Final Report on MH370

by Balan Nair ~ 8 August 2018

Final Report on MH370

Contributed by:

Balan Nair (Partner)

Tel: 603-6201 5678 / Fax: 603-6203 5678



According to the Preliminary Report published by the Office of the Chief Inspector of Air Traffic Accidents from the Department of Ministry of Transportation in Malaysia, Flight MH370, scheduled for departure from Kuala Lumpur International Airport (KLIA), to Beijing, China, departed at 00:41:43 MYT on Saturday, March 8 2014.

Last week, the Malaysian ICAO Annex 13 Safety Investigation Team for MH370 (the “Malaysian Safety Investigation Team”) issued the final report on this incident. In a press conference that followed, Dr. Kok Soo Chon, the head of the Malaysian Safety Investigation Team reiterated that the disappearance of MH370 remains a mystery. The release of this report has finally laid to rest the theory that the cargo carried 221kg of lithium-ion batteries and 5 tons of mangosteens caused the disappearance of the aircraft. Experts suggested that the combustible concoction likely caused a fire which may have released carbon monoxide into the airline during flight. It was further suggested that this was the cause of the disappearance notwithstanding the fact that the cargo was stored in separate compartments, rendering the risk of contact highly unlikely.

... the disappearance of MH370 remains a mystery.

Furthermore, the batteries had not been registered as dangerous goods and no added precautions were deemed necessary after passing screening at customs. New findings in the report show that tests were carried out by Malaysia’s Science & Technology Research Institute for Defence and have been quick to undermine this theory as highly unlikely.

However, one new observation that surfaced from the report sparked public interest - the fact that the critical turn undertaken by the aircraft was not the result of system anomalies in the aircraft. Further investigation showed that the aircraft changed course shortly after it passed the northern tip of Sumatra (Indonesia) and travelled south until it ran out of fuel in the southern Indian Ocean west of Australia.

“The disappearance of the radar position symbol of MH370 was captured by the KL ACC radar at 1721:13 UTC [0121:13 MYT]. The Malaysian military radar and radar sources from two other countries, namely Vietnam and Thailand, also captured the disappearance of the radar position symbol of MH370. The Bangkok radar target drop occurred at 1721:13 UTC [0121:13 MYT]”

Thorough investigation led to the shocking revelation that the critical turn was carried out manually. This is particularly concerning due to the lack of contact from the aircraft moments before the aforementioned deviation. At 1.07am, the plane’s signaling device sent a final message before being disabled deliberately or otherwise for the next half hour right before the handover to the air traffic controllers in Ho Chi Minh from Kuala Lumpur. In the span of a few minutes, MH370 was out of sight and out of reach. In that crucial moment, the plane had undertaken a sharp manual turn back from its planned flight path. Investigators have refrained from ruling out the possibility of foul play as a potential cause but offer no resolve that anything of that magnitude had actually taken place. The report concluded that there was nothing to imply any sort of malfunction, defect or technical failure which resulted in the disappearance. The aircraft was in fact deemed air-worthy and well maintained upon taking flight. However, it is critical to bear in mind that the wreckage of the flight was never recovered.

The report concluded that there was nothing to imply any sort of malfunction, defect or technical failure which resulted in the disappearance.

The report articulates that the critical turn was recorded 40 minutes after takeoff. A reconstruction of the entire flight profile was attempted using a Boeing 777 simulator, leading to observations of limitations in speed and height variations that investigators found unattainable even after repeated simulator sessions.

“It was also noted that, in the absence of autopilot or continuous manual control, an aircraft is very much unlikely to maintain straight and level flight,” the report said. “Further, it is extremely unlikely for an aircraft to enter and maintain a turn and then return to straight and level flight for any significant period of time”

Despite delving deeper into the report, the question still persists, what happened to flight MH370? Did the aircraft catch fire mid-flight leading to its demise? Was this a case of possible hijacking? To those looking for relief from this report, it is easy to be disappointed.

The first point of examination fell onto the Pilot, Co-pilot and First Officer of the flight. The flight captain in question was Zaharie Ahmad Shah, being a 53-year-old Penangite with over 16 years of experience and over 18,000 hours of flight time (the “Pilot”). The First Officer Fariq Abdul Hamid, aged 27, with seven years’ experience (the “First Officer”) was in the cockpit beside the Pilot. Various background checks were undertaken which indicated that both the Pilot and the First Officer were well rested.

Similarly, it was determined that they were not under any financial stress and showed no evidence of anxiety or stress. It is, however, important to note that investigators have also refrained from ruling out third party interference as a potential possibility leading up to the disappearance. The cockpit transcripts recorded seemed ‘perfectly routine’. Observations of the Pilot and the First Officer on video prior to take off showed no visual signs of distress.


The disappearance of MH370 occurred within the region of airspace delegated to the Kuala Lumpur Area Control Centre (“KL ACC”). The KL ACC is responsible for the provision of Air Traffic Control Service, Flight Information Service and Alerting Service to all aircrafts within Kuala Lumpur Flight Information Report, the “released airspace” on ATS route R208 and the “delegated airspace”.

