Malaysia

MH370: safety team releases report, but cannot determine the cause of the plane’s disappearance

This article has been updated and includes details of the resignation of the chairman of the Civil Aviation Authority of Malaysia, Azharuddin Abdul Rahman and the response of the family support group Voice 370.

A full report of the international investigation into the disappearance of Malaysia Airlines flight MH370 was released today (Monday).

Lead investigator Kok Soo Chon said the team was “unable to determine the real cause for the disappearance of MH370”.

Kok Soo Chon said the remit of the investigation team was limited to matters of safety and, in today’s briefings, there were no answers to questions about the search for the plane.

MH370 disappeared on March 8, 2014, with 239 people on board when en route from Kuala Lumpur to Beijing.

This morning, the new report was presented to the next-of-kin of those on board MH370 by Kok Soo Chon, who heads the Malaysian International Civil Aviation Organisation (ICAO) Annex 13 Safety Investigation Team for MH370.

The report is nearly 1,500 pages long and is made up of a main document totalling 495 pages and six separate appendices. It is due to be tabled in parliament tomorrow.

Kok Soo Chon said that the report was not the “final” one about MH370.

“To allay the fears of some people, this is not the final report,” he told the media. “This is just a report.”

He said it would be presumptuous of the team to call the report final when the wreckage of MH370 had not been found.

The next of kin were briefed at the Ministry of Transport in Putrajaya by Kok Soo Chon (pictured right) and senior investigators Mohd Shah Mahmood, Abdul Wahab Ibrahim, and Mohan Suppiah. There will a briefing for Chinese next of kin in Beijing on August 3.

The ICAO investigation report does not apportion blame. “We are not here to witch hunt,” Kok Soo Chon said. “We are not here to go for somebody’s blood.”

He added that that the team was not of the opinion that MH370’s chief pilot, Captain Zaharie Ahmad Shah, caused the plane’s disappearance.

“But at the same time we cannot deny the fact that there was an air turn back. We cannot deny the fact that, as we have analysed, the systems were manually turned off, with intent or otherwise.”

The report says there is no evidence to suggest that MH370 was flown by anyone other than the designated Malaysia Airlines pilots, but Kok Soo Chon said the team could not rule out the possibility that there was “unlawful interference” by a third party.

Talking about the plane’s diversion from its scheduled flight path, he said that, based on the military record, there was no evidence of a rapid change in altitude and speed that would indicate deliberate evasion of radar.

The report states: “Based on the team’s review of the military recorded radar display and printout, the aircraft’s flight path could not be determined, and there is no evidence of rapid altitude and/or speed changes to indicate that MH370 was evading radar.

“Without further evidence, the reason for the transponder information from the aircraft ceasing could not be determined.”

It has been determined, the report says, “that only the transponder signal of MH370 ceased from the ATC Controller display whilst displays from other aircraft were still available”.

Relatives’ frustration

The next of kin present at today’s briefing expressed frustration and disappointment about the new report, saying that many unanswered questions remain.

Several of the relatives were visibly upset. Sarah Nor, whose son Norliakmar Hamid was on board MH370, broke down in tears. Selamat Omar, whose son Mohd Khairul Amri Selamat was also on board, looked exhausted. He understood little of the briefing as it was in English, a language he doesn’t speak.

Grace Subathirai Nathan, whose mother Daisy was on board MH370, said she was grateful to the investigating team, but there was nothing new in the report that the next of kin did not know before.

“We were not given any answers about the future of the search,” she said.

The families had asked for a video link to be established for those unable to attend the briefing, but their request was refused and no reason was given.

Australian Danica Weeks, whose husband Paul was on board MH370, is furious that she was given just a few days’ notice that her flight could have been paid for to attend the briefing in Malaysia.

She says that if she had been given more notice that the flights would be paid for, she would have attended.

She is angry that she missed out on the opportunity to ask questions of the authorities.

Weeks had thought that she would have to cover her own travel costs, then was told last Friday that those costs would be covered. This was much too late for her to organise a trip to Malaysia.

Next of kin at the press conference after their briefing.

Nathan said that as well as the safety team’s investigations being limited in their scope, they were also carried out based on information that was supplied to the team “so the investigation was not carried out independently”.

It is not known, Nathan says, whether the Annex 13 team investigations were based on accurate information “or on information that was inaccurate to begin with”.

