BRIEFING to MEDIA

by

The Malaysian ICAO Annex 13 Safety Investigation Team for MH370

30th July 2018

on

SAFETY INVESTIGATION REPORT

MALAYSIA AIRLINES BOEING B777-200ER (9M-MRO)
8th March 2014
 OBJECTIVE
AIR ACCIDENT OR INCIDENT INVESTIGATON

“The sole objective of investigation of an accident or incident shall be the

prevention of accidents and incidents. It is not for the purpose of this activity
to apportion blame or liability.”

ICAO’s Annex 13, Chapter 3, General, para. 3.1, page 3-1 to the Convention on Civil
Aviation Aircraft Accident and Incident Investigation

2
 ESTABLISHMENT
THE MALAYSIAN ICAO ANNEX 13 SAFETY INVESTIGATION TEAM FOR MH370

The Government of Malaysia, under Regulation 126(1) of the Malaysian Civil Aviation
Regulations (MCAR) 1996, established on 25th April 2014 The Malaysian ICAO Annex 13
Safety Investigation Team for MH370 with 19 Malaysians and 7 Accredited Representatives
(ARs) of 7 international air safety investigation authorities to investigate into the
disappearance of MH370 on 8th March 2014

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 ACCREDITED REPRESENTATIVES
MALAYSIAN ICAO ANNEX 13 SAFETY INVESTIGATION TEAM FOR MH370

No. COUNTRY ORGANISATION

1. Australia Australian Transport Safety Bureau (ATSB)
2. China Civil Aviation Administration of the People’s Republic of China (CAAC)
3. France Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation civile (BEA)
4. Indonesia National Transportation Safety Committee (NTSC)
5. Singapore Transport Safety Investigation Bureau (TSIB)
6. United Kingdom Air Accidents Investigation Branch (AAIB)
7. United States of National Transportation Safety Board (NTSB)
America
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 SECTION 1 - FACTUAL INFORMATION (ANNEX 13, CHAPTER 1, ITEMS 1.1 - 1.19)

Section Item Section Item

1.1 History of the Flight 1.11 Flight Recorders
1.2 Injuries to Persons 1.12 Wreckage and Impact Information
1.3 Damage to Aircraft 1.13 Medical and Pathological Information
1.4 Other Damages 1.14 Fire
1.5 Personnel Information 1.15 Survivability
1.6 Aircraft Information 1.16 Tests and Research
1.7 Meteorological Information 1.17 Organisational & Management Information
1.8 Aids to Navigation
1.18 Additional Information
1.9 Communications
1.19 New Investigation Techniques
1.10 Aerodrome Information
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 KEY AREAS ANALYSED

1) Diversion from Filed Flight Plan Route

2) Flight Crew Profile

3) Airworthiness & Maintenance and Aircraft Systems

4) Satellite Communications (SATCOM)

5) Wreckage and Impact Information

6) Cargo Consignment

7) Air Traffic Services from 0119 to 0632 MYT

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 HISTORY OF THE FLIGHT

1. DEP at
9. KL ATC captured 2. At 0042 MYT -
0042 MYT
last radar KL ATC cleared
(08 March14)
position MH370 to climb
on Runway 32R
at 0121 MYT to FL180
KLIA

8. Radar recording 3. At 0043 MYT -

MH370 passed KL ATC coordinated
IGARI with HCM on direct
at 0120 MYT line ETA at Waypoint
IGARI at 0122 MYT
7. At 0119 MYT 6. At 0119 MYT 5. MH370 reported
“Goodnight KL ATC FL350 at 0101
4. Last ACARS
Malaysian 370 instructed MYT.
report occurred
(last recorded MH370 to Repeated same
at 0107 MYT
transimission) contact HCM transmission
on 120.9 MHz at 0107 MYT
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TURN BACK AND MILITARY RADAR (RMAF)

8
 DIVERSION FROM FILED FLIGHT PLAN

1) Evidence shows that Flight MH370 diverted from the Filed Flight Plan Route.

