SIR 2018:1 Factual Information/1.18
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
SECTION 1 – FACTUAL INFORMATION
1.18 ADDITIONAL INFORMATION
1.18.1 Provision of Air Traffic Services and Areas of Responsibilities
1) Introduction
For the provision of Air Traffic Services (ATS), the Kuala Lumpur FIR is divided
into seven Sectors, namely Sector 1, Sector 2, Sector 3, Sector 4, Sector 5,
Sector 6 and Sector 7.
Each Sector has a specified area of responsibility. Sectors 1 to 5 are manned by
Sector Planning and Radar Controller jointly responsible for the safe, efficient
and orderly provision of air traffic control service, flight information service
and alerting service in their Sectors. Each Sector has an Assistant Flight Data
(AFD) Controller.
Sector 6 is manned by a Radar Controller and supported by the Sector 1 Planning
Controller and Sector 1 AFD Controller. Sector 7 is manned by a Radar Controller
and supported by the Sector 2 Planning Controller and Sector 2 AFD Controller.
a) Responsibilities of Sector Radar Controller:
• Handle all radiotelephony functions;
• When necessary, coordinate to effect transfer of radar identity and control;
• Monitor the Sector Inbound List (SIL) to ensure appropriate action for orderly
acceptance, control and transfer of aircraft; and
• Comply with instructions issued by FLOW control.
b)Responsibilities of Sector Planning Controller:
• Plan and coordinate as necessary for the management of all flights that will
operate in their sectors; and
• Ensure that the information on the electronic flight strips (EFS) is updated.
228
========274========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
The Radar and Planning Controllers will make available to each other information
that is essential to enable them to carry out their responsibilities, e.g.
change in cruising level/altitude or revision to transfer of control point
estimates.
c) Responsibilities of Controllers at AFD Position:
• Assist the Planning Controller by ensuring that information displayed on the
EFS is kept updated in a timely manner;
• Ensure that essential information found on the EFS is also available on the
paper strips;
• Display the paper strips on the display board in the correct manner;
• Make paper strips available to the EXE Controller if requested;
• Wrap up all used strips, and place them at a common place for collection; and
• Clear wrong ADP Message Queues as follows:
- AFD Sector 2
- wrong AFTN Message Queue
- AFD Sector 5 - wrong METEO and AIS
Message Queue
- AFD Sectors 1 & 4 - wrong FDP Message Queue
2) Sector 3 Area of Responsibility
a) Sector 3 is responsible for the provision of air traffic services in
controlled airspace and outside controlled airspace above
FL145 within:
That airspace from VKL to PIBOS then to 033658N 1022253E then to 040051N
1034109E at the border of Peninsular Malaysia/Singapore International Boundary,
thence southwards along the FIR boundary to 012652N 1034540E thence northwards
to 021958N 1034235E (10 nm west of VMR) thence westwards to DAMAL thence
northwards along the airway R325 to SAROX (but
229
========275========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
excluding ATS Route R325) thence along the airway G334 to VKL but excluding the
Kuantan TMA.
b) Sector 3 is also responsible for the provision of FIS and
Alerting Service in the South China Sea Corridor (SCSC). The
lateral and vertical limits of the SCSC (Refer Table 1.18A
[below]) are as follows:
Vertical Limits West of 105E
FL150
GND/SL
Laterals Limits
From 023600N 1044500E to
020000N1070000E and along 020000N till the Singapore/Kota Kinabalu FIR Boundary,
thence along this Boundary to 060000N 1132000E, thence along 060000N till the
Singapore/Kuala Lumpur FIR Boundary, thence along this Boundary to 023600N
1044500E
East of 105E
FL200 GND/SL
Table 1.18A - Lateral and Vertical Limits of South China Sea Corridor
c) Sector 3 encompasses the following ATS routes or route
segments (Table 1.18B [below]):
Routes
A224
B338
B469
G334
G582
G584 L629 L635 L642 M751
M758 M761 M763 M771
Segments VMR - VJR VTK - VMR VPK - PU VKL - UKASA - VPT - KIBOL Sector 1
boundary - VPK VKL – VPK VPK - BUVAL VPK - DOVOL VMR - EGOLO VPK - A/VKE (FL240
& above) VPK - ISDEL VPK - KETOD VPK - TAXUL VMR - RAXIM
Routes Segments N884 VMR – LENDA N891 PU – MANIM N892 KIBOL - VMR R221 VMR - VPT
R325
W533 W540 Y331 Y332 Y333
MATSU - SAROX (FL280 & below)
VKL - VKN - VKE
VPK - A/VKE (FL235 & below) PIBOS - TAXUL
TAXUL - PADLI
PADLI - BUVAL
Y334 Y335 Y336 -
PADLI - DOVOL PADLI - IDSEL ISTAN - PADLI - KETOD
-
Table 1.18B - ATS routes or route segments of Sector 3
230
========276========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Note:
SAROX is not a waypoint on R325. It is a waypoint on G334 that intersects R325.
It is used here for ease of reference.
d) Delegation of Airspace and Communication Watch
i) Delegation of Airspace from Kuala Lumpur ACC (Sector 3) to Singapore ACC
The contiguous airspace Areas A, C, E and H along eastern Johor/South China Sea
and responsibility for provision of air traffic services in these areas remains
delegated to Singapore.
ii) Communication Watch
To ease air traffic management, communications watch shall be maintained by
Singapore HF, Lumpur Sector 3 and Lumpur HF within South China Sea Corridor (AIP
Malaysia ENR 2.1-13 [below]).
