MH370 Safety Investigation Report
July 30, 2018 9:58 AM   Subscribe

The Malaysian Ministry of Transport has issued its 449-page Safety Investigation Report into the disappearance of flight MH370.

Some extracts from the conclusion:
“There is no evidence to indicate that MH370 was evading radar.

“The reason for the transponder information disappearing from the aircraft could not be established.

“It could not be established whether the aircraft was flown by anyone other than the pilots.

“There is no evidence to suggest any recent behavioural changes for the [Pilot-in-Command], [First Officer] and cabin crew.

“Although it cannot be conclusively ruled out that an aircraft or system malfunction was a cause, based on the limited evidence available, it is more likely that the loss of communication (VHF and HF communications, ACARS, SATCOM and Transponder) prior to the diversion is due to the systems being manually turned off or power interrupted to them or additionally in the case of VHF and HF, not used, whether with intent or otherwise.

“The recorded changes in the aircraft flight path following [a waypoint], heading back across Peninsular Malaysia, turning south of Penang to the north-west and a subsequent turn towards the Southern Indian Ocean are difficult to attribute to any specific aircraft system failures. It is more likely that such manoeuvres are due to the systems being manipulated.

“The SATCOM data indicated that the aircraft was airborne for more than 7 hours suggesting that the autopilot was probably functioning, at least in the basic modes, for the aircraft to be flown for such a long duration.

“Without the benefit of the examination of the aircraft wreckage and recorded flight data information, the investigation is unable to determine any plausible aircraft or systems failure mode that would lead to the observed systems deactivation, diversion from the filed flight plan route and the subsequent flight path taken by the aircraft.

“Recovery of the cabin interior debris suggests that the aircraft was likely to have broken up. However, there is insufficient information to determine if the aircraft broke up in the air or during impact with the ocean.

“In conclusion, the Team is unable to determine the real cause for the disappearance of MH370.”

Coverage: MH370 previously on Metafilter.
posted by alby (22 comments total) 9 users marked this as a favorite
 
It sounds like Patrick Smith was right. He wrote this in 2016 when the search was called off:
I’m disappointed, but not surprised. I’ve been saying from the start that we should prepare for the possibility of the disaster remaining forever unsolved. It happens this way sometimes. If it helps you feel better, the air crash annals contain numerous unsolved accidents. What makes this one different, maybe, is that major air crashes are so rare to begin with nowadays. On top of that, we’ve come to expect and demand easy and fast solutions to pretty much everything, with a fetishized belief that “technology,” whatever that even means anymore, can answer any question and fix any problem.

But it can’t.
posted by shapes that haunt the dusk at 10:12 AM on July 30, 2018 [10 favorites]


What makes this one different, maybe, is that major air crashes are so rare to begin with nowadays.

Well, there's also the sheer strangeness of the whole episode. It's been a while since I've delved into the details, but there seems to be no reasonable way to chalk it up to an accident (equipment failure, operator error, etc.). It looks very much like a deliberate act by the pilot (or someone else with control of the aircraft) – for reasons that remain totally unexplained. This report only serves to reinforce that.
posted by escape from the potato planet at 10:33 AM on July 30, 2018


...Or the aircraft environmental control system suffered a failure where the pilots, crew and passengers suffocated while the plane flew on until it ran out of fuel.

Just as plausible an explanation.
posted by JamesBay at 10:58 AM on July 30, 2018 [2 favorites]


Well no, an environmental control system seems to be ruled out by the evidence that "the Boeing 777’s controls were likely deliberately manipulated to take it off course". Or from the report itself
the recorded changes in the aircraft flight path following waypoint IGARI, heading back across peninsular Malaysia, turning south of Penang to the north-west and a subsequent turn towards the Southern Indian Ocean are difficult to attribute to any specific aircraft system failures. It is more likely that such manoeuvres are due to the systems being manipulated.
posted by Nelson at 11:12 AM on July 30, 2018 [4 favorites]


I think the reason for going off perpendicular to the route could easily be that the pilot was incapacitated while programming a new heading to turn to, or even just incapacitated mid-turn.

There are a few known cockpit fires in 777s which happened on the ground. If one happened in mid air, it could easily cause huge panic before incapacitation struck.
posted by ambrosen at 11:21 AM on July 30, 2018 [1 favorite]


The plane didn't just "go off perpendicular to the route", it made a series of turns.

It feels disrespectful for me for people to continue to engage in rampant speculation about their pet theories. Both the Australian and Malaysian reports are incredibly detailed and informed by actual expert opinion. At least absorb what they've said before speculating.

The Malaysian report is very clear they don't have a final answer, but some best guesses on what is likely or not. Page 367 goes specifically into the question of oxygen failure. (tl;dr: they don't really know, but there's no reason to expect the system failed or if it did, that the backups also failed). There's discussion throughout the report about the possibility of a fire, but as page 170 says the primary finding is no fire was reported.

The biggest room for question to me before this report was the pilots, particularly Captan Zaharie. The Australian report found that he'd flown a similar route on his home flight simulator a few weeks earlier. The Malaysian police say they found no unusual activity on his home flight simulator. The Malaysian report also says they had no concerns about the crew: background, training, or mental health. I have no evidence otherwise.

