Malaysia B772 over Gulf of Thailand on Mar 8th 2014, aircraft missing, data indicate flight MH-370 ended west of Australia, first MH-370 debris identified, search ended

Last Update: July 30, 2018 / 08:07:03 GMT/Zulu time

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Incident Facts

Date of incident
Mar 8, 2014

Classification
Crash

Aircraft Registration
9M-MRO

Aircraft Type
Boeing 777-200

ICAO Type Designator
B772

On Jul 30th 2018 Malaysia's Investigation Commission by Malaysia's Transport Ministry released their Safety Investigation Report concluding:

On 08 March 2014, MH370, a scheduled passenger flight from Kuala Lumpur to Beijing, operated by MAS went missing soon after a routine handover from the Malaysian ATC to Viet Nam ATC. Communications with the aircraft were lost after it passed waypoint IGARI, less than 40 minutes after take-off. The aircraft operating the flight was a Boeing 777-200ER, registered 9M-MRO. On board the aircraft were 12 crew and 227 passengers (239 persons in total).

Evidence shows that Flight MH370 diverted from the Filed Flight Plan route. The aircraft’s transponder signal ceased for reasons that could not be established and was then no longer visible on the ATC radar display. The changes in the aircraft flight path after the aircraft passed waypoint IGARI were captured by both civilian and military radars. These changes, evidently seen as turning slightly to the right first and then to the left and flying across the Peninsular Malaysia, followed by a right turn south of Penang Island to the north-west and a subsequent (unrecorded) turn towards the Southern Indian Ocean, are difficult to attribute to anomalous system issues alone. It could not be established whether the aircraft was flown by anyone other than the pilots. Later flight simulator trials established that the turn back was likely made while the aircraft was under manual control and not the autopilot.

KL ATSC operation was normal with no significant observation until the handover to Viet Nam ATC. Being the accepting unit, HCM ACC did not notify the transferring unit (KL ATSC) when two-way communication was not established with MH370 within five minutes of the estimated time of the transfer of control point (Establishment of Communications, page 11 of Operational LOA between DCA Malaysia and Vietnam Air Traffic Management effective 1 November 2001). Likewise, KL ATSC should have taken action to contact HCM ACC, instead, relied on position information of the aircraft provided by MAS Flight Operations. By this time, the aircraft had left the range of radars visible to the KL ATSC. It is noted that about one minute elapsed from the last transmission from MH370 and the SSR being lost from the radar display. The Air Traffic Controllers of both Centres did not initiate the various emergency phases as required then, thereby delaying the activation of the alerting and Search and Rescue operations.

The PIC and FO held valid airman licences and medical certification. There is no evidence to suggest that the PIC and FO experienced recent changes or difficulties in personal relationships or that there were any conflicts or problems between them. All the flight and cabin crew were certified fit to fly and were within duty-time limits at the time of the flight and were adequately rested. There had been no financial stress or impending insolvency, recent or additional insurance coverage purchased or recent behavioural changes for the crew. The radio-telephony communications conducted by the PIC and the FO with the Air Traffic Controllers conformed to the routine procedure and no evidence of anxiety or stress was detected in the communications.

The aircraft maintenance records indicated that the aircraft was equipped and maintained in accordance with existing regulations and approved procedures, except for the instance of the SSFDR ULB battery which had expired. The aircraft had a valid Certificate of Airworthiness and was airworthy when released for the flight and there was no record or report of any defect or malfunction in the aircraft that could have contributed to the event. Although it cannot be conclusively ruled out that an aircraft or system malfunction was a cause, based on the limited evidence available, it is more likely that the loss of communications (VHF and HF communications, ACARS, SATCOM and Transponder) prior to the diversion is due to the systems being manually turned off or power interrupted to them or additionally in the case of VHF and HF, not used, whether with intent or otherwise. No ELT signal from the aircraft was reported by the Search and Rescue agencies or any other aircraft. The SATCOM data indicated that the aircraft was airborne for more than 7 hours suggesting that the autopilot was probably functioning, at least in the basic modes, for the aircraft to be flown for such a long duration. This in turn suggests that the air and inertial data were probably available to the autopilot system and/or the crew. The inter-dependency of operation of the various aircraft systems suggests that significant parts of the aircraft electrical power system were likely to be functioning throughout the flight. The analysis of the relevant aircraft systems taking into account the route followed by the aircraft and the height at which it flew, constrained by its performance and range capability, does not suggest a mechanical problem with the aircraft’s airframe, control systems, fuel or engines.

