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B772 en-route suspected location southern Indian Ocean, 2014

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Summary
On 8 March 2014, contact was lost with a Malaysian Airlines Boeing 777-200ER operating a scheduled night passenger flight from Kuala Lumpur to Beijing as MH370. The available evidence indicates that it crashed somewhere in the South Indian Ocean but a carefully- targeted underwater search coordinated by the Australian Transport Safety Bureau has failed to locate the aircraft wreckage and the Investigation process is now effectively stalled. A comprehensive Investigation Report has been published and Safety Recommendations informed by the work of the Investigation have been made but it has not been possible to establish what happened and why.
Event Details
When March 2014
Actual or Potential
Event Type
Air-Ground Communication, Loss of Control
Day/Night Night
Flight Conditions Not Recorded
Flight Details
Aircraft BOEING 777-200 / 777-200ER
Operator Malaysian Airlines
Domicile Malaysia
Type of Flight Public Transport (Passenger)
Origin Kuala Lumpur International Airport
Intended Destination Beijing Capital International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Cruise
ENR
Location En-Route
Origin Kuala Lumpur International Airport
Destination Beijing Capital International Airport
General
Tag(s) Flight Crew Training,
Root Cause Not Determined,
Copilot less than 500 hours on Type
AGC
Tag(s) Loss of Comms
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Fatalities Most or all occupants (239)
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness,
Air Traffic Management,
Airport Management
Investigation Type
Type Independent

Description

On the evening of 7 March 2014, contact was lost with a Boeing 777-200ER (9M-MRO) being operated by Malaysian Airlines on a scheduled night passenger flight from Kuala Lumpur to Beijing as MH370 after it deviated from its flight-planned route for no known reason. It is subsequently believed to have crashed in international waters somewhere in the South Indian Ocean. An extensive underwater search for wreckage overseen by the Australian Transport Safety Bureau was unsuccessful, although some debris was recovered consistent with having drifted towards the African continent for nearly two years from the area in which impact is thought to have occurred before being washed ashore. The Malaysian-led Investigation has been unable to establish why the aircraft failed to complete its intended flight. There were 239 people, including 12 crew members, on board the aircraft.

Investigation

An Investigation led by the Malaysian Air Accident Investigation Bureau according to ICAO Annex 13 principles was opened and has conducted a comprehensive investigation of all aspects of the flight. Considerable assistance has been rendered to the Investigation Team by some of the Accredited Representatives of other States and their advisers. These Representatives were from:

Progress with the Investigation was published in a Preliminary Report on 9 April 2014, a Factual Information Report on 8 March 2015 and in Interim Statements published on 8 March 2015, 8 March 2016, 8 March 2017 and 8 March 2018. Note that the Preliminary Report uses a mixture of UTC and Malaysian Local time (MYT) without necessarily identifying which is being used correctly, which affects whether the associated calendar date for the flight is 8 March or 9 March.

The 53 year-old Training Captain in command of the flight was supervising a 27 year-old First Officer undergoing route training as the final stage of type conversion, with his Final Line Check scheduled for his next flight. It was established that the Captain had decided that the First Officer would act as PF for the flight to Beijing. Both pilots were Malaysian nationals who had begun flying as cadet pilots with the airline and remained with it thereafter. The Captain had a total of 18,423 flying hours of which 8,659 hours were on type. He had gained his first command on the Fokker 50 in 1990 and after flying the Boeing 737-400 and the Airbus A330 had joined the Boeing 777 fleet in 1998 and been appointed as a Training Captain in 2007. The First Officer had a total of 2,813 flying hours of which 39 hours were on type.

The flight to Beijing was expected to take around 5½ hours and the fuel loaded prior to departure resulted in a fuel endurance of around 7½ hours which was a normal margin. The initial progress of the aircraft up to the point where it turned onto and thereafter maintained a southerly track was established from recorded ATC data including primary and secondary radar. The aircraft climbed on its flight planned route track after departure and the crew reported having reached the initial cruise level of FL350 some 20 minutes after takeoff. Just under 20 minutes after this, as the aircraft approached the ACC boundary with Vietnamese airspace at waypoint IGARI, it was instructed by Kuala Lumpur ATCC to change to Ho Chi Minh ATCC. The acknowledgment of this instruction was the last R/T call received from the aircraft which did not then check in on the Vietnamese frequency. Almost immediately after this last transmission from the aircraft, the secondary radar signal from the aircraft ceased and primary radar returns showed that it had turned about 150° to the left and taken up a constant track back towards and then across peninsula Malaysia - see the illustration below.

