Safety Investigation Report 2018:2 Analysis/2.2 Air Traffic Services Operations

SAFETY INVESTIGATION REPORT MH370 (9M-MRO)

SECTION 2 – ANALYSIS

2.2 AIR TRAFFIC SERVICES OPERATIONS

2.2.1 Review of Flight MH370 before its Disappearance

The MH370 from Kuala Lumpur to Beijing was a normal daily scheduled flight. It took off at 1642 UTC [0042 MYT].
There was no indication of any unusual operations prior to departure and during the flight until the last secondary radar position symbol was recorded by ATC at 1721 UTC [0121 MYT] as detailed in Table 2.2A -Chronological of events before disappearance of MH370 below.
Preparation of the flight was in order from the time the Filed Flight Plan²⁹ (FPL) message was filed and transmitted 12 hours before the flight.
The flight crew reported on time for duty and there was no delay in the departure of the flight (Figure 2.2C [below] - Departure message).
There was also no report of any significant or unusual health-related issues for the flight and cabin crew.
The radiotelephony speech segments from the cockpit with KL ACC were determined from the voice analysis of the ATC radiotelephony communications recording to be that of the FO before take-off and the PIC after take-off.
The transfer of control was effected three minutes before the estimate for IGARI. There was no recording of transmission (voice or in written form) of KL ACC informing HCM ACC (via direct land line) when MH370 was transferred 3 minutes earlier than the estimate for the Transfer of Control Point (TCP).

Note:
Based on reconstruction (Section 2.1) of the flight profile conducted on the B777 simulator, the flight would be at waypoint IGARI one minute earlier than the original estimate of 1722 UTC [0122 MYT].

²⁹ Filed Flight Plan – The flight plan as filed with an ATS unit by the pilot or his designated representative, without any subsequent changes.

2.2.2 Chronology of ATC Events before the Disappearance of Flight MH370

No.	Time	Event	Remarks
1.	0444 UTC [1244 MYT]	Filed Flight Plan (FPL) of scheduled flight of MH370 transmitted at 070444 UTC [071244 MYT], about 12 hours earlier over the Aeronautical Fixed Telecommunications Network (AFTN).	As required under Annex 10, Volume II.
1.	0444 UTC [1244 MYT]	Flight planned on ATS/RNAV Routes R208 IGARI M765 BITOD L637 TSN… ZBAA.	Filed Flight Plan (Figure 2.2A)
2.	1450 UTC [2250 MYT]	PIC of MH370 signed in for duty.	As per operational requirements.
3.	1515 UTC [2315 MYT]	FO of MH370 signed in for duty.
3.	1515 UTC [2315 MYT]	MAS Operations Despatch Centre (ODC) released flight.
4.	1625:52 UTC (0025:52 MYT)	Airway clearance request to Lumpur Airways Clearance Delivery.
5.	1625:52 UTC [0025:52 MYT]	Airway clearance request to Lumpur Airways Clearance Delivery.
6.	1627:31 UTC (0027:31 MYT)	Pushback and start-up clearance request to Lumpur Ground.	As per operational requirements.
7.	1640:31 UTC ~~0040:31 MYT~~ (0040:37 MYT)	Lumpur Tower cleared MH370 for take-off.	As per operational requirements.
8.	1642 UTC (0042 MYT)	MH370 departed from Runway Three Two Right KLIA.	Departure message (Figure 2.2C)
9.	1642:53 UTC 0042:53 MYT)	Lumpur Departure cleared MH370 to climb to FL180 and to cancel the Standard Instrument Departure (SID) clearance by tracking direct to waypoint (Figure 2.2A) IGARI.	Normal ATC practice for track shortening.
10.	1643:31 UTC (0043:31 MYT)	KL ACC Sector 3+5 coordinated with HCM ACC via direct land line the estimate of MH370 for waypoint IGARI at 1722 UTC on [0122 MYT], request flight level 350 and the assigned SSR Code 2157.	As per Letter of Agreement between Malaysia and Viet Nam. (Appendix 1.1A)
11.	1646:39 UTC (0046:39 MYT)	MH370 transferred to Lumpur Radar (Sector 3+5).	As per operational requirement.
12.	1646:58 UTC (0046:58 MYT)	Lumpur Radar (Sector 3+5) cleared MH370 to climb to FL250.	As per operational requirement.
13.	1650:08 UTC (0050:08 MYT)	Lumpur Radar (Sector 3+5) cleared MH370 to climb to FL350.	As per operational requirement.
14.	1701:17 UTC (0107:17 MYT)	MH370 reported maintaining FL350.	It was noticed that the PIC made the same statement of “maintaining flight level three five zero’ twice at 1701:17 UTC [0101.17 MYT] and at 1707:56 UTC [0107:56 MYT].
15.	1707:56 UTC (0107:56 MYT)	MH370 reported maintaining FL350.	However, the Team did not find any significance of that statement spoken twice by PIC in a short interval of 6.39 minutes. Also refer para. 2.2.9 para 1) a) (1-6) on Radiotelephony Readback on frequency changes for more details.
16.	1719:26 UTC (0119:26 MYT)	The KL ACC radar Controller transferred MH370 to HCM ACC by instructing MH370 to contact Ho Chi Minh on the VHF radio frequency 120.9 MHz.	Transfer of control was effected 3 minutes before the estimate for IGARI. KL ACC passed to HCM ACC estimate for IGARI as 1722 UTC. Transfer of control to HCM ACC was effected at 1719 UTC before MH370 was over IGARI. There was no arrangement between KL ACC and HCM ACC for an “electronic handoff” or other methods to hand over the radar picture.
17.	1719:30 UTC (0119:30 MYT)	MH370 responded with: “Good night Malaysian Three Seven Zero”.	Thereafter there was no further voice communication.