Except for the first report, the ACARS reports normally sent every 30 minutes by the SATCOM system were not received. Data from the last seven SATCOM ‘handshakes’ were used to help establish the approximate path of the aircraft over the Indian Ocean. The initial log-on request and the hourly pings have been termed as ‘handshakes'. SATCOM transmissions indicated that a link was available from 1825 UTC on 07 March 2014 to 0011 UTC on 08 March 2014 although not used for any voice, ACARS or other data services apart from two unanswered ground-to-air telephone calls. Two log-ons, at 1825 UTC (07 March 2014) and 0019 UTC (08 March 2014), were initiated by the aircraft most likely due to power interruptions to the SATCOM avionics. The power interruption leading up to 1825 UTC was probably due to power bus cycling, the reason for it being unknown. The power interruption leading up to 0019 UTC was probably due to low fuel at this time resulting in the loss of both engines and their respective generators. There was probably enough fuel for the APU to start up and run long enough for its generator to power the SATCOM avionics to initiate a log-on request.

To date, the main wreckage of MH370 has still not been found despite a 4-year search in the South Indian Ocean. However, items of debris possibly from MH370, have been found as far north as the eastern coast of Tanzania and far south as the eastern coast of South Africa. This is in addition to several islands and island nations off the east coast of the African continent. Of these, the flaperon, a part of the right outboard flap and a section of the left outboard flap were confirmed to be from MH370. A few other pieces of debris were determined to be almost certain from MH370 which included some cabin interior items. Damage examination on the recovered part of the right outboard flap, together with the damage found on the right flaperon has led to the conclusion that the right outboard flap was most likely in the retracted position and the right flaperon was probably at, or close to, the neutral position at the time they separated from the wing. Recovery of the cabin interior debris suggests that the aircraft was likely to have broken up. However, there is insufficient information to determine if the aircraft broke up in the air or during impact with the ocean. Apart from the above, no other information about in-flight emergencies, aircraft configuration or impact could be inferred from the nature and damage of the debris.

MH370 did not carry any cargo classified as dangerous goods. Two cargo items of interest (the Lithium ion Batteries and Mangosteens) which were carried on MH370 had also been transported via scheduled flights on MAS before and after the event. These items were packed and loaded according to standard operating procedures.

As a result of the identified issues, the investigation has issued safety recommendations to enhance the safety of the aviation system. The recommendations made address the Malaysian and foreign air traffic surveillance systems, cargo scanning, flight crew medical and training records, reporting and following-up of crew mental health, flight-following system, development of a Quick Reference for Operations Control and ELT effectiveness.

It should be recognised that there is a significant lack of evidence available to the Team to determine with any certainty the reasons that the aircraft diverted from its filed flight plan route. However, the change in flight path likely resulted from manual inputs. The lack of evidence includes the exact location and disposition of the main aircraft wreckage and the evidence that it could provide, the information recorded on the Flight Data Recorder, Cockpit Voice Recorder and other recording devices on the aircraft and the absence of any aircraft voice or data transmissions that could indicate why the aircraft flew to the Southern Indian Ocean.

Without the benefit of the examination of the aircraft wreckage and recorded flight data information, the investigation was unable to identify any plausible aircraft or systems failure mode that would lead to the observed systems deactivation, diversion from the filed flight plan route and the subsequent flight path taken by the aircraft. However, the same lack of evidence precluded the investigation from definitely eliminating that possibility. The possibility of intervention by a third party cannot be excluded either.

The disappearance of MH370 and the search effort are unprecedented in commercial aviation history. Improvements must be undertaken to ensure that this type of event is identified as soon as possible, and mechanisms are in place to track an aircraft that is not following its filed flight plan for any reason.

In recent years, several States have expended significant amounts of funds and resources searching for missing commercial aircraft in remote oceanic locations, including AF447 and MH370. In this technological epoch, the international aviation community needs to provide assurance to the travelling public that the location of current-generation commercial aircraft is always known. It is unacceptable to do otherwise.

In conclusion, the Team is unable to determine the real cause for the disappearance of MH370.

While the report does not contain anything significantly new, there are several points worth re-iterating (being the foundation of a lot of speculation):

The captain owned a home made simulator (editorial note: it is not mentioned in the report, although it would be highly relevant, that the captain was part of the beta testing group for an add-on provider engaged in representation of Boeing 777-200 systems and instrumentation and as such tested in particular the FMS to its limits). Malaysian police examined the simulator and the PC. Of the 2700 waypoints found on the simulator 7 were identified to have been manually entered. The investigation writes:

The Royal Malaysia Police (RMP) seized the PIC’s home flight simulator from the residence of the PIC on 15 March 2014.

The RMP Forensic Report dated 19 May 2014 documented more than 2,700 coordinates retrieved from separate file fragments and most of them are default game coordinates.