Extract from Malaysia AIP ENR 2.1-13
iii) Singapore will pass to Sector 3 Estimate for flights bound
for the Natuna and Matak Islands. Sector 3 in turn, shall
notify Aeronautical Mobile Service (AMS) High Frequency
(HF) who shall provide additional communications watch
in order to discharge its Flight Information Service
(FIS)/Alerting Service functions.
231
========277========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
3) Sector 5 Area of Responsibility
a) Sector 5 is responsible for the provision of air traffic services
in controlled airspace and outside controlled airspace above FL145 within:
That airspace from VKL to PIBOS then to 033658N 1022253E then to 040051N
1034109E at the border of Peninsular Malaysia/Singapore International Boundary,
thence northwards along the FIR boundary, thence westwards along the Peninsular
Malaysia/Thailand International Boundary to 054342N 1010038E thence southwards
to 044021N 1012704E, then to VKL but excluding the Kota Bharu TMA/Terengganu and
Kerteh CTRs. Sectors 5 encompasses the following ATS routes or route segments
(Table 1.18C [below]):
Routes A334 B219 B463 G466 M644 M751 M765 R208 R325 W540
Segments
PASVA – VKB
Butterwort TMA Boundary East – VKB KADAX – VKB
VKL – VKB
VKB – ABTOK
A/VKE – VKB – GOLUD (FL240 and above) VKB – VENLI – IGARI
VKL – GUNBO – VKR – IKUKO – IGARI ANSOM – MATSU (FL 280 and below) A/VKE – VKB
(FL235 and below) Table 1.18C - ATS routes or route segments
b) Delegation of Airspace
i) Delegation of Airspace from Singapore ACC to Kuala
Lumpur ACC (Sector 5)
RNAV route M765 between VENLI and IGARI has
been delegated by Singapore ACC. Lumpur Sector
5 shall provide air traffic services and carry out
coordination with Ho Chi Minh ACC.
232
========278========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
ii) Route segment between IKUKO and IGARI on ATS
R208 is released by Singapore ACC subject to daily
coordination between Singapore ACC and Kuala Lumpur
ACC.
iii) Communication Watch
To ease air traffic management, communication watch is maintained by Lumpur
Sector 5 and Lumpur HF between IKUMI and IGARI along N89. Refer Figure 1.18A -
Sector 3 and 5 Area of Responsibilities (below).
Source: DCA Malaysia
Figure 1.18A - Sector 3 and 5 Area of Responsibilities
233
========279========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: DCA Malaysia
Figure 1.18B - Airspace Delegated to Malaysia by Singapore
234
========280========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
4) Air Traffic Services Operations
a) The disappearance of MH370 occurred in the Singapore FIR
where the airspace is delegated to KL ACC. The portion of
airspace delegated is RNAV route M765 between VENLI13 and
IGARI14, and the portion released is ATS route R208 between
IKUKO15 and IGARI. (References: Malaysia Aeronautical
Information Publication (AIP) ENR 2.1-15 (Figure 1.18B
[below]), ENR 3.1-10 and ENR 3.3-5 and Manual of Air Traffic
Services [MATS] Vol. 2 page 2-2-10 paragraphs 2.4.3.1 &
2.4.3.2).
b) KL ACC is responsible for the provision of Air Traffic Control
Service, Flight Information Service and Alerting Service to all
aircraft within Kuala Lumpur FIR and the “released airspace”
on ATS route R208 and the “delegated airspace” on RNAV
route M765 (Figure 1.18B [above]).
c) MATS part 9, page 9-6-5 para 6.7.2 states that:
“If alerting service is required for an aircraft that is flight planned to
operate through more than one FIR including the airspace delegated to the Kuala
Lumpur and Kota Kinabalu ATSCs and, the position of the aircraft is in doubt,
the responsibility for coordinating such service shall normally rest with the
ATSC of the respective FIRs:
a) Within which the aircraft was flying at the time of last
radio contact;
b) That the aircraft was about to enter when last radio
contact was established at or close to the boundary
of the two FIRs.
d) Operational Letter of Agreement for the Provision of Search
and Rescue Services between the Department of Civil Aviation
Malaysia and the Department of Civil Aviation Singapore dated
August 1984 page 6 para. 7.1 states that:
13
Coordinates VENLI: 062846N 1024900E 14
Coordinates IGARI: 065612N 1033506E 15
Coordinates IKUKO: 054512N 1031324E
235
========281========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
“In the event of an aircraft emergency occurring within
the South China Sea Corridor (SCSC), the KL ATSC shall be responsible to take
initial alerting action whilst the Singapore RCC shall be responsible for
subsequent coordination of all SAR efforts. While the responsibility for the
provision of SAR service within the SCSC rests with Singapore RCC, the Singapore
RCC may as provided for in paragraph 3.2.2 delegate responsibility for the
overall control of the SAR mission to Kuala Lumpur RCC or Kota Kinabalu RCC,
whichever is deemed appropriate”
Para. 3.2.2, page 3 of the same agreement, para. (d) above states that:
“When a transfer of responsibility for the overall SAR co-ordination is to take
place, either from subsequent establishment of an aircraft’s position or
movement, or because an RCC other than the one initiating the action is more
favourably placed to assume control of the mission by reason of better
communication, proximity to the search area, more readily available facilities
or any other reasons, the following procedures shall be adopted:
i. direct discussions, wherever possible, shall take
place between the Search and Rescue Mission Co-
ordinators (SMCs) concerned to determine the
course of action.
ii. if it decided that a transfer of responsibility is
appropriate for the whole mission or part thereof,
full details of the SAR mission shall be exchanged.
iii. the initiating RCC shall continue to retain
responsibility until the accepting RCC formally
assumes control for the mission.