Table 2.2A - Chronology of ATC Events before the Disappearance of Flight MH370

2.2 Air Traffic Services Operations

2.2.3 Filed Flight Plan of MH370

Figure 2.2A - Filed Flight Plan of MH370

Figure 2.2A - Filed Flight Plan of MH370
Source: DCA Malaysia

1) Message Code of FPL of MH370 and Meaning

Message Code	Meaning
KLA297 070444
KL	KLIA message
A	Series
297	Sequence Number
070444	Date-time-group or the transmission time of the filed flight plan message at 070444UTC

FF WMKKZQZX WMKKZRZX
FF	Priority Indicator for the message category
WMKKZQZX	8-letter addressee for Lumpur “Area Control Centre”
WMKKZRZX	8-letter addressee for Lumpur “Approach Radar Office”

070441 WMKKYOYX
070441	Message Filling Time (in UTC)
WMKKYOYX	8-letter Message Originator for KLIA Aeronautical Information Office

Field Type 3 - Message type, number and reference data
(FPL	Filed Flight Plan Message
WMKKYOYX	Message Originator Indicator i.e. KLIA Aeronautical Information Service Office.

Field Type 7- Aircraft Identification and SSR mode and code
-MAS370	Aircraft identification Malaysian 370

-Field Type 8 - Flight rules and type of flight
-I	Instrument Flight Rules
-S	Status: - Scheduled Air Transport

Field Type 9 - Number and type of aircraft and wake turbulence category
-B772/H	Boeing 777-200/wake turbulence category/Heavy

Field Type 10 - Equipment and capabilities
(a) Radio communication, navigation and approach aid equipment and capabilities
-SDFGHIJ3J5M1RWXY/LB1D1
-S	Equipped with: Standard COM/NAV/approach aid equipment for the route is carried and serviceable. Standard equipment is considered to be VHF RTF, VOR and ILS.
D	DME
F	ADF
G	GNSS
H	HF RTF
I	Inertial Navigation
J3	CPDLC FANS 1/A VDL Mode 4
J5	CPDLC FANS 1/A SATCOM (INMARSAT)
M1	ATC RTF SATCOM (INMARSAT)
R	PBN approved
W	RVSM approved
X	MNPS approved
Y	VHF with 8.33 kHz. channel spacing capability/

