2018-马航MH370调查报告（英文版）-10mb

报告摘要

MH370 Safety Investigation Report Summary

I. Core Content Overview

The Malaysia Airlines Boeing B777-200ER (9M-MRO) 08 March 2014 safety investigation report, issued by the Malaysian ICAO Annex 13 Safety Investigation Team, is a comprehensive analysis of the circumstances surrounding the disappearance of Malaysia Airlines Flight MH370. The report includes detailed factual information, operational analysis, findings, and safety recommendations.

II. Main Sections and Key Information

1. Factual Information (Pages 1–273)

1.1 History of the Flight
- Describes the flight plan and route of MH370.
- Includes details on the diversion from the planned route, with specific radar data from:
  - Malaysian Military Radar
  - DCA Civilian Radar (Kota Bharu – Sultan Ismail Petra Airport Runway)
  - Ho Chi Minh Air Traffic Services
  - Kuala Lumpur ACC Radar
  - Medan and Bangkok Air Traffic Control
  - Singapore Air Traffic Services
- Notes the detection of a handphone signal and the search efforts for the aircraft.
1.2 Injuries to Persons
- No injuries reported as the aircraft was not found and no survivors were identified.
1.3 Damage to Aircraft
- No direct evidence of damage to the aircraft itself was found, but debris was recovered.
1.4 Other Damages
- Details on other potential damages, such as environmental or financial implications.
1.5 Personnel Information
- Profiles of the flight crew, including:
  - Pilot-in-Command (PIC)
  - First Officer
  - Cabin crew members
- Includes information on their training, work schedules, and psychological and social background.
- Also mentions disciplinary actions and insurance coverage.
1.6 Aircraft Information
- Overview of the aircraft's airframe, engine, and auxiliary power unit.
- Details on airworthiness and maintenance records, including:
  - Maintenance schedule
  - Major repairs
  - Cabin configuration changes
  - Technical logs and deferred defects
  - Engine health monitoring
  - Central Maintenance Computing System
- Covers weight and balance, fuel, and emergency systems such as the Emergency Locator Transmitter (ELT).
1.7 Meteorological Information
- Describes the weather conditions during the flight.
- Includes forecast charts, significant meteorological information, and volcanic ash advisories.
1.8 AIDS to Navigation
- Not applicable.
1.9 Communications
- Covers various communication systems:
  - High Frequency (HF)
  - Very High Frequency (VHF)
  - Mode S Transponder
  - Aircraft Communications Addressing and Reporting System (ACARS)
  - Satellite Communications (SATCOM)
- Includes ground station logs, log-on bursts, and Doppler analysis for the 1825 and 0019 events.
1.10 Aerodrome Information
- Not applicable.
1.11 Flight Recorders
- Describes the Solid State Flight Data Recorder (SSFDR) and Cockpit Voice Recorder (CVR).
- Includes information on underwater locator beacons and their expiry.
1.12 Wreckage and Impact Information
- Details on the location and examination of recovered debris.
- Includes damage analysis and marine life examination.
1.13 Medical and Pathological Information
- Focuses on the health and medical history of the crew.
1.14 Fire
- Analysis of potential fire-related issues.
1.15 Survivability
- Assessment of the likelihood of survival based on wreckage and environmental data.
1.16 Test and Research
- Not applicable.
1.17 Organisation and Management Information
- Overview of the Department of Civil Aviation Malaysia (DCAM) and Malaysia Airlines (MAS):
  - DCAM's structure and responsibilities
  - MAS's engineering, maintenance, and flight operations
  - In-flight services and crew performance
  - Safety management and flight operations quality assurance
1.18 Additional Information
- Includes details on air traffic services, cargo consignment, and crew/passenger data.
- Covers lithium-ion batteries, mangosteen fruits, and other cargo items.

III. Analysis (Pages 275–428)

2.1 Diversion from Filed Flight Plan

The aircraft deviated from its planned route, with multiple simulator sessions used to recreate the flight path.
Specific focus on the left turn past IGARI and the right turn south of Penang Island.

2.2 Air Traffic Services (ATS) Operations

Reviews the ATS procedures and actions taken by various centers.
Examines the communication timeline and responsibilities of air traffic controllers.
Highlights issues with the MATS manual and the handling of unidentified aircraft.

2.3 Medical/Human Factors Issues

General and specific human performance issues.
Analysis of human factors in ATC recordings.

2.4 Airworthiness & Maintenance and Aircraft Systems

Assessments of airworthiness, maintenance, and aircraft systems including:
- Air conditioning, pressurisation, and oxygen
- Autopilot and flight control systems
- Electrical power and navigation
- Engines and fuel systems

2.5 Satellite Communications Analysis

Summary of SATCOM ground station logs.
Analysis of possible reasons for log-on events and link losses.
Doppler analysis for the 1825 and 0019 events.

2.6 Wreckage and Impact Information

Details on debris examined and their location relative to the aircraft.
Includes analysis of damage and marine life impact.

2.7 Organisation and Management

Reviews the structure and responsibilities of DCAM and MAS.
Discusses safety management systems and operational procedures.

2.8 Aircraft Cargo Consignment

Details on the cargo, including:
- Li-ion batteries
- Mangosteen fruits
- Dangerous goods
- Laboratory tests conducted on cargo items
- Potential effects of cargo proximity on the aircraft

IV. Findings and Conclusion (Pages 429–443)

Findings include:
- Diversion from the flight plan
- Air traffic services operations and communication issues
- Human factors related to the flight crew
- Aircraft systems and maintenance status
- Satellite communications and debris analysis
- Organisational and management aspects
- Cargo-related findings
Conclusion outlines the likely causes and factors contributing to the disappearance, based on the available data and analysis.

V. Safety Recommendations (Pages 444–448)

Safety Recommendations are provided for:
- Department of Civil Aviation Malaysia (SR #01–07)
- Civil Aviation Authority of Viet Nam (SR #08–09)
- Malaysia Airlines Berhad (SR #10–17)
- Malaysia Airports Holdings Berhad (SR #18)
- International Civil Aviation Organization (SR #19)

These recommendations aim to improve safety protocols and prevent similar incidents in the future.

VI. Appendices (Pages 449–)

A list of appendices includes:
- Agreements between DCAM and Vietnamese ATMs
- Technical log entries
- ELT activation summary
- ACARS traffic log
- Debris examination reports
- Air-ground communication logs
- Cargo manifest and guidance documents

VII. Summary of Key Points

Diversion from Flight Plan: MH370 deviated from its original route, with radar data and satellite logs indicating possible changes in direction.
Communication Breakdown: The last communication was with Ho Chi Minh ATS, and subsequent contact was lost. ATC procedures and responsibilities were reviewed.
Crew Profile: Detailed profiles of the flight crew, including training, work schedules, and medical background.
Aircraft Systems: Analysis of aircraft performance, systems, and maintenance records.
Debris and Wreckage: Examination of recovered debris and its implications.
Cargo Issues: Investigation into lithium-ion batteries and other cargo items for potential hazards.
Safety Recommendations: Targeted improvements in air traffic services, maintenance, and operational procedures.