She asks why, when MH370 disappeared, were only two attempted phone calls made from the ground (to the co-pilot’s phone). Those calls, Nathan says, were made four or five hours apart and the investigators were not able to give the families an adequate response as to why more phone calls were not made.

The next of kin also questioned the investigators about the debris “that has been languishing in Madagascar”, and, Nathan says, they did not receive a satisfactory response.

Nathan says she wants the Malaysian government to make it clear that the search for MH370 is not over. “We don’t want Malaysia to give the impression that the door is closed,” she said.

The government, Nathan says, needs to be open and welcoming to people offering to search for MH370 on a “no cure, no fee” basis. She also said the new Malaysian government should call on whistleblowers to come forward if they have information that has been overlooked.

The next of kin continue to emphasise that finding MH370 is not just vital for the families, but also for aviation safety in general.

K.S. Narendran, whose wife Chandrika was on board MH370, said: “After more than four years, I don’t think we are any the wiser.”

Narendran referred to the narrow terms of reference of the investigation team, which precluded discussion today about accountability and how the search for MH370 was conducted.

Intan Maizura Othman (pictured left), whose husband, Mohd Hazrin Mohd Hasnan, was a flight steward on MH370, said she felt dejected after today’s briefing, not least because there were no representatives present from the transport ministry or the civil aviation authority who could answer more general questions.

Intan said that many of her questions were not answered and she felt let down by the authorities.

“We have been waiting for an answer about our loved ones and the information has been manipulated since Day 1,” she said.

Intan points to information provided about MH370’s cargo, which keeps changing.

She was also shocked by the investigators’ admission that there are serious problems with Emergency Locator Transmitters.

The report states that “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”.

It added: “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.”

The report further states that a review of ICAO accident records over the past thirty years indicates that of the 114 accidents in which the status of ELTs was known, only 39 cases recorded effective ELT activation.

“This implies that of the total accidents in which ELTs were carried, only about 34% of the ELTs operated effectively.”

Other experts have put the percentage as even lower.

ELTs can be activated automatically by the shock typically encountered during aircraft crashes or manually. While it is possible for the flight crew to activate the ELT manually, existing flight operating procedures do not call for ELT activation until the incident has occurred.

MH370 was fitted with four ELTs, but no signal from them was reported by search and rescue agencies or any other aircraft.

“There have been reported difficulties with the transmission of ELT signals if an aircraft enters the water, such as in the case of Air France flight AF447,” the report states.

“In these instances, the ELT does not activate, or the transmission is ineffective as a result of being submerged under water.

“Furthermore, the ELT itself could be damaged or, very commonly in the case of fixed ELTs, the antenna or antenna cables become disconnected or broken. This significantly hampers any search and rescue effort and may mean the aircraft location remains undetected for a considerable time.”

Procedural failures

The new report points to procedural failures by Air Traffic Control (ATC) in Malaysia and Vietnam.

Kuala Lumpur ATC had been scheduled to hand over MH370 to Ho Chi Minh (HCM) ATC at 0122 Malaysian time, but did this earlier, at 1719:26 UTC (0119:26 Malaysian time).

The Malaysian air traffic controllers acted too fast, telling the pilots to contact HCM at 0119:26, Kok Soo Chon said.

Neither KL ATC nor the pilots of MH370 informed HCM ATC of the early handover.

At 1719:30 UTC (0119:30 Malaysian time), MH370 acknowledged with “Good night Malaysian Three Seven Zero”. This was the last recorded radio transmission from the plane.

Radar recording showed that MH370 passed through waypoint IGARI at 1720:31 UTC (0120:31 Malaysian time).

The last radar capture was at 1.21. “After 1.21 the aircraft was lost,” Kok Soo Chon

HCM ATC didn’t call KL ATC until just after 1.39. When a grace period of five minutes is deducted, there was a period of 12 minutes during which no ATC was monitoring the plane, Kok Soo Chon said.

The report states that Vietnam Air Traffic Management “only initiated an enquiry on the whereabouts of MH370 at 1739:03 UTC (0139:03 Malaysian time) after a lapse of 12 minutes”.

It also says that KL ACC controllers relied solely on information about the position of MH370 that was provided by the Malaysia Airlines flight operations despatch centre rather than checking with other ATC authorities.