(b) Surveillance equipment and capabilities
L	Transponder Mode S, including aircraft identification, pressure-altitude, extended squitter (ADS-B) and enhanced surveillance capability
B1	ADS-B with dedicated 1090 MHz ADS-B “out” capability
	D1 ADS-C with FANS 1/A capabilities

Field Type 13 - Departure aerodrome and time
-WMKK1635	-Departure aerodrome KLIA estimated off-block time 1635 UTC

Field Type 15 – Route

-N0470F290 DCT PIBOS R208 IKUKO/M081F330 R208 IGARI M765

BITOD/N0480F330 L637 TSN/N0480F350 W1 BMT W12 PCA G221

BUNTA/N0480F370 A1 IKELA/N0480F370 P901 IDOSI/N0480F390

DCT CH DCT BEKOL/K0900S1160 A461 YIN/K0890S1130 A461 VYK

-airspeed 470 knots requested flight level 290 - the flight will proceed direct to waypoint PIBOS joining Airway R208 and to waypoint IKUKO, thence the airspeed will be Mach 0.81 flight level 330 on Airway R208 to waypoint IGARI joining Airway M765 thence to waypoint BITOD. Thence the airspeed will be 480 knots and flight level 330 on Airways L637 and proceed to TSN (Tansonnhat), thence the airspeed will be 480 knots and flight level 350. Thence on Airway W1 to BMT (Buon Ma Thout), thence Airway W12 to PCA (Phu Cat), thence on Airway G221 to waypoint BUNTA, thence airspeed will be 480 knots and flight level 370, thence proceed via Airway A1 to waypoint IKELA, thence airspeed will be 480 knots and flight level 370, thence via Airway P901 to waypoint ISODI, airspeed 480 knots and flight level 390. Thence track direct to CH (Cheung Chau), and direct to waypoint BEKOL. Thence the airspeed will be 900 kilometres per hour and level 11600 meters on Airway A461, thence to YIN (Yingde). Thence, the airspeed will be 890 kilometres per hour and level 11300 metres on Airway A461 to VYK (Dawangzhuang).

Field Type 16 - Destination aerodrome and total estimated elapsed time, destination alternate aerodrome(s)
-ZBAA0534 ZBTJ ZBSJ
-Destination aerodrome ZBAA - Beijing Capital International Airport and total estimated elapsed time 5 hours and 34 minutes Destination alternate aerodrome(s) ZBTJ - Tianjin Binhai International Airport, and ZBSJ - Shijiazhuang Zhengding International Airport

Field Type 18 – Other information
PBN/A1B1C1D1L1O1S2 DOF/140307 REG/9MMRO EET/WSJC0032 VVTS0042 ZJSA0210 VHHK0233 ZGZU0304 ZHWH0356 ZBPE0450 SEL/QRC RMK/ACASII EQUIPPED)
PBN	Performance Based Navigation/Indication of RNAV and or RNP capabilities.
PBN	RNAV Specifications
A1	RNAV 10 (RNP 10)
B1	RNAV 5 all permitted sensors
C1	RNAV 2 all permitted sensors
D1	RNAV 1 all permitted sensors
	RNP Specifications
L1	RNP 4
O1	Basic RNP 1 all permitted sensors
S2	RNP APCH with BARCO-VNAV
DOF/140307	Date of flight/2014 March 7^th
REG/9MMRO	Aircraft registration 9MMRO
EET	FIR boundary designators and accumulated estimated elapsed times from take-off to such FIR boundaries. Singapore FIR 32 minutes Ho Chi Minh FIR 42 minutes Sanya FIR 2 hours 10 minutes Hong Kong FIR 2 hours 33 minutes Guangzhou FIR 3 hours 4 minutes Wuhan FIR 3 hours 56 minutes Beijing FIR 4 hours 50 minutes
SEL/QRC	Selective Calling code/QRC
RMK/ACAS II EQUIPPED	Equipped with ACAS II)

