Safety Investigation Report 2018:Report/i Contents/II Synopsis
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
II. SYNOPSIS
On 08 March 2014, a scheduled passenger flight from Kuala Lumpur to Beijing, operated by Malaysia Airlines (MAS) and designated flight MH370, went missing soon after a routine handover from the Malaysian Air Traffic Control (ATC) to Viet Nam ATC. The aircraft operating the flight was a Boeing 777-200 ER, registered as 9M-MRO. On board the aircraft were 12 crew and 227 passengers (239 persons in total). A review of available radar and satellite communications indicated that the aircraft flew back across the Malaysian Peninsula and subsequently travelled to the southern Indian Ocean. Despite an extensive air and sea search, the location of the aircraft and occupants remains unknown. However, some debris have been recovered consistent with having drifted over nearly two years from the area in which impact is thought to have occurred.
By international convention, the investigation of aircraft accidents and incidents is conducted in accordance with Annex 13 to the Convention on International Civil Aviation, Aircraft Accident and Incident Investigation. The Standards and Recommended Practices (SARPs) in Annex 13 are applied in Malaysia through Part XII of the Malaysian Civil Aviation Regulations (MCAR) 1996.
In accordance with the MCAR 1996, an independent international investigation team (The Team) comprising 19 Malaysians and 7 Accredited Representatives (ARs) of 7 safety investigation authorities from 7 countries was established by the Malaysian Minister of Transport to investigate the disappearance of MH370. The ARs appointed are from the:
- Air Accidents Investigation Branch (AAIB) of United Kingdom
- Australian Transport Safety Bureau (ATSB) of Australia;
- Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation civile (BEA) of France;
- Civil Aviation Administration of the People’s Republic of China (CAAC);
- National Transportation Safety Board (NTSB) of United States of America;
- National Transportation Safety Committee (NTSC) of Indonesia; and
- Transport Safety Investigation Bureau (TSIB) of Singapore
(formerly Air Accident Investigation Bureau [AAIB]).
Advisors to the ARs were appointed from the States’ investigation agencies, as well as the aircraft, engine and satellite communications systems manufacturers.
While this investigation report documents the safety investigation aspects as noted above, the Team is aware of other investigations being undertaken for other purposes, including criminal investigations.
Investigation Organisation
The investigation was organised in accordance with the ICAO Manual of Accident Investigation and Incident Investigation (Doc. 9756-AN965) practices and comprised an Investigator-in-Charge (IIC) and three main Committees, comprising:
- Airworthiness;
- Flight Operations; and
- Medical/Human Factors.
Preliminary Report
On 09 April 2014, the Malaysian Ministry of Transport released the Preliminary Report into the investigation activities at that time. The Preliminary Report contained a Safety Recommendation to ICAO in regard to in-flight tracking of large commercial aircraft. A copy of the Preliminary Report is available on the Department of Civil Aviation website here:
http://www.dca.gov.my/wp-content/uploads/2015/02/Preliminary-Report1.pdf
1st Interim Statement and Factual Information Report
On 08 March 2015, the Team released the 1st Interim Statement and a Factual Information Report detailing the factual information available at that time. The report contained no analysis, findings/conclusions or safety recommendations. Copies of both the Interim Statement and the Factual Information Report are available from the Malaysian Ministry of Transport’s two websites here:
2nd Interim Statement
On 08 March 2016, the Team released the 2nd Interim Statement.
3rd Interim Statement
On 08 March 2017, the Team released the 3rd Interim Statement.
4th Interim Statement
On 08 March 2018, the Team released the 4th Interim Statement.
This Safety Investigation Report (Report) builds on the previous Factual Information Report and extends the available information publicly released to include analysis, findings/conclusions and safety recommendations. Recognising that at the time of issue of this Report, the main aircraft wreckage, including the aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) have not yet been located, this Report will necessarily be limited by a significant lack of evidence.
Based on the available evidence, the analysis of factors considered relevant to the disappearance of MH370 include:
- Diversion from Filed Flight Plan Route;
- Air Traffic Services Operations;
- Flight Crew Profile;
- Airworthiness & Maintenance and Aircraft Systems;
- Satellite Communications;
- Wreckage and Impact Information;
- Organisation and Management Information of DCA and MAS; and
- Aircraft Cargo Consignment.
Other factors examined by the investigation and not considered relevant include the aircraft weight and balance, the amount and quality of fuel on-board and meteorological conditions.
Significant Issues and Safety Recommendations
In the analysis of the above factors, several significant issues were identified that could affect the safety of international commercial aviation, including the lack of effectiveness of certified Emergency Locator Transmitters (ELT) if a large commercial aircraft ditches or crashes into the ocean.
While this issue is currently being addressed by ICAO and the international aviation industry, the Team is of the view that work needs to be expedited in this area to implement effective changes to enhance aviation safety into the future.
Additionally, a number of issues were identified that could affect the monitoring and timely initiation of search and rescue of commercial aircraft in Malaysian airspace by the Air Navigation Services provider. Issues were also identified in the Airline Operations. They include the following:
- Malaysian and adjacent air traffic management;
- Cargo screening;
- Flight crew medical and training records;
- Reporting and following-up of crew mental health;
- Flight following system;
- Quick reference for operations control; and
- Emergency locator transmitter effectiveness.
As a result of the issues identified in the investigation and in accordance with para. 6.8 of Annex 13 which states that: “At any stage of the investigation of an accident or incident, the accident investigation authority of the State conducting the investigation shall recommend in a dated transmittal correspondence to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety”, a number of safety recommendations (Section 4 - Safety Recommendations), have been made to the Department of Civil Aviation (DCA), Civil Aviation Authority of Viet Nam, Malaysian Airlines Berhad (MAB, formerly MAS), the Malaysia Airports Holdings Berhad (MAHB) and the International Civil Aviation Organization (ICAO) to enhance aviation safety.