It's interesting to me the report also blamed air traffic control in Kuala Lampur and Ho Chi Minh City for not tracking the plane according to protocol. That's not going to have caused the accident, but it did delay recognizing there was a problem.
posted by Nelson at 11:39 AM on July 30, 2018 [19 favorites]


Well no, an environmental control system seems to be ruled out by the evidence that "the Boeing 777’s controls were likely deliberately manipulated to take it off course". Or from the report itself

I WANT TO BELIEVE
posted by JamesBay at 12:03 PM on July 30, 2018


Fwiw, I don't have a pet theory (such as " It looks very much like a deliberate act by the pilot"). We just don't know what happened, and likely never will.
posted by JamesBay at 12:04 PM on July 30, 2018


The plane didn't just "go off perpendicular to the route", it made a series of turns.

To be clear, my reading is that it's inconclusive what state of consciousness/hypoxia the crew were in when they were making those turns, but you're right, I should read the report in full.
posted by ambrosen at 12:12 PM on July 30, 2018 [1 favorite]


Yeah, we will never know what happened unless the wreckage is found, which is highly unlikely. I used to read a lot of Ask the Pilot, and it seems like almost every time there’s a modern major air disaster, it was a combination of multiple factors, like failure of multiple systems (often redundant systems somehow) or a failure to follow even minor protocols, or both. So many of them read like totally a perfect storm of unlikely and unanticipated events. Like, a plane will lose power but then also fail to deploy the backup power turbine because of this specific condition, but then also no one knows because this other condition prevented the warning light from illuminating...

It seems like the odds of anything like this happening nowadays are so vanishingly slim that whatever does happen is often hard to imagine without a detailed investigation, and obviously that’s not possible here. We do know at least one thing, which is that ATC failed to properly track the plane, allowing it to disappear like it did.
posted by shapes that haunt the dusk at 12:32 PM on July 30, 2018


One of the pilots' associations had a writeup that had a pretty good potential explanation for some of the odder things: smoke in the cockpit. You smell smoke in the cockpit, you start shutting down electronics until you can figure out what might be on fire, and you turn towards a place to land.

Obviously they have their own dog in the fight, since they have a motive for people to not blame pilots, but of all the speculation I've seen, it was the one that required the least weirdness. Maybe the real truth is the Australian theory that the pilot asphyxiated all the passengers, spent hours flying a dead plane, and only when he was out of fuel power dived it in the ocean, but it doesn't map that well to known pilot suicides.
posted by tavella at 3:00 PM on July 30, 2018 [1 favorite]


One of the pilots' associations had a writeup that had a pretty good potential explanation for some of the odder things: smoke in the cockpit. You smell smoke in the cockpit, you start shutting down electronics until you can figure out what might be on fire, and you turn towards a place to land. [...] but of all the speculation I've seen, it was the one that required the least weirdness.

I don't think there is any evidence the plane descended from altitude, which would be a super-likely action in the event of severe smoke, so I'm not sure I can agree with any characterization of this as "least wierdness". It also doesn't really explain the flown track.
posted by thegears at 3:31 PM on July 30, 2018 [1 favorite]


Also wouldn't a pilot report that unless the radio was on fire. And if they've identified the fire why not just pick a runway and land the plane.
posted by Mitheral at 4:00 PM on July 30, 2018


Aviate, Navigate, Communicate.

If they were dealing with an extreme crisis in the cockpit, getting on the radio would come last. Like everything else involved with the flight, it's just going to be a theory, probably forever unless the wreckage is discovered by chance.
posted by tavella at 5:09 PM on July 30, 2018


Maybe the real truth is the Australian theory that the pilot asphyxiated all the passengers, spent hours flying a dead plane, and only when he was out of fuel power dived it in the ocean, but it doesn't map that well to known pilot suicides.

What it reminds me of in this sense is the 1975 Moorgate train crash in London. Underground train didn't stop coming into a dead-end station, hit the end of the tunnel and was killed along with a number of passengers. No fault with the train, the driver just didn't stop. Driver suicide is one of the main theories for that as well, because it does at least fit the mechanics of what happened; but then you have to accept the premise that this person would do something so bizarre, when there's no evidence at all to suggest he ever would, no precedent for that kind of behaviour anywhere else, and plenty of evidence that he was just an ordinary train driver.

In the same way, I can accept that one of the theories which does explain MH370 is that someone flying that plane wanted to kill themselves along with everyone on board and ditch the plane in such a way that nobody would ever know what happened. It fits the mechanics of why the plane did what it did when it did. But to assume one of the pilots would do something like that, with no prior evidence that they ever would, no precedent, and the only reason to think it being that nothing else makes sense of the evidence? That just seems a jump too far for me - although I can't think what the hell else happened to that plane.
posted by Catseye at 4:52 AM on July 31, 2018 [3 favorites]


Committing suicide by charting a course into the middle of the ocean makes no sense, especially if one of the compounding factors was that ATC didn't follow tracking protocol. It's one thing to plan something that outlandish in the first place, but it's another thing to expect that other people will behave differently than should be expected.