Figure 2.2B - Message Code of Filed Flight Plan of MH370 and Meaning
Source: Safety Investigation Report MH370/01/2018 2.2.3 Filed Flight Plan of MH370

2.2.7 Chronology of ATC Events following the Disappearance of MH370 (Table 2.2C, below)

No.	Time	Event
1.	1720:31 UTC (0120:31 MYT)	Radar recording showed MH370 passed over waypoint IGARI.
2.	1720:36 UTC (0120:36 MYT)	Mode S radar symbol of MH370 dropped off from radar display.
3.	1721:13 UTC (0121:13 MYT)	3.2 nm after passing IGARI, SSR radar position symbol of MH370 dropped off from radar display. Two radar sources, from Viet Nam and Thailand respectively, captured the disappearance of the radar position symbol of MH370 vis-à-vis Bangkok radar target drop at 1721:13 UTC [0121:13 MYT] and Viet Nam’s at 1720:59 UTC [0120:59 MYT].
4.	1739:03 UTC (0139:03 MYT)	HCM ACC queried KL ACC on whereabouts of MH370 and informed KL ACC that verbal contact with MH370 was not established and the radar target was last seen at waypoint BITOD. Note: MH370 did not arrive over waypoint BITOD (Refer to Item 3 above).
5.	1741:22 UTC (0141:22 MYT)	HCM ACC enquired for information on MH370. KL ACC informed HCM ACC that after waypoint IGARI, MH370 did not return to Lumpur radar frequency.
6.	1741:23 UTC (0141:23 MYT)	KL ACC Radar Controller made a ‘blind transmission’³⁰ to MH370.
7.	1746:47 UTC (0146:47 MYT)	HCM ACC queried on MH370 again, stating that radar contact was established at IGARI but there was no verbal contact. HCM ACC advised that the observed radar blip disappeared at waypoint BITOD. HCM ACC also stated that efforts had been made to establish communications by calling MH370 several times for more than twenty minutes.
8.	1750:28 UTC [0150:28 MYT] (0150:27 MYT)	KL ACC queried HCM ACC if there was any contact with MH370. HCM ACC’s reply was: “Negative”.
9.	1757:49 UTC (0157:49 MYT)	HCM ACC informed that there was officially no contact with MH370 until this time. Attempts on many frequencies and aircraft in the vicinity received no response from MH370.
10.	1803:48 UTC (0203:48 MYT)	KL ACC queried HCM ACC on status of MH370. HCM ACC confirmed there was no radar contact at this time and no verbal communications was established. KL ACC relayed the information received from Malaysia Airlines Operations that aircraft was in Cambodian airspace.
11.	1807:47 UTC (0207:47 MYT)	HCM ACC queried for confirmation that MH370 was in Phnom Penh FIR as Phnom Penh did not have any information on MH370. KL ACC indicated it would check further with the supervisor.
12.	1812:15 UTC (0212:15 MYT)	KL ACC informed HCM ACC that there was no update on status of MH370.
13.	1815 UTC (0215 MYT)	Extract from Watch Supervisor Log Book (in written form only, no voice recording): KL ATSC WS queried Malaysia Airlines Operations who informed that MH370 was able to exchange signals with the Flight Explorer.
14.	1818:50 UTC (0218:50 MYT)	KL ACC queried if flight planned routing of MH370 was supposed to enter the Cambodian airspace. HCM ACC confirmed that planned route was only through the Vietnamese airspace. HCM ACC had checked and Cambodian had advised that it had no information on or contact with MH370. HCM ACC confirmed earlier information that radar contact was lost after BITOD and radio contact was never established.
15.	1833:59 UTC (0233:59 MYT)	KL ACC Radar Controller enquired with MAS Operations Despatch Centre (ODC) on communications status on MH370. Personnel was not sure if the message went through successfully. ODC informed that aircraft was still sending movement message indicating it was somewhere in Viet Nam, and that its last position was at coordinates N14.90000 E109 15500 at 071833 UTC [080233 MYT].
16.	1834:56 UTC (0234:56 MYT)	HCM ACC queried on the status of MH370 and was advised that the Watch Supervisor was talking to the Company at this time.
17.	1854:28 UTC (0254:28 MYT)	Requested MH386, which was then in the HCM FIR, to try to establish contact with MH370 on emergency frequencies.
18.	1930 UTC (0330 MYT)	Extract from KL ACC Watch Supervisor ATS logbook: MAS Operations Centre informed KL ACC that the flight tracker was based on flight projection and not reliable for aircraft positioning.
19.	1930:03 UTC (0330:03 MYT)	KL ACC queried if HCM ACC had checked with next FIR HAINAN.
20.	1948:52 UTC (0348:52 MYT)	KL ACC queried if HCM ACC had checked with the SANYA FIR. HCM ACC informed KL ACC that there was no response until then.
21.	1956:13 UTC (0356:13 MYT)	KL ACC queried MAS Operations Centre for any latest information or contact with MH370.
22.	2025:22 UTC (0425:22 MYT)	HCM ACC Supervisor queried KL ACC on the last position that MH370 was in contact with KL ACC.
23.	2109:13 UTC (0509:13 MYT)	Singapore, on behalf of Hong Kong ACC enquired for information on MH370.
24.	2118:32 UTC (0518:32 MYT)	HCM ACC queried for information on MH370, KL ACC queried if any information had been received from Hong Kong or Beijing.
25.	2120:16 UTC (0520:16 MYT)	Capt. xxxx [name redacted] of MAS requested for information on MH370. He opined that based on known information,”MH370 never left Malaysian airspace.”
26.	2130 UTC (0530 MYT)	Duty ATSC Watch Supervisor activated the Kuala Lumpur Aeronautical Rescue Coordination Centre (ARCC).
27.	2214:13 UTC (0614:13 MYT)	KL ACC queried HCM ACC if SAR was activated.
28.	2232 UTC (0632 MYT)	KL ARCC issued a DETRESFA message.

