Malaysia Airlines MH370, a human error?

On 09 April 2014, the Malaysian Ministry of Transport released the Preliminary
Report into the investigation activities at that time. The Preliminary Report
contained a Safety Recommendation to ICAO in regard to in-flight tracking of large
commercial aircraft.

Introduction of the flight

Malaysia Airlines Flight 370 was a passenger flight operated by Malaysia Airlines that disappeared on 8 March 2014 while flying from  Malaysia to its planned destination, Beijing Capital International Airport. It has been the most famous aircraft disaster and many theories around safety revolve about this accident.

On 08 March 2015, the Team released the 1st Interim Statement and a Factual
Information Report detailing the factual information available at that time. The
report contained no analysis, findings/conclusions or safety recommendations.
Copies of both the Interim Statement and the Factual Information Report are
available from the Malaysian Ministry of Transport’s.

Recognising that at the time of issue of this Report, the main aircraft wreckage, including the
aircraft’s Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) have not
yet been located, this Report will necessarily be limited by a significant lack of
evidence.

Based on the available evidence, the analysis of factors considered relevant to the
disappearance of MH370 include:

• Diversion from Filed Flight Plan Route;
• Air Traffic Services Operations;
• Flight Crew Profile;
• Airworthiness & Maintenance and Aircraft Systems;
• Satellite Communications;
• Wreckage and Impact Information;
• Organisation and Management Information of DCA and MAS; and
• Aircraft Cargo Consignment.
Other factors examined by the investigation and not considered relevant include
the aircraft weight and balance, the amount and quality of fuel on-board and
meteorological conditions.

Significant Issues and Safety Recommendations

In the analysis of the above factors, 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.
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.
Additionally, a number of issues were identified that could affect the monitoring and
timely initiation of search and rescue of commercial aircraft in Malaysian airspace
by the Air Navigation Services provider. Issues were also identified in the Airline
Operations. They include the following:

• Malaysian and adjacent air traffic management;
• Cargo screening;
• Flight crew medical and training records;
• Reporting and following-up of crew mental health;
• Flight following system;
• Quick reference for operations control; and
• Emergency locator transmitter effectiveness.

Aftermath and conclusion

As a result of the issues identified in the investigation, at any stage of the investigation of an accident or
incident, the accident investigation authority of the State conducting the investigation
shall recommend in a dated transmittal correspondence to the appropriate authorities,
including those in other States, any preventive action that it considers necessary to be
taken promptly to enhance aviation safety”, a number of safety recommendations have been made to the Department of Civil
Aviation (DCA), Civil Aviation Authority of Viet Nam, Malaysian Airlines Berhad (MAB,
formerly MAS), the Malaysia Airports Holdings Berhad (MAHB) and the International
Civil Aviation Organization (ICAO) to enhance aviation safety.

References:

[1] “SAFETY INVESTIGATION REPORT Malaysia Airlines Boeing B777-200ER (9M-MRO) By The Malaysian ICAO Annex 13 Safety Investigation Team for MH370 The Malaysian ICAO Annex 13 Safety Investigation Team for MH370,” 2014. Available: https://reports.aviation-safety.net/2014/20140308-0_B772_9M-MRO.pdf

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