section 1.1 - history of the flight

38 Pages·2015·1.82 MB·English

FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

SECTION 1.1 - HISTORY OF THE FLIGHT
1.1.1 Flight between 1642 to 1719:30 UTC [0042 to 0119:30]

On 07 March 2014 at 1642 UTC1 [0042 MYT, 08 March 2014], a Malaysia Airlines (MAS)
Flight MH370, a Beijing-bound international scheduled passenger flight, departed from
Runway 32R, KL International Airport [KLIA] with a total of 239 persons on board (227
passengers and 12 crew). The aircraft was a Boeing 777-200ER, registered as 9M-MRO.

The Captain had signed in for duty at 1450 UTC, 07 March 2014 [2250 MYT, 07 March 2014]
followed by the First Officer who signed in 25 minutes later. The MAS Operations Despatch
Centre (ODC) released the flight at around 1515 UTC [2315 MYT].

The Captain, an authorised examiner for the Department of Civil Aviation (DCA), Malaysia,
was conducting line training for the First Officer, who was transitioning to the Boeing 777
(B777) aircraft type from the Airbus A330.

The Captain ordered 49,100 kilograms (kg) of fuel for the flight that gave an endurance of 07
hours and 31 minutes including reserves. The planned flight duration was 05 hours and 34
minutes.

The recorded radio transmissions between Air Traffic Controllers (ATC) at Kuala Lumpur Air
Traffic Control Centre (KL ATCC) and the flight crew showed that an airways clearance
request to Lumpur Airways Clearance Delivery was made at 1625:52 UTC [0025:52 MYT]
and pushback and start clearance at 1627:37 UTC [0027:37 MYT] to Lumpur Ground.

Lumpur Tower cleared MH370 for take-off at 1640:37 UTC [0040:37 MYT]. At 1642:53 UTC
[0042:53 MYT] Lumpur Departure cleared MH370 to climb to Flight Level (FL) 180 (the
aviation term for 18,000 feet [ft.]) and to cancel the Standard Instrument Departure (SID)
clearance by tracking direct to waypoint IGARI.

At 1643:31 UTC [0043:31 MYT] KL ATCC Sector 3 Planner coordinated with Ho Chi Minh
(Vietnam) Air Traffic Control Centre (HCM ATCC) on the direct land line, the flight’s Estimate
Time of Arrival (ETA) of MH370 for waypoint IGARI as 1722 UTC [0122 MYT] and the
assigned transponder code A2157.

There was no record of transmission that a revision of ETA was passed by KL ATCC to HCM
ATCC when MH370 was cleared direct to waypoint IGARI. However, based on the
reconstruction of the flight profile conducted on the B777 simulator, the flight would be at
waypoint IGARI one minute earlier than the original ETA of 1722 UTC [0122 MYT].

It was later established that normal automated Aircraft Communication Addressing and
Reporting System (ACARS) transmissions (refer to Section 1.9.4 - ACARS) were made
through the aircraft’s satellite communication system up to 1707:29 UTC [0107:29 MYT]
when the last ACARS communication occurred.

1 Unless specified, all times in this report are in Universal Coordinated Time (UTC). Malaysian Time (MYT) is UTC
+8 hours.
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M alaysian ICAO Annex 13
Safety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

MH370 was transferred to Lumpur Radar at 1646:39 UTC [0046:39 MYT].

At 1646:58 UTC [0046:58 MYT] MH370 was cleared to climb to FL250 and subsequently to
FL350 at 1650:08 UTC [0050:08 MYT]. MH370 reported maintaining FL350 at 1701:17 UTC
[0101:17MYT] and reported maintaining FL350 again at 1707:56 UTC [0107:56 MYT].

At 1719:26 UTC [0119:26 MYT], MH370 was instructed to contact HCM ATCC on the radio
frequency of 120.9 MHz.

At 1719:30 UTC [0119:30 MYT], MH370 acknowledged with “Good night Malaysia Three
Seven Zero”. This was the last recorded radio transmission from MH370.

Radar recording showed that MH370 passed through waypoint IGARI at 1720:31 UTC
[0120:31 MYT].