It was also discovered that there were seven ‘manually programmed’ waypoint coordinates (Figure 1.5A [below), that when connected together, will create a flight path from KLIA to an area south of the Indian Ocean through the Andaman Sea. These coordinates were stored in the Volume Shadow Information (VSI) file dated 03 February 2014. The function of this file was to save information when a computer is left idle for more than 15 minutes. Hence, the RMP Forensic Report could not determine if the waypoints came from one or more files.

The RMP Forensic Report on the simulator also did not find any data that showed the aircraft was performing climb, attitude or heading manoeuvres, nor did they find any data that showed a similar route flown by MH370.

The RMP Forensic Report concluded that there were no unusual activities other than game-related flight simulations.

The investigation commission also reported that both captain and first officer were observed by CCTV surveillance cameras at Kuala Lumpur Airport and wrote:

The CCTV recordings at KLIA on 07 March 2014 were evaluated to assess the behavioural pattern of the PIC, and the FO from the time of arrival at KLIA until boarding time.

Three previous CCTV recordings of the movements of the PIC in KLIA were also viewed to see the behavioural pattern and were compared with the CCTV recordings on 07 March 2014.

The PIC’s movement was captured on CCTV at KLIA on the following days:

- 07 March 2014 - To Beijing
- 03 March 2014 - To Denpasar
- 26 February 2014 - To Melbourne
- 21 February 2014 - To Beijing

On studying the PIC’s behavioural pattern on the CCTV recordings on the day of the flight and prior 3 flights there were no significant behavioural changes observed. On all the CCTV recordings the appearance was similar, i.e. well-groomed and attired. The gait, posture, facial expressions and mannerism were his normal characteristics.

The FO’s movement captured on CCTV at KLIA on 07 March 2014 was observed. The FO’s behavioural pattern on CCTV recordings on the day of the flight showed no significant behavioural changes.

The investigation commission further reported that the first officer's mobile phone was detected by an antenna at Bandar Baru Farlim Penang (Malaysia, Pulau Pinang Island). The commission wrote:

A Telco service provider in an interview with the RMP confirmed a signal “hit” occurred at 0152:27 MYT on 08 March 2014, coming from the mobile phone tower (LBS Location Base station) at Bandar Baru Farlim Penang. The signal “hit” however did not record any communication except to confirm that it was in the ON mode signal related to the “hit”. The phone number xxxxxxx was later traced to that registered under the FO. This was supported by the RMP’s report.

To ascertain the probability of making calls inside an aircraft from different altitudes, a reconstructed flight using a King Air 350 over the said area and during the same time when the signal “hit” happened was carried out shortly after the disappearance of MH370. The flight was conducted from an altitude of 24,000 ft with step descents every 4,000 ft until 8,000 ft. The next descent was to 5,000 ft but at 1,000 ft interval. An expert from a Telco service provider conducted the test using three different brands of phone and related equipment that were carried on board the King Air 350. Test call will be automatically answered by the server in the event of connectivity.

In summary, during the tests, it was found that it was difficult to maintain successful call connectivity above 8,000 ft. However, one brand of phone was able to make a call at 20,000 ft. Only one cell phone service provider recorded the highest call attempts using their 3G network above 8,000 ft. Two service providers could only provide connection below 8,000 ft.

The Telco service provider expert cautioned the Team that the tests would be difficult to conclude and use as scientific/theoretical assumptions for the case of MH370, as the measurement results were only valid for that specific time, flight path, speed, altitude, devices used, and environment during the tests.

The investigation analysed:

From the foregoing discussion it can be generally deduced that there is no evidence to suggest that a malfunction had caused the aircraft to divert from its filed flight plan route. The aircraft’s maintenance history and events prior to the last flight do not show any issues that could have contributed and resulted in the deviation and subsequent changes in the flight path. Although it cannot be conclusively ruled out that an aircraft or system malfunction was a cause, based on the limited evidence available, it is more likely that the loss of communication (VHF and HF communications, ACARS, SATCOM and Transponder) prior to the diversion is due to the systems being manually turned off or power interrupted to them or additionally in the case of VHF and HF, not used, whether with intent or otherwise.

Similarly, the recorded changes in the aircraft flight path following waypoint IGARI, heading back across peninsular Malaysia, turning south of Penang to the north-west and a subsequent turn towards the Southern Indian Ocean are difficult to attribute to any specific aircraft system failures. It is more likely that such manoeuvres are due to the systems being manipulated.

The analysis of the relevant aircraft systems taking into account the route followed by the aircraft and the height at which it flew, constrained by its performance and range capability, does not suggest a mechanical problem with the aircraft.
Incident Facts

Date of incident
Mar 8, 2014

Classification
Crash

Aircraft Registration
9M-MRO

Aircraft Type
Boeing 777-200

ICAO Type Designator
B772

This article is published under license from Avherald.com. © of text by Avherald.com.
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