“The air traffic controllers did not initiate, in a timely manner, the three standard emergency phases in accordance with the standard operating procedures,” it adds.

The report also says there is no evidence to suggest that the KL ACC controllers kept continuous watch on the radar display and no record to suggest that they took any action to alert the Royal Malaysian Air Force’s Joint Air Traffic Control Centre.

Recommendations

The ICAO team has made seven recommendations to the Department of Civil Aviation (DCA), which is now known as the Civil Aviation Authority of Malaysia (CAAM), eight to Malaysia Airlines, two to the Civil Aviation Authority of Vietnam, and one to Malaysia Airports Holdings Berhad.

It recommends that Malaysia Airports “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”.

Debris finds

The report points out that items of debris possibly from MH370 have been found as far north as the eastern coast of Tanzania and as 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.”

The report states that 27 significant pieces of debris have been recovered and examined.  In addition to the three pieces confirmed to be from MH370, seven pieces, including some cabin interior items, have been determined to be “almost certainly” from the plane. Eight pieces are “highly likely” to be from MH370 and one piece is “likely” to be from the plane. Eight pieces of debris were not identifiable.

Twenty-six pieces of debris are with the Malaysian authorities, but the flaperon found on Reunion island is still with French judicial authority.

The flaperon found on Reunion island in July 2015, which the French authorities say is from MH370.

The report states that examination of 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,” the report states.

“However, there is insufficient information to determine if the aircraft broke up in the air or during impact with the ocean.”

Appendix 1.12A-2 contains a translation of the full report about the examination of the flaperon that was issued by the French government defence procurement and technology agency the Direction générale de l’armement (DGA).

The French report states: “It appears possible to exclude in-flight loss of the flaperon since its weight is concentrated forwards, which would a priori lead to a fall with the leading edge forwards and the probable destruction of the latter. The damage to the trailing edge would also likely be different.”

While the French investigators haven’t entirely excluded possible in-flight loss of the flaperon, they consider an impact with water to be likely.

They state: “In the absence of data from Boeing, and despite the deterioration of some fracture surfaces, a hypothesis was nevertheless formulated: taking into account the results of the examinations, it appears that the flaperon impacted the water while still attached to the aeroplane and that at the time of the impact it was deflected.

“A fall simulation for the flaperon with an initial speed corresponding to that of an aeroplane in flight could definitively exclude the loss of the latter in flight.

“The little data supplied by Boeing did not enable the examination to be progressed by making calculations that would have made it possible to confirm or reject the proposed hypothesis.”

American amateur investigator Blaine Alan Gibson with debris found on an island in eastern Madagascar.

The safety team’s report states that MH370 did not carry any cargo classified as dangerous goods.

It states that two cargo items of interest (the lithium ion batteries and mangosteen fruits) had been transported via scheduled flights on Malaysia Airlines before and after the disappearance of MH370.

“These items were packed and loaded according to standard operating procedures,” the report states.

The report refers to the expiry of the battery on the Underwater Locating Beacon (ULB) of the flight data recorder, which was revealed in the first interim report into the disappearance of MH370, released in March 2015.

According to maintenance records, the battery on the beacon attached to the flight data recorder expired in December 2012.

The investigation team says that, except for the battery expiry, maintenance records indicated that MH370 was “equipped and maintained in accordance with existing regulations and approved procedures”.

The aircraft had a valid Certificate of Airworthiness, the report states, and “was airworthy when dispatched for the flight”.

The mass and the centre of gravity of the aircraft were within the prescribed limits, it adds.

The investigators say that “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, they say.

“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.”

The investigating team has concluded that the turnback of MH370 towards the Malaysian peninsula had to be manual.

Kok Soo Chon said the investigators carried out seven flight simulator tests, three at high speed and four at low speed, and found that the turn was indeed made manually, not by autopilot.

The report states that the recorded changes in MH370’s flight path after waypoint IGARI, heading back across peninsular Malaysia, turning south of Penang to the northwest and a subsequent turn towards the southern Indian Ocean “are difficult to attribute to any specific aircraft system failures”.

It is more likely, the report states, that such manoeuvres were 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.”

The investigators say they have been unble to establish whether the turns over the south of Penang and the north of MEKAR were made under manual control or autopilot.