The Mode S symbol of MH370 dropped off from radar display at 1720:36 UTC [0120:36
MYT], and the last secondary radar position symbol of MH370 was recorded at 1721:13 UTC
[0121:13 MYT].

The disappearance of the radar position symbol of MH370 was captured by the KL ATCC
radar at time 1721:13 UTC [0121:13 MYT]. Military radar and radar sources from two other
countries, namely Vietnam and Thailand, also captured the disappearance of the radar
position symbol of MH370 at about the same time.
(Refer to Figure 1.1A - Chronological Sequence of Events of Disappearance of MH370)

1.1.2 Activities by Ground Air Traffic Controllers Thereafter

At 1739:06 UTC [0139:06 MYT] HCM ATCC queried KL ATCC on the whereabouts of
MH370.
Thereafter KL ATCC initiated efforts involving MAS Operations Centre, Hong Kong ATC
(China) and Phnom Penh (Cambodia) ATC in an attempt to establish the location of MH370.
No contact had been established by any of the ATC units.
The Kuala Lumpur Rescue Coordination Centre (KL RCC) was activated at 2232 UTC [0632
MYT].

1.1.3 Diversion from Filed Flight Plan Route - 1721:13 to 1822:12 UTC [0121:13
to 0222:12 MYT]
(Figure 1.1B shows the diversion from the filed flight plan route in pictorial form [not
to scale])

a) Malaysia Military Radar
The Military data provided more extensive details of what was termed as “Air Turn Back”.
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MH370/01/15
M alaysian ICAO Annex 13
Safety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

At 1721:13 UTC [0121:13 MYT] the Military radar showed the radar return of MH370
turning right but almost immediately making a constant left turn to a South Westerly
direction.
At 1730:35 UTC [0130:35 MYT] to 1735UTC [0135 MYT] the radar return was on heading
231 magnetic (M), ground speed of 496 knots (kt.) and registered height of 35,700 ft.
At 1736 UTC [0136 MYT to 1736:40 UTC [0136:40 MYT] heading was 237M, ground
speed fluctuation between 494 and 525 kt. and height fluctuation between 31,100 and
33,000 ft.
At 1739:59 UTC [0139:59 MYT] heading was 244M, ground speed 529 kt. and height at
32,800 ft.
At 1752:35 UTC [0152:35 MYT] radar return was observed to be slightly south of Penang
Island.
It was noted by the Investigation Team that the position and heading of the radar return
from both Civilian and Military Radar, suggested that it was from the same target.
After the last radar return disappeared from KL ATCC Primary Radar at 1752:35 UTC
[0152:35 MYT], the Military Radar continued to track this radar return as it headed
towards Pulau Perak, a small island over the Straits of Malacca. The time registered over
Pulau Perak was 1802:59 UTC [0202:59].
The tracking by the Military continued as the radar return was observed to be heading
towards waypoint MEKAR, a waypoint on Airways N571 when it disappeared abruptly at
1822:12 UTC [0222:12 MYT],10 nautical miles (Nm) after waypoint MEKAR.

b) DCA Civilian Radar Data from Kota Bharu

The aircraft diversion from the filed flight plan route was recorded on the DCA radar
playback.
(Figure 1.1B shows the diversion from Filed Flight Route in pictorial form [not to scale] and
Figure 1.1D shows the Filed Flight Plan message)
From 1730:37 UTC [0130:37 MYT] to 1744:52 UTC [0144:52 MYT] a primary aircraft
target was captured by the Terminal Primary Approach Radar located to the south of Kota
Bharu Airport runway.
 The appearance of an aircraft target on the KL ATCC radar display, coded as P3362,
was recorded at 1730:37 UTC [0130:37 MYT] but disappeared from the radar display
at 1737:22 UTC [0137:22 MYT].

 At 1738:56 UTC [0138:56 MYT] an aircraft target, coded as P3401, appeared on the KL
ATCC radar display and disappeared at 1744:52 UTC [0144:52 MYT].

 At 1747:02 UTC [0147:02 MYT] an aircraft target, coded as P3415, appeared on the KL
ATCC radar display but disappeared at 1748:39 UTC [0148:39 MYT].

