SIR 2018:2 Analysis

Safety Investigation Report: 2 Analysis - Table of Contents

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Safety Investigation Report

1 Factual Information

2 Analysis

3 Findings

4 Recommendations

5 Comments

Appendices

SAFETY INVESTIGATION REPORT
MH370 (9M-MRO)

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SECTION

TITLE

2

ANALYSIS

 

Introduction

2.1

Diversion from Filed Flight Plan

2.1.1

Seven Simulator Sessions

• 1) Recreating the Left Turn past Waypoint IGARI
• 2) Session 2
• 3) Session 3
• 4) Session 4
• 5) Session 5 (Manual Flying)
• 6) Session 6 (Manual Flying)
• 7) Analysis on Re-enactment Sessions (Sessions 1-6)
• 8) Session 7 – Recreating the Right Turn South of Penang Island

2.1.2

Ho Chi Minh Air Traffic Services Operation

2.2

AIR TRAFFIC SERVICES OPERATIONS

2.2.1

Review of Flight MH370 before its Disappearance

2.2.2

Chronology of ATC Events before the Disappearance of Flight MH370

2.2.3

Filed Flight Plan of MH370

• 1) Message Code of FPL of MH370 and Meaning

2.2.4

Departure message of MH370

• 1) Message Code of Departure message of MH370 and Meaning

2.2.5

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

2.2.6

Analysis on FPL Message of MH370

2.2.7

Chronology of ATC Events following the Disappearance of MH370

2.2.8

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

• 1) Analysis of ATS Operational Issues after Last Radio Communication with MH370 and subsequent Activities/Actions
• a) Transfer of Control Point at Waypoint IGARI
• b) Responsibilities of Accepting Air Traffic Control Service Unit on Establishment of Communications
• c) Marking on MH370 Flight Progress Strip
• d) Responsibilities of Air Traffic Controllers
• e) Recognising Emergency Situations and Air Traffic Control Actions
• f) Information to be passed to other Radar Units – Civil and Military
• g) Provision of Alerting Service for Flight operating through more than one FIRs and ATC actions
• h) Actions taken by Air Traffic Service Centre Duty Watch Supervisor
• i) Flight-Following System of Malaysia Airlines
• j) Communication Exchanges between KL ACC and HCM ACC and KL ACC and MAS Operations Despatch Centre on MH370
• k) Delegation of Airspace by Singapore Area Control Centre to KL ACC
• l) ATC Actions on Strayed/Unidentified Aircraft (Primary Radar Target) within the Area of Responsibility
• m) KL ATSC Duty Shift System for Air Traffic Controllers
• n) Roles played by the Duty ATSC Watch Supervisor
• o) Activation of Aeronautical Rescue Coordination Centre
• p) Play-back of Radar and Radiotelephony Recordings by ATSC Duty Watch Supervisor
• q) Entries in ATS Logbooks of ATSC Watch Supervisor and Sector 3 Controller Working Position
• r) Distress Message
• s) Issues with Manual of Air Traffic Services (MATS)

2.3

MEDICAL/HUMAN FACTORS ISSUES

2.3.1

Introduction

2.3.2

General Human Performance Issues

2.3.3

Specific Human Factors Issues

2.3.4

Human Factor Aspects of Air Traffic Control Recordings

2.4

AIRWORTHINESS & MAINTENANCE AND AIRCRAFT SYSTEMS

2.4.1

Airworthiness & Maintenance

2.4.2

Emergency Locator Transmitters

2.4.3

Aircraft Health Monitoring

2.4.4

Aircraft Systems Analysis

• 1) Air-conditioning, Pressurisation and Oxygen
• 2) Autoflight
• 3) Electrical Power
• 4) Flight Control and Hydraulics
• 5) Instrumentation
• 6) Navigation
• 7) Engines
• 8) Fuel Systems
• 9) Auxiliary Power Unit
• 10) Communications
• 11) Airplane Information Management System

2.4.5

Summary

2.5

SATELLITE COMMUNICATIONS ANALYSIS

2.5.1

Summary of Key Observations of the SATCOM Ground Station Logs

2.5.2

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

2.5.3

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

2.6

WRECKAGE AND IMPACT INFORMATION

2.6.1

Debris Considered for Detailed Examination

2.6.2

Location of Debris with respect to Aircraft

2.6.3

Damage Analysis of Significant Debris

2.6.4

Marine Life Examination

2.7

ORGANISATION AND MANAGEMENT OF DEPARTMENT OF CIVIL AVIATION AND MALAYSIA AIRLINES

2.7.1

Department of Civil Aviation Malaysia

• 1) Introduction
• 2) Department of Civil Aviation Organisation Structure
• 3) Air Traffic Management Sector
• 4) Air Traffic Inspectorate Division
• 5) Search and Rescue
• 6) Kuala Lumpur Air Traffic Service Centre
• 7) Airworthiness Sector
• 8) Flight Operations Sector

2.7.2

Malaysia Airlines

• 1) Engineering & Maintenance
• 2) Flight Operations Management
• 3) In-flight Services

2.8

AIRCRAFT CARGO CONSIGNMENT

2.8.1

Cargo on Board MH370

2.8.2

Li-ion Batteries on Board MH370

2.8.3

Mangosteen Fruits on Board MH370

2.8.4

Dangerous Goods

2.8.5

Laboratory Tests Conducted

• 1) Li-ion Batteries
• 2) Mangosteen Fruits

2.8.6

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

• 1) Location of Cargo
• 2) Results of Tests

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Disclaimer

Source:  Malaysian ICAO Annex 13 Safety Investigation Team for MH370, 02 July 2018, Safety Investigation Report MH370/01/2018

The Safety Investigation Report and Appendices can be downloaded from the Ministry of Transport (Malaysia) website at MoT/Aviation/Reports/MH370

Note: As at May 2023 the Appendices were not linked from that page.

A predetermined geographical position that is defined in terms of latitude and longitude coordinates, used for navigation. More Info

Waypoint Country SG Latitude 6° 56' 10.00" N Longitude 103° 35' 6.00" E

Filed Flight Plan message

Air Traffic Services

A defined point located along the flight path of an aircraft, at which the responsibility for providing air traffic control service to the aircraft is transferred from one control unit or control position to the next.

It contains essential flight and control data and is the basic tool which enables Controllers to visualize the disposition of traffic within their area of responsibility including traffic arriving and departing an aerodrome, assess conflicts and control aircraft in a safe manner.

Flight Information Region

Air Traffic Control

Kuala Lumpur Area Control Centre (or Air Traffic Control Centre)

Ho Chi Minh (Viet Nam) Area Control Centre (or Air Traffic Control Centre)

Malaysia Airline Systems

Kuala Lumpur Air Traffic Services Centre

Air Traffic Services Centre

Manual of Air Traffic Services

The Safety Investigation Report MH370/01/2018 was released by the Malaysian ICAO Annex 13 Safety Investigation Team for MH370 in July 2018. More Info