The known ground track of the aircraft for the first 100 minutes of its flight. [Reproduced from the Official Report]

As it approached the peninsula, it was picked up and tracked continuously on military radar and also picked up intermittently on civil radar. It arrived just south of Penang and turned about 45° to the right and to begin tracking approximately west northwest on RNAV route N571. This kept it clear of Indonesian airspace and after 200 nm, the primary radar return was lost over the Andaman Sea north of the Indonesian island of Sumatra one hour after it had ceased contact and begun deviating from its flight plan route.

It was found subsequently that whilst the aircraft was in the vicinity of Penang, a mobile phone communications mast there had picked up a signal ‘hit’ from the First Officer’s mobile phone but this did not record any communication except to confirm that the phone was switched on at that time. Attempts to establish whether this could have allowed the determination of the aircraft’s maximum attitude were inconclusive.

Subsequently, some complex analysis of a series of signals automatically transmitted by the aircraft’s satellite communications terminal to Inmarsat’s Indian Ocean Region satellite indicated that soon after being lost to radar, the aircraft had turned onto and maintained a southerly track. Based on these signals and the known fuel endurance, it was concluded that the flight had ended over the southern part of the Indian Ocean some time after the aircraft had been airborne for 7 hours 38 minutes.

Whilst the aircraft was eventually determined to be missing, this reconstruction of the aircraft’s track was not immediately available and the initial search and rescue effort was directed towards the South China Sea on the assumption that the aircraft had been following its flight track. There was particular concern also that ATC had not raised the alarm more quickly when contact was lost. Despite an unprecedented sea surface and then subsea search effort coordinated by the Australian Transport Safety Bureau (ATSB), and reported separately in the 2017 ATSB Report ‘The Operational Search for MH370’, no trace of the wreckage of the aircraft has been found. Subsequently, however, several pieces of debris identified as from the missing aircraft have been washed ashore along the east African coast and islands to the east of it, which oceanographers confirmed based on the surface water circulation characteristics of the Indian Ocean were likely to have been transported from the area where the sea search for wreckage had been focussed. In the first half of 2018, by agreement the Malaysian Government and a specialist US Company, a further 90 day subsea search utilising the most advance underwater search technology currently available was carried out in an area that was considered, in the light of the lack of success in other areas, the most likely location for the wreckage. This search ended on 29 May 2018 without success.

The Investigation determined that based on the available evidence, eight factors justified its primary focus. These were:

  • The deviation from the Flight Plan Route.
  • Aspects of Air Traffic Services Operations.
  • The profile of the Flight Crew.
  • Airworthiness & Maintenance and Aircraft Systems.
  • Satellite Communications.
  • Available Wreckage and Impact Information.
  • The relevant organisation and management of the Malaysian Department of Civil Aviation (DCA) and of the aircraft operator, Malaysian Airlines (MAS).
  • The Aircraft Cargo items on board.

A number of other factors were examined by the Investigation and it was concluded that they were not relevant. These included:

Findings and Conclusion

The evidence indicated that the aircraft remained airborne for more than 7 hours. This was considered to be indicative of the autopilot probably continuing to function, at least in its basic modes. This in turn made it likely 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 made it also likely that significant parts of the aircraft electrical power system continued to function throughout the flight. It was also considered, after analysis of the relevant aircraft systems and taking into account the route followed by the aircraft and the height at which it flew constrained by its performance and range capability, that it was unlikely that there was any mechanical problem with the aircraft airframe, control systems, fuel or engines.

The failure to locate the aircraft and recover its flight recorders means that it was impossible at this time to determine with any certainty the reasons that the aircraft diverted from its flight planned route. However, it is considered that the change in flight track “likely resulted from manual inputs”. It has not been possible 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 lack of sufficient evidence also precluded the elimination of this possibility and “the possibility of intervention by a third party” cannot be excluded either.

It is considered that the disappearance of the aircraft and the search effort made to find it have been “unprecedented in commercial aviation history” and that action is needed 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”. It is further considered that “the international aviation community needs to provide assurance to the travelling public that the location of current-generation commercial aircraft is always known”. Finally, “in conclusion, the Investigation Team is unable to determine the real cause for the disappearance of MH370”.

