SAFETY INVESTIGATION REPORT Malaysia Airlines Boeing B777-200ER (9M-MRO) 08 March 2014
Total Page：16
File Type：pdf, Size：1020Kb
Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 1 of 495 SAFETY INVESTIGATION REPORT Malaysia Airlines Boeing B777-200ER (9M-MRO) 08 March 2014 By The Malaysian ICAO Annex 13 Safety Investigation Team for MH370 The Malaysian ICAO Annex 13 Safety Investigation Team for MH370 Issued on 02 July 2018 MH370/01/2018 Email: [email protected] Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 2 of 495 SAFETY INVESTIGATION REPORT MH370 (9M-MRO) _________________________________________________________________________________ I. CONTENTS i - TABLE OF CONTENTS NO. TITLE PAGE/S I. i. Table of Contents i-xi ii. List of Appendices xii-xiii II. Synopsis xiv-xvii III. Dedication xviii IV. Acknowledgement xix V. Objective xx VI. Disclaimer xxi VII. Glossary of Terms xxii-xxvii VIII Abbreviations and Codes xxviii-xliii IX The Malaysian ICAO Annex 13 Safety Investigation Team xliv-xlv for MH370 SECTION TITLE PAGE/S 1 FACTUAL INFORMATION 1-273 1.1 HISTORY OF THE FLIGHT 1-21 1.1.1 Introduction 1 1.1.2 Actions by HCM ACC and KL ACC 3 1.1.3 Diversion from Filed Flight Plan Route 3 1) Malaysian Military Radar 3 2) DCA Civilian Radar Data from Kota Bharu – Sultan 6 Ismail Petra Airport Runway 3) Ho Chi Minh Air Traffic Services 15 4) Kuala Lumpur ACC Radar 17 5) Medan Air Traffic Control Radar 18 6) Bangkok Air Traffic Control Radar 18 7) Singapore Air Traffic Services 19 1.1.4 Role of the Malaysian Military 19 1.1.5 Detection of Hand Phone Signal 20 1.1.6 Search for Aircraft 20 1.2 INJURIES TO PERSONS 22 1.3 DAMAGE TO AIRCRAFT 23 1.4 OTHER DAMAGES 24 i Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 3 of 495 SAFETY INVESTIGATION REPORT MH370 (9M-MRO) _________________________________________________________________________________ SECTION TITLE PAGE/S 1.5 PERSONNEL INFORMATION 25-38 1.5.1 Introduction 25 1.5.2 Malaysia Airlines Training and Check Records 25 1.5.3 Pilot-in-Command 26 1) Personal Profile of Pilot-in-Command 26 2) Royal Malaysia Police’s Report on Flight Simulator of PIC 27 1.5.4 First Officer 29 1) Personal Profile of First Officer 30 1.5.5 Summary of Work Schedule for Flight Crew of MH370 30 1.5.6 Cabin Crew and Personal Profiles 30 . 1) In-flight Supervisor (IFS) 31 2) Chief Steward (CS) 31 3) Chief Stewardess (CSS) 32 4) Leading Steward (LS) 32 5) Leading Stewardess (LSS) 33 6) Flight Stewardess (FSS) 1 33 7) Flight Stewardess (FSS) 2 34 8) Flight Steward (FS) 1 34 9) Flight Steward (FS) 2 35 10) Flight Steward (FS) 3 35 1.5.7 Disciplinary/Administrative Actions 36 1.5.8 Financial Background and Insurance Cover 36 1.5.9 Significant Past Medical and Medication History 36 1.5.10 Psychological and Social Events 37 1.5.11 Behavioural Events 37 1.5.12 Voice Recognition of the Radio Transmissions between 38 MH370 and Air Traffic Control 1.6 AIRCRAFT INFORMATION 39-95 1.6.1 Airframe 39 1.6.2 Engine 39 1.6.3 Auxiliary Power Unit 39 1.6.4 Airworthiness and Maintenance 40 1) Aircraft Maintenance Schedule 40 2) Major Repair 44 3) Cabin Configuration Change 45 4) Mandatory Occurrence Reports 45 5) Airworthiness Directives 46 6) Technical Log 47 7) Deferred Defects (Maintenance Report 2) 48 ii Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 4 of 495 SAFETY INVESTIGATION REPORT MH370 (9M-MRO) _________________________________________________________________________________ SECTION TITLE PAGE/S 1.6.4 8) Engine Health Monitoring 49 cont. 9) Central Maintenance Computing System 49 1.6.5 Weight and Balance 50 1.6.6 Fuel 51 1.6.7 Emergency Locator Transmitter 52 1) Review of Effectiveness of Emergency Locator 54 Transmitters 1.6.8 Aircraft Systems Description 56 1) Air Conditioning and Pressurisation 57 . 2) Autopilot Flight Director System 58 a) Take-off Mode 59 b) Roll Modes 59 c) Pitch Modes 61 d) Landing Modes 63 e) Autothrottle (Thrust Management Computing 64 Function) f) Autothrottle Modes 65 3) Electrical Power 67 a) Electrical Load Management System 69 b) Alternating Current Electrical System Power Sources 69 c) Integrated Drive Generators 69 d) Auxiliary Power Unit Generator 70 e) Alternating Current Electrical Power Distribution 70 f) Autoland 71 g) Backup Alternating Current Electrical System 71 h) Backup Generators 71 i) Direct Current Electrical System 72 j) Batteries 73 k) Flight Control Direct Current Electrical System 73 l) Standby Electrical System 73 4) Cabin and Cargo Compartments 75 5) Flight Controls 76 6) Fuel System 78 7) Hydraulics 80 8) Instrumentation 81 9) Airplane Information Management System 85 10) Navigation Systems 86 11) Oxygen Systems 88 12) Central Maintenance Computing System 90 iii Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 5 of 495 SAFETY INVESTIGATION REPORT MH370 (9M-MRO) _________________________________________________________________________________ SECTION TITLE PAGE/S 1.6. 