5) KL ATSC Duty Shift System for Air Traffic Controllers
a) The duty shift system (Table 1.18D [below]) on 07 March 2014
for Air Traffic Controllers was as follows:
Sectors 1, 2, 3, 4 and 5 were manned by a Radar Controller, a Planning
Controller and an Assistant Flight Data Controller in each Sector from 1100-1600
UTC [1900-2400 MYT]. Sector
236
========282========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
6 was manned by a Radar Controller and Sector 7 was not manned.
Day
Shift
Period
1
Afternoon
• 0500 UTC [1300 MYT] - 1100 UTC [1900 MYT]
2
Morning & Night
3
Midnight shift
4
• 2300 UTC [0700 MYT] - 0500 UTC [1300 MYT] and • 1100 UTC [1900 MYT] - 1600 UTC
[2400 MYT] • 1600 UTC [0000 MYT] -
2300 UTC [0700 MYT]
Off duty
Table 1.18D - Duty Shift System for Air Traffic Controllers
b) From 1600 UTC [0000 MYT] until 2200 UTC [0600 MYT], the
number of Controllers in the KL ATSC were scaled down by or
to half to enable the Controllers to take a rostered break - the
first half from 1600 UTC [0000 MYT] to 1900 UTC [0300 MYT]
and the second half from 1900 UTC [0300 MYT] to 2200 UTC
[0600 MYT], as follows:
•Sector 1, Sector 2 and Sector 4 each were manned by a Radar Controller with an
AFD Controller.
•Sector 3 and Sector 5 were combined and operating from a Controller working
position with a Radar Controller and an AFD Controller.
•The area of responsibility would be that of Sector 3 and Sector 5. Between 1600
UTC [0000 MYT] and 2200 UTC [0200 MYT], Sectors 3 and 5 Assistant Flight Data
Controller carried out the duty of Planning Controller.
c) The last radio transmission between KL ACC and MH370 took
place at 1719:30 UTC [0119:30 MYT]. A contact should have
occurred at around 1722 UTC [0122 MYT] at waypoint IGARI.
Reference is made to Malaysia AIP ENR 6, En-route Charts - IGARI has been
designated as a compulsory reporting point, and MATS page 8-2-6, Part 8
Surveillance para 2.4.1 - Controllers may instruct a radar identified aircraft
to omit making compulsory position reports unless:
• the position report is required for control purposes.
237
========283========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
There was no instruction by the KL ACC Controller to MH370 to omit making
compulsory position report as stated in MATS.
KL ACC should have declared the Distress Phase16 at 1827 UTC [0227 MYT] and the
transmission of the DETRESFA17 message, as KL ACC was the ATS unit last in
contact with MH370 at 1719:30 UTC [0119:30 MYT] when MH370 acknowledged the
transfer of control by KL ACC at 1719:26 UTC [0119:26 MYT].
MH370 did not contact Ho Chi Minh ACC on radio frequency 120.9 MHz. and Ho Chi
Minh ACC was not able to establish two-way communication with MH370.
Reference
Manual of Air Traffic Services, Part 9 - Emergencies, page 9-6- 5, para. 6.7.2
dated 15/3/2009 No.1 states:
If alerting service is required for an aircraft that is flight planned to
operate through more than one FIR including the airspace delegate to the Kuala
Lumpur and Kota Kinabalu ATSCs and the position of the aircraft is in doubt, the
responsibility for co-ordinating such service shall normally rest with the ATSC
of the respective FIRs:
• within which the aircraft was flying at the time of last air-ground radio
contact;
• that the aircraft was about to enter when last air- ground contact was
established at or close to the boundary of two FIRs or control areas;
• within which the aircraft’s intermediate stop or final destination point is
located:
1) if the aircraft was not equipped with suitable two-
way radio communication, or
16
Distress Phase - A situation wherein there is a reasonable certainty that an
aircraft and its occupants are
threatened by grave and imminent danger and require immediate assistance.
17
DETRESFA - The code for a Distress Phase
238
========284========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
2) was not under obligations to transmit position
reports.
and
ICAO Doc 4444 ATM/501 Procedures for Air Navigation - Air Traffic Management
(PANS-ATM), page 9-6, para 9.2.2.2, dated 22/11/07 states:
When alerting services is required in respect of a flight operated through more
than one FIR or control area, and when the position of the aircraft is in doubt,
responsibility for coordinating such service shall rest with the ATS unit of the
FIR or control area:
a) within which the aircraft was flying at the time of last
air-ground radio contact;
b) that the aircraft was about to enter when last air-
ground contact was established at or close to the
boundary of two FIRs or control areas;
c) within which the aircraft’s intermediate stop or final
destination point is located:
1) if the aircraft was not equipped with suitable two-
way radio communication, or
2) was not under obligations to transmit position
reports.
The Team noted that MH370 was operating in the airspace delegated to KL ACC and
the last air-ground radio contact was with KL ACC. MH370 did not contact Ho Chi
Minh ACC and Ho Chi Minh ACC was unable to establish radio communication with
MH370.
Hence KL ACC shall be responsible for the provision of alerting service for
MH370.
At 2232 UTC [0632 MYT] KL ARCC transmitted the first DETRESFA message. A total
of 4 hours and 05 minutes had passed from the time the Distress Phase should
have been declared.
239
========285========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
d) As the ‘custodian’ of the airspace, the KL ACC transferred
MH370 to HCM ACC 3 minutes before the estimated time of
arrival over the Transfer of Control Point18 (TCP).
