Malaysia Airlines flight MH370*

What went wrong ?

By
Aerotunisie.com Vice-Manager

* Vanished in the indian ocean in March the 3rd 2014

 About us
• First aviation portal in Tunisia
started in 2012.

• Very attractive website and

updated aviation news.

• Over 200K page views and

42K monthly visits.

AeroDAY’14 Mai the 03rd 2014 Malaysia Airlines flight MH370 What went wrong ? 2
 Plan
Motivation
1. Good airline, Good airliner
2. Things you need to know
3. What happened ?
4. Possible Scenarios
5. Most possible Scenario
6. J. Reason’s Swiss Cheese Model
Conclusion
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 Motivation

AeroDAY’14 Mai the 03rd 2014 Malaysia Airlines flight MH370 What went wrong ? 4
 Motivation
• The MH370 flight makes the headlines of worldwide press.

• People start to ask questions about the sudden vanishing

of the aircraft : rumour, inaccurate news…

• Democratize some basics about aircraft functions and air

transport safety.

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1. Good airline, Good airliner

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 1. Good airline, Good airliner
Good airline
• The Malaysia Airlines is one of
the best compagnies in south east of Asia.

• Fleet of 108 aircrafts, 14 of which are Boeing 777-200ER.

• 61 destinations are served.

• Only two fatal crashs occured in 67 years of service : 134

are killed.
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 1. Good airline, Good airliner
Good airliner
• The biggest wide-body
twin-engine jet airliner
in the world.

• 1 147 units have been delivered, 1 473 units on order.

• Fully computerized, huge engines, world records of longest

non-stop distance flown…

• Very strong safety record : until 2014, Not a single disaster

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2. Things you need to know

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 2. Things you need to know
Radio Communication System
• Each aircraft has several radio sets : the Boeing B777 has 5.

• Use VHF or HF
frequencies.

• Can be used in Data

mode or Voice mode.

1
AeroDAY’14 Mai the 03rd 2014 Malaysia Airlines flight MH370 What went wrong ? 0
 2. Things you need to know
SATCOM System
• Use VHF, HF frequencies and satellite channels.

• Can be used for both voice and data transmission.

• Provide many services : ATIS messages, ATC instructions,

operations messages, ACARS.

• Operated with a MFD central panel.

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 2. Things you need to know
Primary surveillance radar
• Every Aircraft has a radar signature (even birds!! )

• Radars can “see” objects in the sky and assign for each a
point in the radar scope without any identification.

• Radar operator can monitor only the position and the

speed of aircrafts in regular time lapse.

• Used today for emergencies and training.

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2. Things you need to know
Primary surveillance radar

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 2. Things you need to know
Secondary surveillance radar
• With the help of a Transponder, an aircraft transmits vital
navigation informations.

• Allows to monitor an increasing number of planes at once.

• Compare Aircraft navigation with planned flight plan.

• Each aircraft is identified with a 4 digit Code (exp : 7700 )

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2. Things you need to know
Secondary surveillance radar

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3. What happened ?

1
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 Lost Transponder.
Last 01:21MYT
CRUISING
Handshake Last ACARS
ping Lost Radar Last ATC
08:11MYT 02:15MYT 01:19MYT

TAKE-OFF
00:41MYT
17
 3. What happened ?
Why is it so mysterious ?
• Only 2 minutes between the last Voice contact and the
start of contact systems shutdown !

• No sign of an emergency or alert indication before the

crew radio silence.

• No attempt to land in nearest airport or flying back to K.L.

• ACARS pings were still responding after 6 hours.

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 3. What happened ?
Search.. and we search again…

• 3, 000, 000 square miles

is the surface of
search operations !!

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 3. What happened ?
What we are looking for ?
• Crash site (wreckage)

• 2 Black Boxes (CVR & DFDR ).

• Engines

• Wires

• Fuselage remains
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 3. What happened ?
Availables informations
• Primary/Secondary Radar informations.

• ATC conversations.

• Aircraft maintenance history and other B777 in the fleet.

• Pilots/Crew/Passengers backgrounds.

• Possible flight path (ACARS…)

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4. Possible Scenarios

2
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 4. Possible Scenarios
Why Hijacking can be the cause ?
• Two passengers have boarded with 2 stolen passports.

• Systems shutdown, silent navigation.

• No radio communication.

• Aircraft still flying for extra 6 hours.

• It’s not the first time: B737 Flight 653 in 1977.

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 4. Possible Scenarios
Exemples of Hijacking accidents
• 9/11 events : 4 aircrafts have been hijacked
and turned toward four targets.

• Ethiopian Airlines Flight 961.

• Federal Express
Flight 705.

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 4. Possible Scenarios
Why Hijacking can’t be the cause ?
• Possible Hijackers don’t belong to any terrorist group.

• They should be trained to ask pilots to shutdown systems

or/and they did it by themselves. ( circuit breakers )

• What were their intentions ?

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 4. Possible Scenarios
Other scenarios..
• Cyber Hijack ( electronic signal jam ).

• Explosive decompression (Bomb, Fuselage Fatigue…).

• Missile strike.

• Suicide

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5. Most possible Scenario

2
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 5. Most possible Scenario
Electric system failure..
• Electric system failure caused by wire sparks ( or fire ) can
explain the shutdown of transponder and the malfunction
of ACARS, radios..

• Navigation systems and MFD screens could be disabled

too.

• Dark night without a moon has conducted to fly the plan in

blind configuration and cause “Vertigo” to pilots.
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TAKO-OFF
00:41
Climbing
00:50
Wire Sparks
00:55
Cruising
01:01
Possible Fire
01:05
Last ACARS
01:07
Last ATC « Good night MH370 »
01:19
Lost transponder and ADS-B
01:21
Other pilots try to establish contact
01:30
Lost ACARS
01:37
ALL MFD Screens go black
01:40
Lost of altitude
02:00
Lost Primary Radar signature
02:14
Satellites continue to receive pings
until 08:11
Crash in the south of indian ocean
+08:20
6. J. Reason’s Swiss
Cheese Model

4
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“A series of Human Factor problems forms an error chain.
If any one of the links in this chain had been broken the
incident may have been prevented. It might be done by
building in measures/defences, which may not permit an
error at one or more of the stages”

- James T Reason -

4
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6. J. Reason’s Swiss Cheese Model

Maintenance Aircraft

CRASH

Airport ATC Pilots

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 Conclusion

4
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 Conclusion
• Investigators could never solve the tragedy until they found
solid clues such CVR, DFDR or wreckage.

• Fire on board is a strong possible cause of electronic

systems’ loss.

• Flying Blind ( no light, dark night ) causes navigation

problems.

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 Thank you !

Manager : Nidhal CHOGRANI

nidhal.chograni@aerotunisie.com
contact@aerotunisie.com
Tél : (+216) 20 738 378

Vice-Manager : Khaled TOUEL

khaled.touel@aerotunisie.com
Tél : (+216) 97 87 90 06