A series of Safety Recommendations have been made as a direct result of issues highlighted by the Investigation. The Preliminary Report of the Investigation included one Recommendation as follows:

A further 19 Recommendations were made in the July 2018 Report as follows:

  • that the Malaysian Department of Civil Aviation (DCA) review the existing coordination procedures/establish new procedures between Kuala Lumpur Air Traffic Service Centre (KL ATSC) and the Joint Air Traffic Control Centre (JATCC) with regard to an unidentified primary target observed by the Radar Controller. [SR#01]
  • that the Malaysian Department of Civil Aviation (DCA) review the present Duty Roster System for KL ATSC with the objective of improving the working conditions. [SR#02]
  • that the Malaysian Department of Civil Aviation (DCA) develop a comprehensive Quick Reference on ATC actions relating to aircraft emergency to be available at all Controller working positions. [SR#03]
  • that the Malaysian Department of Civil Aviation (DCA) Air Traffic Controllers are to be provided refresher training to ensure established procedures are always complied with. [SR#04]
  • that the Malaysian Department of Civil Aviation (DCA) review and enhance the training syllabi of the courses for Lead-in and On-the-job training to include ATC actions during aircraft emergencies for ATS personnel at KL ATSC. [SR#05]
  • that the Malaysian Department of Civil Aviation (DCA) review and introduce more stringent security measures for cargo scanning at Penang International Airport/all airports and the point of entry into airside at KLIA/all airports. [SR#06]
  • that the Malaysian Department of Civil Aviation (DCA) review the privileging process of the appointment of the designated aviation medical examiners on a regular basis. [SR#07]
  • that the Civil Aviation Authority of Viet Nam observe the provisions of the Operational Letter of Agreement between Civil Aviation Authorities of adjacent Flight Information Regions. [SR#08]
  • that the Civil Aviation Authority of Viet Nam observe the requirement of Language Proficiency as outlined in the following documents:
    • ICAO Annex 1 Personnel Licensing Chapter 1 paragraph 1.2.9.2 Language Proficiency;
    • ICAO Doc 9835 AN/53 Manual on the Implementation of ICAO Language Proficiency Requirements Chapter 6 – Language Testing Criteria for Global Harmonisation. [SR#09]
  • that Malaysian Airlines ensure that flight crew report to Company Flight Operations if they have any serious ailment that can cause medical incapacitation and that therapy is prescribed at Company medical facilities as well as Company-appointed panel clinics. [SR#10]
  • that Malaysian Airlines ensure that the medical records of the flight crew maintained by the Company Medical Centre include records maintained by different panel clinics. The complete medical record of the individual flight crew shall show all visits to any panel clinics, the details of ailments and therapy prescribed. [SR#11]
  • that Malaysian Airlines review the process of their reporting system and the action flow when flight crew and cabin crew health may become a risk factor for the safety of the aircraft operations. [SR#12]
  • that Malaysian Airlines personnel manning the Flight-Following System/Flight Explorer should be adequately trained and qualified to enable them to provide information relating to flights to the relevant authorities and/or organisations. [SR#13]
  • that Malaysian Airlines current Flight-Following System/Flight Explorer should be upgraded to the Global real-time Tracking System. [SR#14]
  • that Malaysian Airlines review and introduce new security measures for cargo scanning at Penang International Airport/all airports and the point of entry into airside at KLIA/all airports. [SR#15]
  • that the Malaysian Airlines document back-up system should be implemented on all training sorties, simulator training details and flight training details completed by a trainee so that the original forms are submitted to the Training Department and a copy is retained by the trainee in their personal training file. [SR#16]
  • that Malaysian Airlines develop a comprehensive Quick Reference for the Operations Control Centre that covers every aspect of abnormal operations / situations. [SR#17]
  • that Malaysia Airports Holdings review and introduce new security procedures for the scanning of cargo at the point of entry at all airports and the point of entry into the airside at KLIA/all airports in Malaysia. [SR#18]
  • that the International Civil Aviation Organisation review the effectiveness of current ELTs fitted to passenger aircraft and consider ways to more effectively determine the location of an aircraft that enters water. [SR#19]

A 495-page Safety Investigation Report was issued by the Malaysian Ministry of Transport on 2 July 2018. A series of 50 Appendices to the Report were issued separately and may be accessed on the Investigation Team website using the links provided. This Report effectively marks the suspension of the Investigation unless the wreckage and flight recorders are subsequently found since it has been concluded that no more progress can be made without them.

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