The estimate19 of the aircraft for IGARI which was 1722 UTC [0122 MYT] had been
passed to, by KL ACC, and duly acknowledged by HCM ACC, as stipulated in the
Operational Letter of Agreement between DCA Malaysia and Viet Nam Air Traffic
Management.
e) Page 11 of Appendix 1.1A - Establishment of Communication
in the Operational Letter of Agreement between DCA Malaysia
and Viet Nam Air Traffic Management stipulates that:
“The accepting unit shall notify the transferring unit if two- way communication
is not established within five (5) minutes of the estimated time over the TCP”.
At 1739:03 UTC [0139:03 MYT] HCM ACC queried KL ACC for news on MH370.
After MH370 was transferred to HCM ACC, the time of transfer was not recorded
manually on the paper Flight Progress Strip as stipulated in MATS Part 2-Gen
Section 11 FLIGHT PROGRESS STRIPS.
Manual of Air Traffic Services Part 9, Table 9-2.2 Overdue Action - Radio
Equipped Aircraft preliminary action stipulates that:
“When an aircraft fails to make a position report when it is expected, commence
actions not later than the ETA20 for the reporting point plus 3 minutes” and
a) The following actions shall be taken:
18
Transfer of Control Point - A defined point located along the flight path of an
aircraft, at which the responsibility
for providing air traffic control service to the aircraft is transferred from
one control unit or control position to
the next.
19
Estimate - The time at which it is estimated that an aircraft will be over a
position or over the destination.
20
ETA - Estimated time of Arrival.
240
========286========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
(1) request information from other ATS units and
likely aerodromes;
(2) notify the RCC that the Uncertainty Phase21
exists;
(3) ensure that RQS22 message is sent.
b) Full Overdue Action: not later than 30 minutes after the declaration of the
Uncertainty Phase:
i. notify the RCC that the Alert Phase23 exists.
ii. notify the RCC that Distress Phase exists if:
-1 hour has elapsed beyond the last ETA for the destination; or
- the fuel is considered exhausted; or
- 1 hour has elapsed since the declaration of the Uncertainty Phase.
MATS Part 9 para 6.2.3 stipulates that:
“If Controllers have reason to believe that an aircraft is
lost, overdue or experiencing communication failure,
they shall:
a) inform appropriate radar units (civil and military) of
the circumstances,
b) request the units to watch out for emergency SSR
code display or the triangular radio failure pattern,
and
c) notify these units when their services are no longer
required.”
21
Uncertainty phase - A situation wherein doubt exists as to the safety of an
aircraft or a marine vessel, and
the Persons on board.
22
RQS - Request Supplementary Flight Plan.
23
Alert phase - A situation wherein apprehension exists as to the safety of an
aircraft or marine vessel and of
the persons on board.
241
========287========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
At 1741:23 UTC [0141:23 MYT] KL ACC Sector (3 & 5) Controller made a call on the
radio frequency 132.5 MHz to MH370 but there was no response from the aircraft.
Event that followed was at the time of 1804:39 UTC [0204:39 MYT] when KL ACC
Radar Controller informed HCM ACC:
“…reference to the Company Malaysian Airlines the aircraft is still flying, is
over somewhere over Cambodia”.
Thirty-one minutes later, at 1835:52 UTC [0235:52 MYT] MAS Operations Centre
(MOC) informed the position of the aircraft was at latitude N14.9 0000 and
longitude E109 15500 which was somewhere east of Vietnam. This information was
relayed to HCM ACC. At 1930 UTC [0330 MYT] MOC called in and spoke to the Radar
Controller, “…admitting that the ‘flight tracker’24 is based on projection and
could not be relied for actual positioning or search.” (Watch Supervisor
Logbook’s entry).
6) Chronology of Activities after Notification by HCM ACC
The paragraphs (Table 1.18E [below]) describe the chronology of activities after
notification by HCM ACC leading to the initiation of the Search and Rescue
operations (SAR) and deployment of resources for the MH370 search.
Refer Radiotelephony Transcripts - Appendices 1.18A to 1.18G - Air-Ground
Communications.
24
MAS Operations Centre used the name ‘Flight Explorer’.
242
========288========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
a) Chronology of ATC Activities after Notification by HCM ACC
No. 1.
Time 1739:03 UTC [0139:03 MYT]
Activities
Ho Chi Minh ACC first enquired about MH370 and informed KL ACC that verbal
contact was not established with MH370 and the radar target was last seen at
BITOD.
2.
1741:22 UTC [0141:22 MYT]
Ho Chi Minh enquired for information on MH370 and KL ACC informed HCM ACC that
after waypoint IGARI, MH370 did not return to Lumpur Radar frequency.
3.
1741:23 UTC [0141:23 MYT]
KL ACC Radar Controller made a “blind transmission” to MH370.
4.
1746:47 UTC [0146:47 MYT]
HCM ACC queried about MH370 again, stating that radar contact was established
over IGARI but there was no verbal contact. HCM ACC advised that the observed
radar blip disappeared at waypoint BITOD. HCM ACC stated that efforts to
establish communication were made by calling MH370 many times for more than
twenty (20) minutes.
5.
1750:28 UTC [0150:28 MYT]
KL ACC queried HCM ACC if there had been any contact with MH370, HCM ACC’s reply
was “negative”.
6.
1757:49 UTC [0157:49 MYT]
HCM ACC informed KL ACC that there was officially no contact with MH370 until
this time. Attempts on many frequencies and through other aircraft in the
vicinity received no response from MH370.
7.
1803:48 UTC [0203:48 MYT]
KL ACC queried HCM ACC on the status of MH370, HCM ACC confirmed there was no
radar contact at this time and no verbal communication was established. KL ACC
relayed the information received from Malaysia Airlines Operations that the
aircraft was in the Cambodian airspace.