The report refers to speculation that control of MH370 could have been taken over remotely.

In 2006, Boeing received a United States patent for a system that, once activated, would remove all controls from pilots and automatically fly and land an aircraft at a predetermined location.

However, the report says, “Boeing has confirmed that it has not implemented the patented system or any other technology to remotely pilot a commercial aircraft and is not aware of any Boeing commercial aircraft that has incorporated such technology. The technology was never installed on an aircraft.”

Kok Soo Chon said that the two psychiatrists in the investigation team concluded that no anxiety or stress was observed during the conversations between the MH370 pilots and air traffic controllers, and the CCTV footage of the pilots at the airport on March 7 showed no significant behavioural changes.

He said that everything appeared to be normal, including the pilots’ health and their financial situations, and all the passengers had also been given a “clean bill of health”.

There has been much debate and speculation about Zaharie’s home flight simulator. The new report says the Royal Malaysia Police forensic report concluded that “there were no unusual activities other than game-related flight simulations”.

Captain Zaharie is referred to in the report as the Pilot-in-Command (PIC).

There are still unanswered questions about two SATCOM logons initiated by MH370, at 1825 UTC and 00019 UTC. Neither of these logons provided flight ID, whereas the logon at 1600 UTC sent a valid ID to the GES (ground station) in Perth.

The investigation team says there are “many quite complicated scenarios” that could have caused the 1825 logon, but they have concluded that the most likely reason is a power interruption to the SATCOM  avionics. They say this is also the most likely reason for the 00019 logon.

The report states that the operation of the Auxiliary Power Unit during most of the flight is uncertain “although it is possible that it started up automatically (as it should) after both engines shut down due to fuel exhaustion at the end of the flight”.

This start-up and power-up of the electrical buses most likely caused the 7th and last aircraft-initiated SATCOM handshake, the report states.

 

Malaysia’s transport minister Anthony Loke Siew Fook said today in a statement that the aspiration to locate MH370 had not been abandoned.

“We remain ever hopeful that we will be able to find the answers we seek when the credible evidence becomes available.”

Not a trace of MH370 was found during lengthy searches in the southern Indian Ocean – initially by an Australian-led team.

The Australia-led search went on for 1,046 days and was suspended on January 17 last year. An area spanning more than 120,000 square kilometres was scoured.

The American seabed exploration company Ocean Infinity then searched, and collected data from, an area spanning about 120,000 square kilometres, which was far in excess of the initial 25,000-square-kilometre target.

Kok Soo Chon said today that, within a month, the Malaysian ICAO Annex 13 team would offer to terminate its investigation contract.

The British Airline Pilots’ Association (BALPA) issued a statement saying that the release of the new report “should put to bed all the unfair speculation around the role of the pilots”.

The association said it was widely speculated that a pilot on MH370 was to blame for the flight going missing, but Kok Soo Chon had made it clear that there was no evidence to suggest this was the case.

The BALPA also urged the aviation industry to invest in new technology.

The association’s head of flight safety, Rob Hunter, said: “People found it incredible that, in this day and age, we could lose track of an aircraft in this way. We believe a global push to replace the old technology that still sits in cockpits would help avoid accidents and help accident investigation.”

 

The MH370 safety investigation team comprises accredited representatives from air accident and incident investigation organisations in Malaysia, Australia, China, France, Indonesia, Singapore, the United Kingdom, and the United States.

 

Update on 31/7/2018

In an article on his website, Victor Iannello from the MH370 Independent Group of investigators writes that the new report “raises more questions than it answers”.

He states that the report provides more details about the radar data, but Malaysia is still failing to provide the raw military data that would allow an independent review.

“After all this time, we still can’t be sure what radar data is available as MH370 passed over the Malacca Strait.”

Iannello adds: “We also can’t be sure when the unidentified radar targets captured over the Malay peninsula were first recognised as MH370.”

According to the safety report, on the day of the disappearance of MH370, the military radar system recognised the “blip” that appeared west after the left turn over IGARI as  MH370.

The report says the Malaysian military did not pursue the aircraft to intercept it as it was designated as “friendly” and was not considered to pose any threat to national airspace security, integrity, and sovereignty.