I've been wondering if the pilot had a heart attack or an aneurysm or something. It is totally possible that they had some kind of medical issue while entering autopilot information, the plane veered off course, ATC didn't notice in time, no one else on the plane could tell they were off course, and then they were gone. It's highly unlikely, but so is an air disaster in the first place.
posted by shapes that haunt the dusk at 8:54 AM on July 31, 2018 [1 favorite]


I don't understand the unwillingness to believe that people do random, unpredictable, crazy shit. Like, forget about hidden mental illness (are we on Metafilter really unsure about people having depression that is completely hidden from public view...?). Everyone has the capacity to behave bizarrely, out of character, out of nowhere.

It usually doesn't result in a catastrophe not because it's rare, but because most people don't have access to the power to take hundreds of others with them. Except in the US, where we all have guns, I guess.

The simplest most convincing theory isn't some highly improbable chain of mechanical failures, or some kind of remote hijacking. It's that people break, suddenly, catastrophically and without reason.
posted by danny the boy at 10:21 AM on July 31, 2018


No, I mean committing suicide that way depends on the pilot anticipating that ATC won't follow tracking protocol and investigate when the plane goes off course. That's what I mean by expected behavior. The pilot had every reason to expect that ATC would have behaved differently than they did, because protocol dictated what their response should be. They would have had to plan around someone else's error, and we have no evidence that could have been anticipated.
posted by shapes that haunt the dusk at 10:30 AM on July 31, 2018 [2 favorites]


Maybe the real truth is the Australian theory that the pilot asphyxiated all the passengers, spent hours flying a dead plane, and only when he was out of fuel power dived it in the ocean, but it doesn't map that well to known pilot suicides.

Maybe there is a creepier image than flying a plane full of dead people,who you just murdered, but I'm not coming up with one right now.
posted by thelonius at 10:41 AM on July 31, 2018 [2 favorites]


Again, the new thing this month is we have the final official Malaysian report on their investigation to the pilots. It's quite readable. Page 37 talks (briefly) about the psychological state of the pilot and co-pilot. No flags for concern. Page 431 revisits the crew and again finds no particular concern. There is zero evidence here for a murderous pilot. I still think it's a plausible explanation, but it's one without evidence.

On the oddities noted in previous reports. Page 310, 362, and 431 talk about slightly less-than-perfect radio communications, like omitting the frequency handoff in the readback. Some folks looked at that as evidence of sinister intent, but it could just as easily could be ordinary sloppiness.

The details of the captain's flight simulator are on page 27. Their conclusion is "there were no unusual activities other than game-related flight simulations". Me, I think it's pretty strange to have been playing around with a flight simulator point 1000 miles southwest of Perth. But as evidence goes that's awfully circumstantial.

If you are truly conspiratorially minded, there's been some chatter in the past this Malaysian report would not be reliable. That they are not experts in aviation investigations. Or that the official Malaysian government report would not want to conclude that the Malaysian pilot of the Malaysian national airline committed an act of murder. That's part of why there was also an Australian investigation, to provide a second perspective. Also it'd be a hell of a conspiracy to cover up evidence that, say, the pilot was secretly a murderous lunatic.
posted by Nelson at 11:41 AM on July 31, 2018 [2 favorites]


Maybe there is a creepier image than flying a plane full of dead people,who you just murdered, but I'm not coming up with one right now.

A plane full of dead people, both crew and passengers, flying on autopilot. The jet flies on, unencumbered by doubts or worries. And the dead are beyond caring. And all who encounter the jet, visually or on a scope, see nothing amiss. All is as it should be.
posted by SPrintF at 12:46 PM on July 31, 2018 [1 favorite]


Well, that's the thing -- the Australian chief investigator's theory was that the plane was under active human control when it plunged into the sea, due to the position of the flaps in some recovered wreckage. And that's... a very strange sequence of events if so. People do sometimes "break, suddenly, catastrophically and without reason", but that's not the footprint here. We've had pilot suicide/murders, and they've been abrupt plunges into the ground or sea. And there's usually plenty of evidence that the pilot was not in a good state -- the Germanwings pilot had been under a psychiatrist's care for suicidal thoughts, for example.

If you take the basic pilot murder/suicide theory, it means overpowering and possibly personally killing the other pilot, it means asphyxiating all the other crew and passengers, and then conducting an elaborate sequence of moves to avoid ATC. If you take the Australian chief investigator's version, it then means flying a plane of the dead for many many hours and *then* diving it into the sea. It wasn't any kind of simple snapping, it would have been an extended plan done by someone thinking coolly. And you'd really expect in that case to see *some* sign of stress or personality problems before the pilot got on the plane.

It's not something impossible, but it's pretty far out of the historical pattern. While the incapacitated pilots theory does fit in with the mumbling in the one radio contact and the ghost plane behavior.
posted by tavella at 4:01 PM on July 31, 2018 [2 favorites]


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