Crew Performance Appraisal (CPA) was an established process in the organisation, monitoring crew performance and standards including safety knowledge. To maintain and achieve a high standard of service and safety, each and every cabin crew was required to have a CPA which was done twice a year. The assessment was carried out by the crew in charge on board during the flight.
Refer Table 1.17D (below) on Rating Score.
The cabin crew would be checked on aspects such as safety and service procedure, product knowledge,
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Customs, Immigration and Quarantine, station documents, grooming and leadership skills. The crew in charge would conduct the checking on the crew by Questions & Answers (Q & A) and how the individual performed as part of the operational crew member in his/her assigned capacity.
Ratings
5
4
3
2
1
Category Amongst the Best Highly Effective Fully Productive Needs Improvement Unacceptable
Range of Score 98% and above 93%-97.90% 87%-92.90% 80%-86.90% <80%
Table 1.17D - Crew Rating Score
iii) In-flight Operation
On board a Boeing 777-200ER aircraft the standard operating cabin crew of 11 was required. The normal cabin crew complement for the Boeing 777-200ER aircraft was as follows:
• 1 In-flight Supervisor
• 2 Chief Steward/Chief Stewardess • 2 Leading Steward/Leading Stewardess • 6 Flight Steward/Flight Stewardess
The 777-200ER fleet had a two-class cabin configuration, namely Golden Class Club (GCC) and Economy Class (EY). Four cabin crew would be designated to work in GCC and six in EY.
The In-flight Supervisor would be in charge of the whole cabin. Two Chief Stewards/Chief Stewardesses looked after the GCC assisted by two cabin crew. Six cabin crew were designated to work in EY class. The EY class was divided into two sections and each section was looked after by one Leading Steward/Leading Stewardess and assisted by two cabin crew.
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The In-flight Supervisor was the person responsible to manage the cabin safety and report to the Commander of the aircraft.
He or she shall:
• have the overall responsibility to the aircraft commander for the conduct, coordination and performance of the cabin operations and the safety duties;
• verify that all the cabin crew members are fit for flight and with all relevant documents valid for flight duty; and
• coordinate and organise the functions and tasks of all cabin crew members:
- Execute cabin crew briefing;
- Nominate positions and working areas;
- Nominate in-flight service duties;
- Checking of emergency equipment, pre-flight safety briefing and reporting matters concerning safety (irregularities and malfunctions) to the Commander;
- Debriefing the cabin crew members when required;
- Ensuring efficient communication with crew members and ground personnel; and
- Ensuring contact with the cockpit on a regular basis.
As per Civil Aviation Regulations 1996 the minimum requirement of the operating cabin crew for B777-200ER fleet is 8 based on the number of exit doors available on the aircraft.
Notwithstanding the above, many other airlines carry additional cabin crew above the minimum required in the interest of customer services.
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iv) Flight and Duty Time Limitations Scheme for Cabin
Crew
The prime objective of a flight time limitations scheme is to ensure that crew members are adequately rested at the beginning of each flying duty period, and whilst flying, be sufficiently free from fatigue so that they could operate to a satisfactory level of efficiency and safety in all normal and abnormal situations.
The maximum duty hours for cabin crew should not exceed:
• 60 hours in 7 consecutive days; • 105 hours in any 14 consecutive days; and • 210 hours in any 28 consecutive days.
Cabin crew would be notified in advance of a flying duty period so that sufficient and uninterrupted pre-flight rest can be assured in preparation for the flight. When away from base, opportunities and facilities for adequate pre- flight rest would be provided by the Company with suitable accommodation.
The minimum rest period which must be taken before undertaking a flying duty period shall be:
• At least as long as the preceding duty period, or • 12 hours, whichever is the greater.
The minimum rest period would be the highest of pre-flight or post-flight rest. It was not cumulative of both rests.
The minimum rest period which must be provided before undertaking a flight, at home base would be:
Flight Pre-flight Post-flight
Rest Period 40 hours (inclusive 2-local nights) 72 hours (inclusive 3-local nights)
The minimum rest period which must be provided after performing a flight, out of base would be:
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Flight Post-flight
Rest Period 24 hours
MAS Employee Union (MASEU) was the recognised union certified by MAS to represent the cabin crew. Flight Time Limitation and working conditions were governed by the Collective Agreement (CA) signed between the union and MAS, in compliance with CAR or whichever was more limiting.
v) Safety Report
(1) Accident/Incident/Hazard Reports Form
MAS managed an in-house reporting system to identify many of these accidents/incidents/hazards by collecting and then analysing hazard and incident reports to audit incidents encountered during flight. The Incident reporting system was one of the most effective tools for pro-active hazard identification. Cabin crew were required to fill up this form and to submit it at the end of the flight within 24 hours.
(2) Confidential Human Factors Incident Reporting
Programme
Confidential Human Factors Incident Reporting Programme (CHIRPs) applicable for the flight crew, cabin crew and engineering personnel only. It was a non-disclosure type of document where one could use and submit to the Company to report any complaints and issues. CHIRPs could only be used for human factor and safety issues, errors and unsafe practices and where some actions might potentially infringe regulatory practises. It was not to be used for mandatory incidents reporting, personality conflicts, industrial issues and employment problems. It would be reviewed by the members of the CHIRPs staff and action would be taken accordingly.
All these reports were managed by the Corporate Safety Oversight and Human Factors Department.
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1.17 Organisational and Management Information

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