8.
1807:47 UTC [0207:47 MYT]
HCM ACC queried for confirmation that MH370 was in Phnom Penh FIR as Phnom Penh
did not have any information on MH370. KL ACC indicated it would check further
with the supervisor.
Table 1.18E – ATC Activities after Notification by HCM ACC
cont…
243
========289========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
a) Chronology of ATC Activities after Notification by HCM ACC
(cont…)
No. 9.
Time 1812:15 UTC [0212:15 MYT]
Activities
KL ACC informed HCM ACC that there was no update on the status of MH370.
10.
1815 UTC [0215 MYT]
(No voice recording).
Extracted from the Watch Supervisor Log Book:
KL ATSC Watch Supervisor queried Malaysia Airlines Operations who informed that
MH370 was able to exchange signals with the Flight Explorer.
11.
1818:50 UTC [0218:50 MYT]
KL ACC queried if the flight plan routing of MH370 was supposed to enter
Cambodian airspace. HCM ACC confirmed that the planned route was only through
the Vietnamese airspace. HCM ACC had checked and Cambodia had advised that it
had no information or contact with MH370. HCM ACC confirmed earlier information
that radar contact was lost after BITOD and radio contact was never established.
KL ACC queried if HCM ACC was taking Radio Failure action, but the query didn’t
seem to be understood by the personnel. HCM ACC suggested KL ACC to call
Malaysia Airlines Operations and was advised that it had already been done.
12.
1833:59 UTC [0233:59 MYT]
KL ACC Radar Controller enquired with Malaysia Airlines Operations Centre about
the communication status with MH370 but the personnel was unsure if the message
went through successfully or not. Malaysia Airlines Operations Centre informed
that the aircraft was still sending the movement message indicating it was
somewhere in Vietnam and giving the last position as coordinates N14.90000 E109
15500 at time of 1833 UTC [0233 MYT].
13.
1834:56 UTC [0234:56 MYT]
HCM ACC queried about the status of MH370 and was informed that the Watch
Supervisor was talking to the Company at this time.
Table 1.18E – ATC Activities after Notification by HCM ACC
cont…
244
========290========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
a) Chronology of ATC Activities after Notification by HCM ACC
(cont…)
No. 14.
Time 1837:34 UTC [0237:34 MYT]
Activities
KL ACC informed HCM ACC that MH370 was still flying and that the aircraft was
continuing to send position reports to the airline, and relayed to HCM ACC the
latitude and longitude as advised by Malaysian Airlines Operations.
15.
1853:48 UTC [0253:48 MYT]
MH386 which was enroute from KLIA to Shanghai and within HCM FIR was requested
by HCM ACC to try to establish contact with MH370 on Lumpur Radar radio
frequency. KL ACC then requested MH386 to try on emergency frequencies as well.
16.
1930 UTC [0330 MYT]
(No voice recording)
Extract from Watch Supervisor’s Log Book:
MAS Operations Centre informed KL ACC that the flight tracker information was
based on flight projection and was not reliable for aircraft positioning.
17.
1930:03 UTC [0330:03 MYT] 1948:52 UTC [0348:52 MYT]
KL ACC queried if HCM ACC had checked with next FIR Hainan.
18.
When KL ACC queried whether HCM ACC had checked with the Sanya FIR, HCM ACC
informed KL ACC that there was no response until now. At 1956:13 UTC [0356:13
MYT] KL ACC queried Malaysia Airlines Operations for any latest information or
contact with MH370.
19.
2025:22 UTC [0425:22 MYT]
HCM ACC Supervisor queried KL ACC on the last position that MH370 was in contact
with KL ACC.
20.
2118:32 UTC [0518:32 MYT]
When HCM ACC queried for information on MH370, KL ACC also queried if any
information had been received from Hong Kong or Beijing.
21.
2109:13 UTC [0509:13 MYT]
Singapore, on behalf of Hong Kong, enquired for information on MH370.
Table 1.18E – ATC Activities after Notification by HCM ACC
cont…
245
========291========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
a) Chronology of ATC Activities after Notification by HCM ACC
(cont…)
No. 22.
Time 2120:16 UTC [0520:16 MYT]
Activities
Capt. xxxx [name redacted] of MAS requested for information on MH370. He opined
that based on known information, “MH370 never left Malaysian airspace”.
23.
2130 UTC [0530 MYT]
Watch Supervisor activated the Kuala Lumpur Aeronautical Rescue Coordination
Centre (ARCC).
24.
2141:20 UTC [0541:20 MYT] 2214:13 UTC [0614:13 MYT] 2232 UTC [0632 MYT]
HCM ACC queried for any updates.
25.
KL ACC queried HCM ACC if SAR was activated.
26.
KL ARCC issued a DETRESFA message (Figure 1.18C [below]).
Table 1.18E – ATC Activities after Notification by HCM ACC
246
========292========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
b) DETRESFA Message of MH370
Source: DCA Malaysia
Figure 1.18C - DETRESFA Message
7) Activation of KL Aeronautical Rescue Coordination Centre
KL ARCC was activated at 2130 UTC [0530 MYT]. The DETRESFA message was
disseminated via the AFTN at 2232 UTC [0632 MYT], 01 hour and 02 minutes later.
No activity was recorded in the RCC Logbook between 2130 UTC [0530 MYT] and 2232
UTC [0632 MYT].
The Kuala Lumpur Aeronautical Rescue Co-ordination Centre, Standard Operating
Procedure for Search and Rescue, page 11, para 3.1 stipulated:
247
========293========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
“The search and Rescue Mission Co-ordinator (SMC) is the officer assigned to
co-ordinate response to an actual or apparent distress situation.