2) The changes in the aircraft flight path after waypoint IGARI are difficult to attribute to
anomalous system issues alone

3) Flight simulator trials established that the turn back was made while the aircraft was under
manual control and not using autopilot

4) Civilian and Military radars consistent with each other

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 DIVERSION FROM FILED FLIGHT PLAN (cont.)

5) Team believes position, bearing and heading of radar returns of Civilian and Military should
be the same target

6) Ho Chi Minh (HCM) and Medan ACC tracked aircraft for a while until it disappeared

7) Autopilot has to be disengaged to achieve time closest to recorded data of 2 minutes 10

seconds

8) Reason could not be established why only transponder signal from MH370 ceased and not
from other aircraft on the radar display

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 DIVERSION FROM FILED FLIGHT PLAN (cont.)

9) Not established if aircraft flew by anyone other than pilots

10) Based on review of the Military recorded radar display and printout - no evidence of rapid
altitude and/or speed changes to indicate that MH370 was evading radar

11) Primary radar designated aircraft as “friendly” by RMAF and posed no threat to airspace
security, integrity and sovereignty

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 FLIGHT CREW PROFILE

1) Pilot-in-Command of MH370

a) Personal Information c) Qualifications/Training

• 53 years old from Penang
• 1981 - Manila Flying School
• Married with 3 children
• 1983 - MAS Fokker 27
• MCE (1978)
• 1985 - FO of B737-200
• 1991 - Captain B737-400
b) Work Experience • 1996 - Captain A330-300
• 18,000 hours • 1998 - Captain B777-200ER
• 8,700 hours on B777

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 FLIGHT CREW PROFILE (cont.)

1) Pilot In Command of MH370 (cont.)

d) Medical History e) Social Habits

• Spinal injury (Jan 2007) • No conflict issues with family or friends

undergoing surgery • No signs of social isolation/self neglect
• Osteoarthritis (May 2007) • No abuse of alcohol/drug
• No long-term medication • No change in habits/interest
• No evidence of mental/psychiatric • No stress or anxiety in audio-recordings
treatment • No signs of behavioural significant in CCTV
• No history of apathy anxiety or recordings
instability • No evidence of stress and anxiety

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 FLIGHT CREW PROFILE (cont.)

1) Pilot-in-Command of MH370 (cont.)

f) Competency
• Smooth career path
• Flawless safety records
• Ability to handle stress well
• Valid license
• Medically fit
• Within Duty Time Limitations and well-rested
• No personal issues with FO though flying first time together

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 FLIGHT CREW PROFILE (cont.)

b) Medical History
• No health-related issue
2) First Officer of MH370 • Yearly medical checkup for continued
a) Personal Information licence to fly

• 27 years old from Kelantan c) Financial

• Not married
• 2 saving and a national trust fund accounts
• SPM
• Not much saving
• Langkawi Airspace Training
• 2 cars
2008
• 1 life insurance policy and a mortgage
insurance policy for a car

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 FLIGHT CREW PROFILE (cont.)

2) First Officer of MH370 (cont.)

d) Career e) Work Experience

• 2010 - FO B737 • Total:2813:43 hours

• 2012 - FO A330-330 • 39:11 hours on B777
• 2013 - FO B777-200
• 2014 - Last training flight B777

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 PILOT-IN-COMMAND’S HOME SIMULATOR

1) PIC’s home flight simulator documented more than 2,700 coordinates retrieved from
separate file fragments, mainly default game coordinates

2) Coordinates stored in Volume Shadow Information (VSI) file dated 03 February 2014
(VSI saved 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

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 1) PILOT-IN-COMMAND’S HOME SIMULATOR

3) The RMP Forensic Report on simulator did not find any data that showed the aircraft
was performing climb, altitude or heading manoeuvres, nor did it show a similar route
flown by MH370

4) The RMP Forensic Report concluded no unusual activities other than game-related flight
simulations

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 DETECTION OF HAND PHONE SIGNAL

1) The Telco service provider confirmed a signal “hit” occurred at 0152:27 MYT on 08 March 2014,
coming from the mobile phone tower Location Base station (LBS) at Bandar Baru Farlim,
Penang