Table 2.2C - Chronology of ATC Events following the Disappearance of MH370
Source: Safety Investigation Report MH370/01/2018

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³⁰ Blind transmission - A transmission from one station to another station in circumstances where two-way communications cannot be established but where it is believed that the called station is able to receive the transmission.

r) Distress Message

i) The distress message (DETRESFA) is intended to convey pertinent information to the recipients that there is a situation wherein there is a reasonable certainty that an aircraft and its occupants are threatened by grave and imminent danger and require immediate assistance.
ii) The DETRESFA message with a date-time-group (DTG) 072232 UTC was transmitted at 2232 UTC [0632 MYT].
iii)The contents of the DETRESFA message, as shown in Figure 2.2P below was not composed in accordance with the standard specified in ICAO DOC 4444, Air Traffic Management (PANS-ATM) Chapter 11, Air Traffic Services Messages, Appendix 3 (Figure 2.2Q below). The errors are, as below:
1. (1) Appendix 3, page A3-9 (Figure 2.2P below) Field type 7 - Aircraft identification and SSR mode and code FPL–MAS370–IS should be “MAS370/A2157”
2. (2) Appendix 3, page A3-14 (Figure 2.2P below) Field type 13 - Departure aerodrome and time WMKK1635 should be “WMKK1642”
3. (3) Appendix 3, page A3-29 & A3-30 (Figure 2.2P below) Omission of Field Type 20 - Alerting search and rescue information. This field consists of the following sequence of elements separated by spaces. Any information not available should be shown as “NIL” or “NOT KNOWN” and not simply omitted.
4. (4) Spelling of DETRESFA should read DETRESFA (Figure 2.2P below)

Figure 2.2P - DETRESFA Message sent over AFTN

Figure 2.2P - DETRESFA Message sent over AFTN

Source: DCA Malaysia