Air Traffic Services Operations maintained that the flight was set to depart and operations carried on as scheduled with no anomalies. The report identified that there was a “transfer of control” from KL ACC to Ho Chi Minh Area Control Centre (“HCM ACC”) three minutes prior to the time the aircraft was predicted to reach waypoint IGARI. It was highlighted that the transmission was not delivered with no signs of any recordings of transmission communicated between KL ACC to HCM ACC upon the aircraft’s early Transfer of Control Point (“TCP”), being the buffering region through which the aircraft hovered between KL ACC and HCM ACC’s watch.

Upon HCM ACC failing to establish two-way communication with MH370, its KL counterpart should have been alerted within five minutes in accordance to standard operating procedures. However, this was only done 12 minutes later. A recreation using a B777 simulation confirms the vessel’s early transfer, indicating that the aircraft would have reached waypoint IGARI a minute before it was scheduled to arrive at 0122 MYT.

“The KL ACC controllers relied solely on positional information of the aircraft by Malaysia Airlines flight operations dispatch centre, rather than checking up with other air traffic control authorities.”

The Distress Phase should have been initiated by KL ACC at 0227 MYT with the transmission of the DETRESFA message as it was KL ACC’s sole responsibility to provide an alerting service. This is due to the fact that KL ACC was last in contact with MH370 at 0119:30 MYT upon MH370’s acknowledgement of the transfer of control by KL ACC at 0119:26 MYT. Failure by KL ACC to contact HCM ACC led to the subsequent struggle to establish two-way communication with MH370. A shocking 4 hours and 5 minutes elapsed from the time on which the Distress Phase should have been rightfully alerted, with the first DETRESFA message transmitted at 0632 MYT by KL ACC.


Paragraph 3 of the Letter of Award between the Department of Civil Aviation Malaysia and Vietnam Air Traffic Management, titled Establishment of Communication (the “LOA”) states that:

“The accepting unit shall notify the transferring unit two-way communication is not established within five (5) minutes of the estimated time for the TCP”

This shed light on the establishment that the HCM ACC had received MH370’s estimate for IGARI from KL ACC at 0122 MYT, but was not able to establish two-way communication with the aircraft. HCM ACC should therefore have notified KL ACC by 0127 MYT. Nonetheless, there was a delay of 12 minutes by HCM ACC to deliver the notification to KL ACC at 0139 MYT.

The delay in notifying the Kuala Lumpur Air Traffic Control Centre (the “KL ATCC”), however, can be attributed to multiple attempts by HCM ACC to establish contact with the missing airline. This is further supported by transcribed communication and the exchange between both parties.

Upon receipt of the aforementioned notification at 0139 MYT, the Lumpur Sector 3+5 Radar Controller should have reached an earlier conclusion that emergency protocols were meant to be initiated. The Sector 3+5 Radar Controller should have immediately notified the Air Traffic Service Centre Duty Watch Supervisor (the “ATSC Duty Watch Supervisor”) that an Uncertainty Phase occurred. This should have been followed by the commencement of an Alert Phase. As per the Manual of Air Traffic Services (“MATS”), Part 9 - Emergencies, page 9-6-5, para. 6.7.2 dated 15/3/2009 No.1, responsibility for the call to initiate emergency services rested on KL ACC.

It should also be noted that the Sector 3+5 Radar Controller did not inform other radar units (civil and military) of the aforementioned adverse circumstances unfolding.

The MATS, PART 9 - Emergencies, para 6.2.3, page 9-6-2, stipulates that:

“If Controllers have reason to believe that an aircraft is lost, overdue or experiencing a communication failure, they shall:

  1. Inform appropriate radar units (civil and military) of the circumstances.
  2. Request the units to watch out for emergency SSR code display or the triangular radio failure pattern
  3. Notify these units when their services are no longer required.”


Interviews conducted with the MAS duty personnel on duty that night revealed that he was not able to explain the operation of the systems due to “lack of training”. Alarmingly, all personnel in this unit were not adequately trained to operate this system. In a revealing interview, investigators were informed that the FFS could not track the aircraft on a real-time basis and that the position was merely a computerized projection based off the flight plan of the aircraft. The status would be updated every half hour, delaying accuracy of tracking. The personnel further admitted that he had inaccurately informed KL ACC that MH370 was in Cambodian airspace as during “that point in time, I did not notice that the position was actually projected movement and not actual.”

Alarmingly, all personnel in this unit were not adequately trained to operate this system.

The report, however, concluded that MAS had continued to deliver information to KL ACC that the aircraft was still in flight. The report also identified an instruction delivered to the vessel at 01:19:24 MYT, whereby the flight staff of MH370 were urged to contact Ho Chi Minh Air Traffic Control Centre (“HCM ATCC”). The flight staff “acknowledged with “good night Malaysian Three Seven Zero”, declaring that all systems were under control.