2) The “hit” was traced to the registered number xxx of the FO

3) The signal “hit” did not record any communication except to confirm that it was in the ON mode
signal related to the “hit”
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 AIRWORTHINESS & MAINTENANCE AND AIRCRAFT SYSTEMS
Manufacturer Total Airframe Time (as of 07 March 2014)
Boeing Company 53,471.6 hours
Model
B777-200ER Engines (Time in Service
Registration (as of 07 March 2014)
9M-MRO 1. Engine 1 (Left): 40,779 hours/5,574 cycles
2. Engine 2 (Right): 40,046 hours/5,508 cycles
Engines
Rolls-Royce Trent
1 Major Repair
Date of Manufacture Damage to right wing tip during taxing at Pudong,
29 May 2002 China on 09 August 2012. Repair approved by FAA
Last Airworthiness Directive
Certificate of Airworthiness Replaced low pressure oxygen hoses in flight deck -
Valid till 02 June 2014 reducing likelihood of potential fire

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 AIRWORTHINESS & MAINTENANCE AND AIRCRAFT SYSTEMS (cont.)

1) Records show all Airworthiness Directives (mandatory inspections and modifications) had
been complied with

2) Technical Log Review since last D Check in June 2010 shows no significant defect trends

3) Engine Health Monitoring (EHM) trend reports over last 3 months show no evidence of
unusual engine behaviour

4) Two EHM reports, (Take-off and Climb) were transmitted. Both show no unusual engine
behaviour)
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 AIRWORTHINESS & MAINTENANCE AND AIRCRAFT SYSTEMS (cont.)

5) Transmission of Central Maintenance Computing System (CMCS) messages during last 10

flights, showing the system was functioning normal

6) No pre-existing defects affecting safety of flight

7) Maintenance complied with Approved Maintenance Schedule except for the instance of
expired SS FDR ULB (solid state flight data recorder underwater locator beacon) battery

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 REMOTE CONTROL TAKEOVER OF AIRCRAFT

1) A system, once activated would remove all controls from pilots and automatically fly and land
aircraft at predetermined location

2) Boeing received patent in November 2006

3) According to patent, bullet-proof cockpit doors and carriage of air marshals are vulnerable,
so a need for such a system to foil hijack attempts

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 REMOTE CONTROL TAKEOVER OF AIRCRAFT (cont.)

4) This ‘uninterruptible’ autopilot could be activated by pilots, on-board sensors or remotely via
radio or satellite links

5) Boeing has confirmed that it has not implemented the patented system or any other system
to remotely pilot a commercial aircraft or aware of any Boeing commercial aircraft that has
incorporated such technology

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 REMOTE CONTROL TAKEOVER OF AIRCRAFT (cont.)

6) 9M-MRO was delivered in May 2002 before the patent was issued in 2006

7) Aircraft modification data do not indicate that any such systems were installed on the aircraft post
delivery

8) No evidence to support the belief that MH370 was taken over control remotely

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 SATELLITE COMMUNICATIONS (SATCOM)
1) Handshake
MYT SATCOM TRANSMISSIONS
0042 Aircraft left KLIA
0107 Last ACARS
0225 1st handshake initiated by the aircraft
0239 Unanswered ground-to-air telephone call
0341 2nd handshake initiated by ground station
0441 3rd handshake initiated by ground station
0541 4th handshake initiated by ground station
0641 5th handshake initiated by ground station
0713 Unanswered ground-to-air telephone call
0810 6th handshake initiated by ground station
0819 7th handshake initiated by the aircraft
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 SATELLITE COMMUNICATIONS (cont.)