In aeronautical search and rescue operations, the SMC is usually in the best
position to assess the circumstances of a particular case, and to take whatever
steps necessary to promote the safety of life and prevent further loss of
property.
The SMC must use his/her best judgment in initiating and coordination operations
to ensure use of the most suitable method of planning with least possible delay.
Initial Actions
On receipt of information regarding aircraft in difficulties normally from the
Watch Supervisor in the ATCC, or from request of assistance from RSCs, MRCC
(vessel or person - maritime distress) or from any adjacent RCCs and is aware
that assistance is required the SMC shall act as follows:
•Activate the SAR operation room;
•Appraise the situation.
Continue to take the following actions if emergency situation involves civil
aviation accident:
•Declare the Distress phase if not done yet by the Duty Watch Supervisor;
•Notify the SAR Chief and the SAR Co-ordinator (SC);
•Request Supervisor to recall SAR trained staff if deemed necessary;
•Initiate ARCC activation message;
•Assign specific position accordingly (SMC, ASMC… etc.);
•Initiate NOTAM25 actions;
25
NOTAM (Notice to Airmen) - A notice issued by, or with the authority of the
State and containing information
or instruction concerning the establishment, condition change in any
aeronautical facility, service, procedure
or hazard, the timely knowledge of which is essential to persons concerned with
flight operations. NOTAM
is distributed by AFTN. (Aeronautical Fixed Telecommunication Network).
248
========294========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
•Initiate RQS26 request from AIS27 and weather report from Meteorological Office
if not done yet by the Supervisor;
•Obtain information of aircraft position if necessary by:
- Information contained in the flight plan or notification; - Check all airports
or possible alighting areas along the route of flight and within the possible
flight range of the aircraft concerned;
- Notify other aircraft or agencies to attempt establishment of the aircraft’s
position, informing them of all known frequencies, request for aircraft lookout
made through the ATCC Watch Supervisor);
- Notify the Police, along the route of flight, and request
them to verify alighting areas, or obtain information on
the aircraft and its occupants;
- Request MRCC28 to alert the vessels in the area if the flight is over or near
water;
- Ascertain the type of emergency equipment carried by the missing or distressed
craft;
- When required, request Radar assistance for search from appropriate radar
station or Radar Plot.
8) Recorded Telephone Conversations
From the recorded telephone conversations between the KL ACC Radar Controller
and MAS Operations Centre, the Radar Controller at 2123:18 UTC [0523:18 MYT]
indicated that he would inform the Watch Supervisor to check on when was the
last contact with MH370.
26
RQS - Request Supplementary Flight Plan.
27
AIS - Aeronautical Information Service.
28
MRCC - Maritime Rescue Coordination Centre.
249
========295========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
9) Watch Supervisor Air Traffic Services and Sector (3 & 5)
Logbook
MATS Part 1 - Admin, page 1-1-7 para 1.7 for recording of entries in the logbook
as follows:
a) The time of entries shall be based on UTC and events
recorded in a chronological order;
b) Entries shall give sufficient details to give readers a full
understanding of all actions taken;
c) The time an incident occurred and the time at which each
action was initiated shall be stated.
10) Flight Progress Strip
The FPS (Figure 1.18D below) of MH370 on 07 March 2014.contains essential flight
and control data and is the basic tool to enable Air Traffic Controllers to
visualise 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.
250
========296========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
1
Figure 1.18D - Flight Progress Strip of MH370 on 07 March 2014
251
========297========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
1.18.2 Aircraft Cargo Consignment
1) Introduction
During the course of the investigation the Team visited and interviewed the
relevant people in MAS at KLIA Sepang, Motorola Solutions Penang, MASkargo Sdn.
Bhd. (MASkargo) Penang, NNR Global Logistic (M) Sdn. Bhd. Penang, Poh Seng Kian,
Muar, Johore (supplier of mangosteen fruit), Freescale Semiconductor, Petaling
Jaya, JHJ International Transportation Co. Ltd. Beijing, China (forwarding agent
of Motorola Solutions China), Motorola Solutions China, TianJin, China and
Beijing GuangChangMing Trading Co. Ltd. Beijing, China.
On 08 March 2014, MAS B777-200ER MH370 was on a scheduled flight from KLIA to
Beijing, China. The aircraft was carrying 227 passengers with a tabulated
passenger weight of 17,015 kg, baggage 3,324 kg, cargo 10,806 kg (gross weight)
and Max Take- off Weight of 223,469 kg. All these are stipulated in the cargo
manifest attached as Appendix 1.18H.
The lists of cargo, Airway Bill, Local Agent and Final Destination, are
tabulated in Table 1.18F (below).
The cargo that had generated interest were:
• Lithium ion Batteries (Li-Ion) and Accessories - 2,453 kg; and • Mangosteens -
4,566 kg.
252
========298========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
No.
COMPANY (MALAYSIA)
.
1.
Grolier (M) SB Balakong Selangor
2.
Motorola Solutions (M) Bayan Lepas Penang
3.
Panasonic Industrial Devices Sales, Shah Alam, Selangor
4.
Freescale Semiconductor Petaling Jaya, Selangor
5.
Agilents Technologies Bayan Baru, Penang
6.
Poh Seng Kian Muar, Johore
7.