8 13) Engines 90 cont. 14) Auxiliary Power Unit 92 15) Communications 93 1.6.9 Aircraft Performance 93 1.6.10 Boeing Patent on Remote Control Takeover of Aircraft 94 1.7 METEOROLOGICAL INFORMATION 96-101 1.7.1 Meteorological Situation 96 1.7.2 Comments on the Information Available 99 1) Forecast Charts 99 a) Significant Weather Chart 99 b) Wind and Temperature Forecast Chart 100 2) Significant Meteorological Information 100 3) Volcanic Ash Advisory 101 1.7.3 Availability of Meteorological Information 101 1.8 AIDS TO NAVIGATION – Not applicable 10 2 1.9 COMMUNICATIONS 103-131 1.9.1 High Frequency System 103 1.9.2 Very High Frequency System 103 1.9.3 Air Traffic Control/Mode S Transponder System 104 1.9.4 Aircraft Communications Addressing and Reporting System 105 1) Aircraft Communications Addressing and Reporting 108 System Traffic Log 1.9.5 Satellite Communications 115 1) Satellite Communications System Description 115 2) Satellite Communications Ground Station Logs of the 119 Event – Introduction 3) Satellite Communications Ground Station Logs of the 121 Event – Summary 4) Satellite Communications Ground Station Logs – Key 124 Observations in Chronological Order 5) Frequencies of Log-on Bursts 130 1.10 AERODROME INFORMATION - Not applicable 132 1.11 FLIGHT RECORDERS 133-137 1.11.1 Solid State Flight Data Recorder 133 1.11.2 Solid State Cockpit Voice Recorder 134 1.11.3 Underwater Locator Beacons 136 1) Solid State Data Recorder Underwater Locator Beacon 137 Battery Expiry 1.12 WRECKAGE AND IMPACT INFORMATION 138-167 1.12.1 Introduction 138 iv Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 6 of 495 SAFETY INVESTIGATION REPORT MH370 (9M-MRO) _________________________________________________________________________________ SECTION TITLE PAGE/S 1.12.2 Location of Where the Debris were Found 139 1.12.3 Details of the Debris 154 1.12.4 Process for Recovery of Debris 167 1.13 MEDICAL AND PATHOLOGICAL INFORMATION 168-169 1.14 FIRE 170 1.15 SURVIVABILITY 171 1.16 TESTS AND RESEARCH - Not applicable 172 1.17 ORGANISATIONAL AND MANAGEMENT INFORMATION 173-227 1.17.1 Department of Civil Aviation Malaysia 173 . 1) Introduction 173 2) Functions and Responsibilities of Department of Civil 174 Aviation 3) Sectors and Divisions of Department of Civil Aviation 175 4) Areas of Focus 175 5) Air Traffic Management Sector 175 a) Air Traffic Inspectorate Division 177 6) Airworthiness Sector 190 7) Flight Operations Sector 194 1.17.2 Malaysia Airlines 196 1) Introduction 196 2) Engineering & Maintenance 197 a) Organisation Structure 197 b) Maintenance and Design Approval 197 c) Training 199 d) Base Maintenance 200 e) Line Maintenance 200 f) Maintenance Authorisation 201 g) Safety Management System 201 3) Operations 202 a) Flight Operations 202 i) Flight Operations Management 202 ii) Organisation and Management related to 203 B777 Operations iii) Technical Crew 204 iv) Technical Crew of MH370 207 v) Working Schedule/Roster Schedule and 208 Management vi) Safety Management System 209 v Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 7 of 495 SAFETY INVESTIGATION REPORT MH370 (9M-MRO) _________________________________________________________________________________ SECTION TITLE PAGE/S 1.17.2 vii) Confidential Human Factors Incident Report 210 cont. viii) Flight Operations Quality Assurance 212 ix) Line Operations Safety Audit 213 x) Crew Resources Management 213 xi) Training and Standards 215 xii) MAS B777 Training and Standards 216 xiii) Multi-Crew Operation MH370 218 xiv) Safety and Emergency Procedures 219 xv) Technical and Development 220 xvi) Fuel Policy 220 xvii) Flight Plan Routing 221 xviii) Hijack and Sabotage Security Procedures 221 b) In-flight Services 221 i) Cabin Crew Training 221 ii) Crew Performance Appraisal 223 iii) In-flight Operation 224 iv) Flight and Duty Time Limitations Scheme for 226 Cabin Crew v) Safety Report 227 1.18 ADDITIONAL INFORMATION 228-273 1.18.1 Provision of Air Traffic Services and Areas of 228 Responsibilities t 1) Introduction 228 2) Sector 3 Area of Responsibility 229 3) Sector 5 Area of Responsibility 232 4) Air Traffic Services Operations 235 5) KL ATSC Duty Shift System for Air Traffic Controllers 236 6) Chronology of Activities after Notification by HCM ACC 242 7) Activation of KL Aeronautical Rescue Coordination 247 Centre 8) Recorded Telephone Conversations 249 9) Watch Supervisor Air Traffic Services and Sector (3 & 250 5) Logbook 10) Flight Progress Strip 250 1.18.2 Air Cargo Consignment 252 1) Introduction 252 vi Case 1:16-mc-01184-KBJ Document 102-1 Filed 08/01/18 Page 8 of 495 SAFETY INVESTIGATION REPORT MH370 (9M-MRO) _________________________________________________________________________________ SECTION TITLE PAGE/S 1.18.2 2) Lithium Ion Batteries 254 cont.