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MH370/01/15
M alaysian ICAO Annex 13
Safety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

 At 1751:45 UTC [0151:45 MYT] an aircraft target, coded as P3426,appeared on the KL
ATCC radar display but disappeared at 1752:35 UTC [0152:35 MYT].

The primary aircraft targets above have been confirmed by DCA and its maintenance
contractor, Advanced Air Traffic Systems (M) Sdn. Bhd. (AAT), that it was Kota Bharu
Primary Radar Station which captured them.
(Figure 1.1E shows primary radar targets (plots) from Kota Bharu Primary Radar Station,
plotted by AAT using Eva & Plotter 01.01-27 [after diversion])
(Figure 1.1F - primary radar targets (track), plotted by AAT using Eva & Plotter 01.01-27
[from take-off]).
All the primary aircraft targets that were recorded by the DCA radar are consistent with
those of the military data that were made available to the Investigation Team.

References: Aeronautical Information Publication [AIP] Malaysia ENR 1.6 dated 05 JUN
2008, AIP AMDT 2/2008 on the Provision of Radar Services and Procedures, which
states in paragraph 1.1.4 that “In the Kuala Lumpur and Kota Kinabalu FIRs, radar
services are provided using the following civil/military ATC Radars:…g) A 60 NM Terminal
Primary Approach Radar co-mounted with 200 NM monopause SSR2 located to the south
of Kota Bharu-Sultan Petra.”
(Figure 1.1C shows the Radar Coverage Chart of Kuala Lumpur and Kota Kinabalu FIRs)
Source: Malaysian AIP ENR 1.6-11 dated 25 AUG 2011 AIP AMDT 3/2011.

c) Ho Chi Minh Radar and Automatic Dependent Surveillance - Broadcast (ADS-B)
The tracking of MH370 was captured by HCM ATCC SSR and ADS-B (located at Conson
Island/range 270 Nm) at 1711.59 UTC [0111:59 MYT] as it was heading for waypoint
IGARI.
At 1720:33 UTC [0120:33 MYT] MH370 SSR and ADS-B radar position symbols
disappeared from the radar display.

d) Medan Indonesia Radar
The Medan ATC Radar has a range of 240 Nm, but for unknown reasons, did not pick up
any radar return bearing SSR transponder code A2157 of MH370. The Military however
admitted that they picked up MH370 earlier as it was heading towards waypoint IGARI.
No other information was made available.

e) Thailand Radar
The radar position symbol with SSR transponder code A2157 was detected on
Aeronautical Radio of Thailand Limited (AEROTHAI) radar display at 1711 UTC [0111
MYT] as the aircraft was tracking for waypoint IGARI. Thailand DCA is a government
agency whereas AEROTHAI is a state enterprise under the Ministry of Transport and
Communications. AEROTHAI is the air navigation service provider responsible for the
provision of Air Traffic Services within Bangkok Flight Information Region (FIR).

2 SSR – Secondary Surveillance Radar – A surveillance radar system which uses transmitters/receivers system
(interrogators) and transponders.

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MH370/01/15
M alaysian ICAO Annex 13
Safety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

As the flight plan of MH370 did not fall under Thailand’s FIR Bangkok ATCC did not pay
much attention to this flight.

On playback of the radar recording it was noted that the radar position symbol of A2157
disappeared at 1721:13UTC [0121:13 MYT].

1.1.4 Search for Aircraft

Extensive work done by the MH370 Search Strategic group, coordinated by Australian
Transport Safety Bureau (ATSB), by analysing signals transmitted by the aircraft’s satellite
communications terminal to Inmarsat’s Indian Ocean Region satellite indicated that the
aircraft continued to fly for several hours after loss of contact. The analysis showed the
aircraft changed course shortly after it passed the northern tip of Sumatra (Indonesia) and
travelled in a southerly direction until it ran out of fuel in the southern Indian Ocean west of
Australia. Details of this work can be found in ATSB’s report: AE-2014-054 dated 26 June
2014, available at ATSB’s website: http://www.atsb.gov.au

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MH370/01/15
M alaysian ICAO Annex 13
Safety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..
Keys