Malaysian Express Worldwide, Subang Jaya Selangor
AIRWAY BILL
232-2009141
AGENT
TRANSPORTER
(MALAYSIA) Kerry Logistics (M) Subang Jaya, Selangor
232-0677085
NNR Global Logistic Batu Maung Penang
walkie-talkie accessories
232-12022382
Panalpina Transport (M) MAS Cargo, KLIA,
232-12022404
Panalpina Transport (M) MAS Cargo, KLIA
232-10664905
Kintetsu World Express MAS Cargo
Penang
232-12007306
Poh Seng Kian Muar, Johore
232-11873632
Malaysian Express Worldwide,
Subang Jaya, Selangor
Table 1.18F - List of Cargo on Board MH370
ITEMS
WEIGHT (nett)
Scholastic assorted books
2,250 kg
Lithium Ion batteries-
2,453 kg
& chargers
Electrical parts capacitors
26 kg
Vehicle electronic chips
6 kg
Electronic measurements
646 kg
Fresh mangosteens
4,566 kg
Courier materials - documents
6 kg
253
========299========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
2) Lithium Ion Batteries
Li-Ion Batteries carried on MH370 were from Motorola Solution Penang. Of the
total consignment of 2,453 kg, only 221 kg were Li- ion batteries, the rest were
chargers and radio accessories.
The batteries were fabricated in the factory before being packed for export.
Figure 1.18E (below) shows a raw single cell battery.
Figure 1.18E - Raw Single Cell Battery
254
========300========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
The step-by-step process of fabricating 2 single cell batteries together to form
a battery pack for shipment is shown in Figure 1.18F (below).
1
2
3
4
5
6
7
8
Figure 1.18F - Step-by-step Process of Fabricating 2 Single Cell Batteries
to form a Battery Pack for Shipment
255
========301========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
The Li-Ion batteries from Motorola Solutions Penang were assembled on 07 March
2014 before being packed, the built-up consigments placed on wooden pallets and
delivered by the forwarding agent (NNR Global Logistic (M) Sdn. Bhd.) to
MASkargo Penang and subsequently transported by MASkargo truck ‘MH6803’ to MAS
Cargo Complex, KLIA, Sepang. The shipment did not go through security screening
in Penang but was inspected physically by MASkargo personnel and went through
Customs’ inspection and clearance before the truck was sealed and allowed to
leave the Penang Cargo Complex.
The shipment arrived at KLIA Cargo Complex on the evening of 07 March 2014
before being loaded onto MH370 without going through additional security
screening.
The Motorola Solutions consignments were loaded in the Aircraft at 90348C (47R)
and PMC5871 (23L, 23R) as per Loading Instruction/Report. Illustration as shown
in Figure 1.18G (below).
There were two (2) different models of Li-Ion battery consignment on MH370 on 08
March 2014:
• PMNN4073AR Li-ion batteries rated at 7.4V, 11.8Wh; and • PMNN4081BRC Li-ion
batteries rated at 7.4V, 11.1Wh.
Both of the batteries were not regulated as Dangerous Goods because the packing
had adhered to the guidelines as per Lithium Battery Guidance Document (3.
Section II - Packing Instructions 965-970). This document is based on the
provisions set out in the 2013-2014 Edition of the ICAO Technical Instructions
for Safe Transport of Dangerous Goods by Air and the 55th Edition of the IATA
Dangerous Goods Regulations (DGR). The ICAO and IATA documents are as per
Appendix 1.18I.
256
========302========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Figure 1.18G - Motorola Solutions Consignment Loading
257
========303========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
The packing of the batteries by Motorola Solutions is shown in Figure 1.18H
(below).
Picture 1
Picture 2
Picture 3
Picture 4
Picture 5
Picture 6
Figure 1.18H - Packing of Batteries by Motorola Solutions
Each Li-Ion battery was placed in a white window box (Picture 1 [above]) and two
of these filled boxes were then placed in a brown box (Picture 2 [above])
printed with Li-Ion battery warning shipping information (Picture 3 [above]).
The brown box filled with two Li-Ion batteries each was then packed into a
larger box. Each box contained twenty-four Li-ion batteries (12 boxes x 2 = 24,
Picture 4, Figure 1.18H [above]), sealed and weighed (Picture 5, Figure 1.18H
[above]). All the sealed boxes were placed on a wooden pallet and the built-up
consignment was wrapped with plastic and polystyrene sheets for protection
(Picture 6, Figure 1.18H [above]). They were then scanned, with the number of
batteries determined by means of weighing the boxes.
From January 2014 to May 2014 there were ninety-nine shipments of Li-ion
Batteries on MAS flights to Beijing.
Refer Appendix 1.18J - List of Airways Bills.
258
========304========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
3) Mangosteen Fruits
The mangosteens on board MH370 on 08 March 2014 originated from Poh Seng Kian of
No.79, 6¼ mile Kesang, 84000 Muar, Johore, Malaysia. About 2,500 kg of the fruit
were harvested from Muar and the rest from Sumatra, Indonesia. Photographs of
the mangosteen orchard and a typical mangosteen plant are shown as Figures 1.18I
and 1.18J (below) respectively.
Figure 1.18I - Mangosteen Orchard in Muar, Figure 1.18J - Mangosteen Plant/Fruit
Johor, Malaysia
The mangosteens were packed in plastic baskets of between 8 to 9 kg per basket
with a piece of sponge soaked with water placed on top of the mangosteens to
maintain their freshness (Figures 1.18K and 1.18L [below]). The packed
mangosteens were then loaded on the trucks which proceeded to MASkargo Complex
at KLIA, Sepang. At the complex, four ULD containers were provided by MASKargo
staff to the forwarding agent. The forwarding agent then loaded the packed fruit
into the ULD containers (Figure 1.18M [below]). The consignment was then
inspected by the Federal Agriculture Marketing Authority (FAMA) of Malaysia.