Iannello writes: “In light of the claim that the military was fully aware of the path of MH370, it is not explained why the initial Search and Rescue operations were coordinated in the South China Sea to the east of Malaysia, and proceeded for some number of days before they were moved west of Malaysia to the Indian Ocean.”

In the new report, the investigators say they were told that the altitude and speed extracted from the military data were subjected to inherent error. “The only useful information obtained from the military radar was the latitude and longitude position of the aircraft as this data is reasonably accurate” the report states.

Iannello writes: “How the military radar data can be so far out of calibration is unexplained.”

He also says it is unexplained whether or not a systematic review of the cell phone numbers of all passengers and crew was ever performed.

“The First Officer’s cell phone registered on a cell tower as MH370 passed to the south of Penang Island. Although it would be unlikely that a cell phone connection would persist long enough to complete a call, a cell phone registration of short duration and at cruise altitude is not that uncommon.

“Considering the large number of Malaysian passengers and crew that were likely carrying cell phones compatible with the Malaysian cell network, and with some fraction of those phones likely in an operational configuration during the flight, it is odd that other cell phone registrations did not occur.”

Further update:

The chairman of the Civil Aviation Authority of Malaysia (CAAM)¹, Azharuddin Abdul Rahman, has resigned.

He said in a statement that, while the MH370 safety investigation team’s report did not suggest that “the accident” was caused by the Department of Civil Aviation (DCA), there were nevertheless “some very apparent findings with regards to the operations of the Kuala Lumpur Air Traffic Control Centre (KLATSC); where it was stated that the Air Traffic Controller did not comply with certain Standard Operating Procedures”.

Azharuddin, who was the head of the DCA when MH370 disappeared, said that “with regret and after much thought and contemplation” he had therefore decided to resign.

He stated: “Over the past four years, I have tried my level best to assist in the search for MH370 and I am ever resolute in finding answers we all seek towards this unfortunate tragedy as we owe it to the families and loved ones. I am saddened to have to leave under these circumstances.

“Serving the industry for more than forty years has been the greatest honour of my life and I apologise for not being able to fulfil the remainder of my tenure. Aviation has been a core part of my life since childhood and it will remain so for the rest of my life.”

Update 3/8/2018

Members of the safety investigation team briefed Chinese next of kin in Beijing today (Friday).

Relatives asked why the safety investigation report had not been translated into Chinese.

Spokesman for the Chinese next of kin, Jiang Hui, told Changing Times that Kok Soo Chon assured the next of kin that a report will now be produced in Chinese.

“We have no idea how long that will take,” Jiang Hui, said.

Jiang Hui said the next of kin told the investigators that they did not want the team to disband.

“Kok Soo Chon said he would return to Beijing in October to meet relatives and answer remaining questions about the report,” he added.

Update 7/8/2018

The family support group Voice 370 has issued a statement about the new report in which the next of kin call upon Malaysia to stay committed to the search for MH370 and to announce that they remain open to search proposals from Ocean Infinity “or other capable entities” on “no find, no fee terms or any other ideas that improve on this”.

The group points out that the report highlights the significant role played by the military’s primary radar in tracing MH370’s flight path.

“Voice 370 calls upon the government of Malaysia to share all available data with independent experts for a thorough peer review and analysis.

“We believe that after 4.5 years since MH370 disappeared, there is no reason to continue to withhold data when its probative value far outweighs any prejudicial effect.”

Voice 370 said the families acknowledged the work of the MH370 Annex 13 safety investigation team in “dealing with an unprecedented aviation incident without the wreckage and flight data recorders”.

However, the group said the families were dismayed that the report was “so poorly framed that it became open to opportunistic interpretations”.

The group stated that, although the report neither favoured nor ruled out in-flight system malfunction, a catastrophic event or catastrophic events on-board, or human intervention, Boeing, who had been silent for the past four and a half years, “wasted no time in absolving themselves of blame in spite of the fact that the report specifically mentions that a lack of evidence precluded the investigation from definitely eliminating any possibility”.

Furthermore, Voice 370 states, “the French authority mentions repeatedly in their report that their investigations on the flaperon had been hampered by an absence of data from Boeing”.

Echoing the words of the lead investigator Kok Soo Chon, who said that the cause of MH370’s disappearance could not be known until the wreckage was found, Voice 370 stated: “Until we know what happened, there will be no way to prevent it from happening again.”

 

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