No SSR radar symbol on the Flight Plan Route
SSR Transponder was not serviceable
9 3.2Nm after passing IGARI at 1721:13 UTC [0121:13
MYT]. The radar position of MH370 dropped off

MH370 Mode S symbol dropped off at 1720:36
8

UTC [0120:36 MYT]

MH370 over waypoint IGARI at 1720:31 UTC
7
[0120:31 MYT]

`KL ATCC transferred MH370 to HCM ATCC at

1719:26 UTC [0119:26 MYT], 8.6 Nm to waypoint
6 IGARI. MH370 acknowledged KL ATCC instruction

FILED FLIGHT PLAN ROUTE to contact HCM ATCC with ‘GOOD NIGHT
MALAYSIAN THREE SEVEN ZERO’ at 1719:30 UTC
IGARI 9 [0119:30 MYT]
8 MH370 reported again maintaining FL350 at 1707:56 UTC
8.6Nm
[0107:56 MYT]
7
BITOD MH370 maintaining FL350 at 1701:17 UTC [0101:17
5
6
MYT]
5

4 MH370 climbing to FL350 at 1650:11 UTC [0050:11
4 MYT]
3
2 3 MH370 climbing to FL250 at 1647:03 UTC [0047:03 MYT]

1 2 MH370 climbing to FL180 at 1643:01 UTC [0043:01

MYT]
Lumpur Tower cleared take-off at 1640:37 UTC
1
[0040:37 MYT] and MH370 departed at 1642 UTC
[0042 MYT]
Figure 1.1A - Chronological Sequence of Events of Disappearance of MH370

MH370/01/15
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Malaysian ICAO Annex 13
S afety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..
KEYS
1 P3362 : Appeared at 1730:37 UTC [0130:37 MYT]
2 P3362 : Coasted at 1737:12 UTC [0137:12 MYT]
Dropped at 1737:22 UTC [0137:22 MYT]
3 P3401: Appeared at 1738:56 UTC [0138:56 MYT]
4 P3401 : Coasted at 1744:42 UTC [0144:42 MYT]
Dropped at 1744:52 UTC [0144:52 MYT]
SOURCE OF INFORMATION: FR0M THE
MILITARY
5 P3415 : Appeared at 1747:02 UTC [0147:02 MYT]
6 P3415 : Coasted at 1748:29 UTC [0148:29 MYT] N571
Dropped at 1748:39 UTC [0148:39 MYT]
10
7 P3426 : Appeared at 1751:45 UTC [0151:45 MYT] 1
2
P3426 : Coasted at 1752:25 UTC [0152:25 MYT] 9
Dropped at 1752:35 UTC [0152:35 MYT]
8
P3426 last seen on radar display approximately
5
6Nm South of Penang 7 3
4
The primary target (military radar) appeared to 6 4
N571 8
9 track west-northwest direction joining RNAV
Route N571 at waypoint VAMPI then to 10Nm
north MEKAR
10
The primary target ended at 10Nm after MEKAR
at 1822.12 UTC [0222.12 MYT]
Figure 1.1B – Diversion from Filed Flight Plan Route (not to scale)

MH370/01/15
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Malaysian ICAO Annex 13
S afety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

Figure 1.1C - Radar Coverage Chart of Kuala Lumpur and Kota Kinabalu FIRs
(Ref: Malaysian AIP ENR 1.6-11dated 25 Aug 2011 AIP AMDT 3/2011)

MH370/01/15
8
Malaysian ICAO Annex 13
S afety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

Figure 1.1D – Filed Flight Plan Message
MH370/01/15
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Malaysian ICAO Annex 13
S afety Investigation Team for MH370
Ministry of Transport, Malaysia
FACTUAL INFORMATION SAFETY INVESTIGATION FOR MH370 (9M-MRO)
…………………………………………………………………………………………………..

Figure 1.1E – Primary Radar Targets (plots) from Kota Bharu Radar Station,
plotted by AAT using EVA & Plotter 01.01-27 (After Diversion)
MH370/01/15
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Malaysian ICAO Annex 13
S afety Investigation Team for MH370
Ministry of Transport, Malaysia