After obtaining the clearance, the forwarding agent handed over the consignments
to the MAS loaders for loading into the aircraft.
259
========305========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Figure 1.18K - Plastic Baskets of Mangosteens
Figure 1.18L - Piece of Soaked Sponge placed on Top of Mangosteens
260
========306========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
1. MASkargo Perishable 2.Unloading crates of
Warehouse mangosteens from plantation
3. Crates of mangosteens ready for loading into ULD
4. Placing large plastic
sheet in ULD before
loading
5. Loading crates of 6. Filling up crates into ULD
mangosteens into ULD .
7. Secured crates of mangosteens with plastic sheets before latching ULD cover.
8. Another piece of plastic
sheet to cover ULD
9.ULD secured with labels for uploading
into aircraft
Figure 1.18M - Processing of Packed Crates of Mangosteens into ULD before
Uploaded to Aircraft
261
========307========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Flight MH370 on 08 March 2014 carried four ULD containers of mangosteens - ULD
AKE3497MH weighing 1,128 kg was placed at cargo bay 41L, ULD AKE90787MH weighing
1,152 kg at cargo bay 41F, ULD AKE3372MH weighing 1,148 kg at cargo bay 43L and
ULD AKE8535MH weighing 1,138 kg at cargo bay 44L. The loading arrangement is
shown in Figure 1.18N (below). Loading Instruction/Report is shown in the MH370
cargo manifest (Appendix 1.18H).
1 2
3
Nose of Aircraft
4
No. 1
ULD AKE3497MH
WEIGHT (KG)
1,128
POSITION
41F
2
AKE90787MH
1,152
41L
3
AKE3372MH
1,148
43L
4
AKE8535MH
1,138
44L
Figure 1.18N - Loading Arrangement of ULDs of Mangosteens
From January 2014 till May 2014 there were a total of eighty-five shipments of
mangosteens to Beijing, China. The list of Airway Bills is shown in Appendix
1.18J. The combination of the two cargo shipments (Li-ion Batteries and
mangosteens) carried together from January to May 2014 were thirty-six times
(highlighted in red in Appendix 1.18J).
262
========308========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
1.18.3 Crew and Passengers on Board MH370
1) Total Number of Crew and Passengers
Total number crew and passengers on board MH370 are shown in Table 1.18G
(below).
Crew
Flight Cabin
Passengers Total
2 10 227 239
Table 1.18G - Total Number of Crew and Passengers
2) Nationalities of the Crew and Passengers
The nationalities of the flight crew and passengers on board MH370 are shown in
Table 1.18H (below).
Countries Crew Passengers Total
Flight Cabin
1. China - - 153 153 2. Malaysia 2 10 38 50 3. Indonesia - - 7 7 4. Australia -
- 6 6 5. India - - 5 5 6. France - - 4 4 7. United States - - 3 3
of America
8. Ukraine - - 2 2 9. Canada - - 2 2 10. New Zealand - - 2 2 11. Netherland - -
1 1 12. Russia - - 1 1 13. Chinese Taipei - - 1 1 14.
Italy* (Iran)
- - 1 1 15.
Austria* (Iran)
- - 1 1
Total 2 10 227 239
Table 1.18H - Breakdown of Nationalities of Passengers
- Travelling on stolen passports and discovered to be Iranian
citizen (Figures 1.18V & W [below] on Passengers’ Seating
Positions).
263
========309========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
a) Crew
All the 12 crew (including the two pilots) were Malaysians.
b) Passengers
A total of 227 passengers (including 3 children and 2 infants) were on board
with the majority of them from China, followed by Malaysia and other citizens
from different countries.
c) Passengers’ Seating Positions
The aircraft was compartmentalised into 2 categories of seating, namely the
business class with a total of 35 seats and the economy class with a total of
249 seats. Passengers from the 14 countries were seated throughout the aircraft
from Row 1 to Row 41. (Figure 1.18O [below]).
A total of 10 passengers were seated in the Business Class in the front portion
of the aircraft, from Row 1 to Row 4. (Figure 1.18P [below]).
In the middle portion of the aircraft, the Economy seating started from Row 11
to Row 27. A total of 127 passengers were seated in this middle portion of the
aircraft. There were 2 children on seats 17F and 18F respectively (Figures
1.18Q, 1.18R, 1.18S and 1.18T [below]).
The rear portion of the aircraft accommodated 90 passengers from Row 29 to Row
41. 2 infants were on board accompanied by adults seated on seats 30E and 37D
respectively. There was a child on seat 30H in the rear portion of the aircraft.
(Figures 1.18U, 1.18V and 1.18W [below]).
264
========310========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18O - Passengers’ Seating Positions
265
========311========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18P - Passengers’ Seating Positions (Business Class)
266
========312========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18Q - Passengers’ Seating Positions (Economy Class - Seats 11, 12, 14 &
15)
267
========313========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18R - Passengers’ Seating Positions (Economy Class - Seats 16, 17, 18 &
19)
268
========314========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18S - Passengers’ Seating Positions (Economy Class - Seats 20, 21, 22 &
23)
269
========315========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18T - Passengers’ Seating Positions (Economy Class - Seats 24, 25, 26 &
27)
270
========316========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18U - Passengers’ Seating Positions (Economy Class - Seats 29, 30, 31 &
32)
271
========317========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18V - Passengers’ Seating Positions (Economy Class - Seats 33, 34, 35 &
36)
272
========318========
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
Source: Royal Malaysia Police
Figure 1.18W - Passengers’ Seating Positions (Economy Class - Seats 37, 38, 39,
40 & 41)
273