2) Data from the last seven SATCOM ‘handshakes’ were used to help establish the approximate
path of the aircraft over the Indian Ocean

3) At 0107 MYT SATCOM was used to send ACARS report which is normally sent every
30 minutes. However next report expected at 0137 MYT and subsequent were not received

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 WRECKAGE AND IMPACT INFORMATION

1) 27 Significant Debris Recovered and Examined:

• 3 pieces (Items 1, 10 and 19) confirmed to be from MH370

• 7 pieces (Items 2, 3, 4, 6, 16, 22 & 27) as almost certain from MH370
• 8 pieces (Items 5, 8, 9, 11, 15, 18, 20 & 26) as highly likely from MH370
• 1 pieces (Item 7) as likely from MH370
• 8 pieces ( Items 12, 13, 14, 17, 21, 23, 24 and 25) not identifiable
(26 of 27 pieces under custody of Malaysia. Flaperon still with French Judicial Authority)

2) Summary on Debris uploaded on: www.mot.gov.my

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 WRECKAGE AND IMPACT INFORMATION (cont.)
3) Confirmed And Almost Certain Debris Identification

Item 22 Item 10
Vertical Stabilizer panel Left Outboard Aft Flap Item 5
Door 1 Right Stowage Closet

Item 4
Engine Nose Cowl

Item 1
Keys Flaperon
Status Total Locations
Item 19 Item 6
1) Reunion Island - Item 1 Item 3
Confirmed 3 2) Mauritius - Items 10 Right hand Right Fan Cowling
Right Horizontal
3) Tanzania - Item 19 Outboard Aft Flap
Stabilizer (upper)
4) Mozambique Item 2
- Items 2, 3, 6 & 22
Right Wing No. 7
Almost Certain 7 5) South Africa -Item 4 Item 16
6) Madagascar - Item 16 Cabin Interior Panel
7) Mauritius - Item 5

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 WRECKAGE AND IMPACT INFORMATION (cont.)

4) To date, the main wreckage of MH370 has still not been found. However, items of debris
possibly/confirmed from MH370, have been found as far north as the eastern coast of
Tanzania and far south as the eastern coast of South Africa

5) Damage examination found on the right flaperon and the right outboard flap has led to the
conclusion that the right outboard flap was most likely in the retracted position and the right
flaperon was probably at the neutral position at the time they separated from the wing

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 CARGO CONSIGNMENT

223,000 kg of take-off weight

17,000 kg of total PAX weight

10,000 kg of total cargo (gross

weight)

3,300 kg of total baggage weight

4,500 kg of mangosteens

220 kg of lithium batteries and

2,200 kg of accessories
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 LITHIUM-ION BATTERIES
1) Assembled on 07 March 2014, packed and placed on wooden pallets

2) From Motorola forwarder NNR Global Logistics sent shipment to MASkargo Penang

3) Battery shipment physically inspected by MASkargo staff but not screened by MAS Security
using x-ray machine (then no available x-ray machine large enough to screen cargo in Penang)

4) Also went through Customs inspection and clearance

5) Li-Ion batteries not classified as dangerous goods because packing adhered to the Guidelines
stipulated in the Lithium Battery Guidance Document
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 MANGOSTEENS

1) 2,500 kg - Poh Seng Kian from Muar, the rest from Sumatra

2) Mangosteens placed in plastic baskets (8 to 9 kg per basket), sponge soaked with

water put on top of baskets to maintain freshness. Loaded onto trucks and sent to
MASkargo, KLIA

3) MAS provided Unit Load Device (ULD) to the forwarding agent

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 MANGOSTEENS (cont…)

5) Fruits put into ULD, checked by Federal Agricultural Marketing Authority (FAMA) and MAS and
loaded into aircraft - 4 ULDs used

6) A total of 85 shipment to China from January to May 2014

7) Regular consignment for the past few years

8) No irregularity in packing process

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 AIR TRAFFIC SERVICES FROM 0119 TO 0632 MYT
1) Transfer of control should be at 0122 MYT or when MH370 was over IGARI on radar
(HCM ACC not aware that MH370 had been transferred at 0119) by transferring at 0119 MYT
KL ATC Controller did not comply with established procedures

2) KL Radar Controller transferred aircraft before 0122 MYT and did not:
• Record the time on the flight strip of MH370
• Monitor progress of flight MH370 after transfer of control, and when aircraft dropped off
from radar display at 0121 MYT