Further analysis and probed investigation uncovered how the aircraft had deviated from the Filed Flight Plan (“FFP”) route. Seven flight simulator sessions were carried out to investigate the two prominent turns taken by the vessel; one looking into the right turn towards the south of Penang, and six in attempt to spatially and temporarily recreate the left turn past waypoint IGARI.

Key factors taken into account were the vessel’s actual weight and meteorological condition during the time of the turn, as well as variations of speed in order to recreate the turn as accurately as possible.

The results of sessions 3 and 6 are noteworthy. In both these sessions, the left turn exit through waypoint was achieved within a time frame closest to that of the actual event (3 minutes and 3 seconds, and 2 minutes and 28 seconds respectively.) Session 6 in particular was the most successful and shed light on a pivotal factor – the disengagement of autopilot being a key factor in the success of the turn, coupled with performing the deviation at a reduced speed of 250 knots. The simulation required the usage of a wider bank-angle of approximately 35°, triggering multiple bank-angle warnings. Mid-way through the turn, it was reported that another emergency measure, a stick-shaker, had been activated.

Despite these measures, this ascertained that the aircraft had to be manually flown, enabling the individual to operate a successful exit through the said waypoint despite warnings. With the most successful simulation being 30 seconds slower than what took place on flight, the operational complexity of the deviation remains a mystery.

Upon investigating the air system, simulator sessions also shed light on the fact that a minimum bank angle of 30° was pivotal in the achievement of a 180° turn in 2 minutes with a ground speed of about 470 knots. Autopilot settings restricted the bank angle to a 25° turn, confirming that the autopilot mode was disengaged upon making the turn. Were it otherwise, it would have taken approximately 3 minutes to achieve the turn, a minute longer than the 2 minutes and 10 seconds the individual took on board. Supplementary simulations using the Lateral Navigation (“LNAV”) mode (the autopilot mode employed) indicated that the turn took longer than 3 minutes, albeit a wider bank angle being possible at a similar ground speed of 425 knots. A slower ground speed of 400 knots decreased the rate of turn, resulting in the turn taking 3 minutes and 30 seconds to achieve. Both situations were minutes further from reality. It is important to note that these simulations were run at 35,000 ft. (FL 350), the last recorded position of the aircraft seconds before its disappearance off radar.


The Search Strategy Group for MH370, spearheaded by the Australian Transport Safety Bureau (“ATSB”), coordinated a rigorous search process involving the analysis of signals transmitted by the aircraft’s satellite communications terminal to Inmarsat’s Indian Ocean Region satellite, revealing that the aircraft continued flight for a number of hours after losing contact. A 52-day surface search covered an area of several million square kilometres. Simultaneously, a sub-surface search for the aircraft’s underwater locator beacons was initiated.

“The underwater search started with a bathymetry survey which mapped a total of 710,000 square kilometres of Indian Ocean seafloor and continued with a high-resolution sonar search which covered an area in excess of 120,000 square kilometres. The last search vessel left the underwater search area on 17 January 2017 without locating the missing aircraft. Although combined scientific studies continued to refine areas of probability, there was no new information at that date to determine the specific location of the aircraft.”

The search commenced on 8 March 2014 for over 1,046 days and was suspended via a mutual decision between the People’s Republic of China, Australia and the Government of Malaysia. The suspension encompassed surface searches covering the southern Indian Ocean, the Straits of Malacca and the South China Sea.

On 10 January 2018, the Malaysian Government had also signed an agreement with a US company, Ocean Infinity to conduct a 90-day underwater search in an area that was considered the most likely location for the wreckage. The search, which begun in said region on 22 January 2018, employed “the most advance underwater search technology currently available” in an attempt to thoroughly investigate beyond 112,000 square kilometres. The search was completed on 29 May 2018 without any sign of the aircraft.

Additionally, the report references what investigators determined to be the “ineffectiveness” of emergency locator transmitter (“ELT”) technology that was featured on the aircraft. The aircraft was equipped with four ELTs supplied by a company called ELTA FRANCE. ELTs are mandatory safety items that must be featured on all passenger-carrying commercial aircrafts, which are designed to send out distress signals that can be detected by satellites and transmitted to the search and rescue agencies. MH370’s ELTs never transmitted any such signals.


Lead Investigator Dr. Kok Soo Chon reinstated that “this is not the final report.”

The wreckage has not been found, no victims have been found. We’re calling it a report, there must be some kind of conclusion.

The mystery behind MH370 is definitely one of the most peculiar cases in aviation history. This report has opened up liability on the part of the Department of Civil Aviation for failure to comply with the Standard Operating Procedures during the course of the incident as cited in the report. The conclusion of the department’s failure to exercise responsibility for the safety of aviation eventually led to the resignation of Azharuddin Abdul Rahman, the Chairman of the Civil Aviation Authority of Malaysia.

The question remains, “How did we lose a plane?”