3) HCM ACC at 0122 MYT (as per estimate time) should call KL by 0127, 5 minutes later (Letter of
Agreement between HCM ATC and KL ATC), but only did at 0139 MYT - 12 minutes later
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 CHRONOLOGY OF KL ATSC EVENTS FROM 0119 - 0632 HOURS

4) Based on above chronology of events from 0119 to 0632 hours, investigation concluded
KL ATSC Radar Control had :

a) Not maintained continuous watch on radar display as required

b) Released control before agreed transfer of control point

c) Relied too much on MAS information

d) Not initiated various emergency phases as required

e) Not made effort to liaise with RMAF

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 CONCLUSION

1) Evidence shows that Flight MH370 diverted from the Filed Flight Plan Route. The changes
in the aircraft flight path after waypoint IGARI are difficult to attribute to anomalous system
issues alone

2) Flight simulator trials established that the turn back was made while the aircraft was under
manual control and not using autopilot

3) HCM ACC did not notify the transferring unit (KL ATSC) when two-way communication was
not established with MH370 within (5) five minutes of the estimated time of the transfer of
control point 37
 CONCLUSION (cont.)

4) KL ATSC relied too much on position information of the aircraft provided by MAS Flight
Operations

5) Air Traffic Controllers did not initiate the various emergency phases as required, thereby
delaying the activation of the Search and Rescue operations

6) The PIC and FO held valid airman licences and medical certification were within duty-time
limits, and were adequately rested
38
 CONCLUSION (cont.)

7) There had been no financial stress or behavioural changes to the PIC and FO

8) The radio-telephony communication by the PIC and the FO with the air traffic controllers showed
no evidence of anxiety or stress

9) 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
FDR ULB battery which had expired

39
 CONCLUSION (cont.)

10) No record or report of any defect or malfunction in the aircraft that could have contributed to
the event

11) It is possible that the absence of communications prior to the flight path diversion was due to
the systems being manually turned off, whether with intent or otherwise

12) The analysis of the relevant systems taking into account the route followed by the aircraft
and the height at which it flew, does not suggest a mechanical problem with the aircraft’s
airframe, control systems, fuel or engines
40
 CONCLUSION (cont.)

13) Data from the last seven SATCOM ‘handshakes’ were used to help establish the approximate
path of the aircraft over the Indian Ocean

14) Log-on at 0225 MYT (08 March 2014) initiated by the aircraft was most likely due to power
interruption to the SATCOM avionics

15) Log-on at 0819 MYT was most likely due to power interruption, probably due to fuel exhaustion
at this time resulting in the loss of both engines and automatic start-up of APU and powering of
the busses 41
 CONCLUSION (cont.)

16) To date, the main wreckage of MH370 has still not been found. However, items of debris
possibly/confirmed from MH370, have been found as far north as the eastern coast of Tanzania
and far south as the eastern coast of South Africa

17) Damage examination found on the right flaperon and the right outboard flap has led to the
conclusion that the right outboard flap was most likely in the retracted position and the right
flaperon was probably at the neutral position at the time they separated from the wing

42
 CONCLUSION (cont…)

18) The flaperon, a part of the right outboard flap and a section of the left outboard flap were
confirmed to be from MH370.

19) 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

20) The possibility of intervention by a third party cannot be excluded

43
 CONCLUSION (cont.)

21) 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

22) The lack of evidence includes the information recorded on the Flight Data Recorder, Cockpit
Voice Recorder and other recording devices on the aircraft that could indicate why the aircraft
flew to the Southern Indian Ocean

23) In conclusion, the Team is unable to determine the real cause for the disappearance of
MH370
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 REPORT AVAILABLE:

mh370.mot.gov.my

FOR ENQUIRIES:

Email: [email protected]

TERIMA KASIH
65
 QUESTIONS & ANSWERS SESSION

SAFETY INVESTIGATION REPORT

MALAYSIA AIRLINES BOEING B777-200ER (9M-MRO)
- 8th March 2014