Safety Investigation Report 2018:1 Factual Information/1.5
SAFETY INVESTIGATION REPORT MH370 (9M-MRO)
1.5 PERSONNEL INFORMATION
1.5.1 Introduction
This investigation emphasised on the Pilot-in-Command (PIC), First Officer (FO) and the 10 cabin crew but did not include the passengers on board Flight MH370. The factual information of the crew was gathered from the following sources:
- Personal records/files of the Pilot-in-Command, First Officer and the Cabin Crew from Malaysia Airlines
These documents included the log book, certificates, licences, medical records and any disciplinary/administrative actions; - Investigation details from the Polis Di Raja Malaysia (Royal Malaysia Police)
These were statements obtained from the next-of-kin and relatives, doctors/ care givers, co-workers, friends and acquaintances; financial records of the flight crew; Closed Circuit Television (CCTV) recordings at KLIA; and analysis of the radio transmission made between MH370 and ground air traffic control; - Medical records from private health care facilities and from the Malaysia Airlines Medical Centre; and
- Interviews with Malaysia Airlines staff and several of the next-of-kin of the crew
The facts obtained were in relation to the demographic and employment history, financial background and insurance cover, significant past medical and medication history, psychological, social and behavioural pattern of the crew.
1.5.2 Malaysia Airlines Training and Check Records
As professional pilots, the two Malaysia Airlines (MAS) flight crew were subjected to periodic checks when flying on the type of aircraft at least on a bi-annual basis to revalidate the currency of their licences. These performance checks were conducted in approved flight simulators and in addition, further checks are conducted on route flying duties on normal commercial flights on a yearly basis.
1.5.3 Pilot-in-Command
The PIC was born in the Island of Penang. He completed his Malaysian Certificate of Education (MCE) - the equivalent of the United Kingdom Ordinary (UK ‘O’) Level - at the Penang Free School, where he sat for his MCE Examination in 1978. In 1981 he was accepted as a Cadet Pilot with MAS under the sponsorship of Majlis Amanah Rakyat (MARA), a People’s Trust Council of the Malaysian Government.
1) Personal Profile of Pilot-in-Command
| Sex | Male |
| Age | 53 years |
| Marital Status | Married with 3 children |
| Date of joining MAS | 15 June 1981 |
| Licence country of issues | Malaysia |
| Licence type | Air Transport Pilot Licence (ATPL) |
| Licence number | A751 |
| Validity Period of Licence | 14 May 2014 |
| Ratings | Boeing B777 |
| Medical Certificate | First Class (valid until 30 June 2014) |
| Aeronautical experience | 18423:40 hours |
| Experience on type | 8659:40 hours |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 07:00:00 hours |
| Last 07 days | 20:39:00 hours |
| Last 28 days | 91:04:00 hours |
| Last 90 days | 303:09:00 hours |
| Last line check | 08 April 2013 |
| Instrument rating check | 15 November 2013 |
| Last proficiency | 15 November 2013 |
| Last promotion | B777 Captain (22 September 1998) |
The PIC was sent to Manila in the Philippines to be provided ab-initio pilot training and graduated 2 years later with a Commercial Pilot Licence & Instrument Rating (CPL & IR). He joined MAS as a Second Officer in 1983 and was posted on the F27 where he obtained his initial airline flying experience. He was then posted to the B737-200 in 1985, thereafter the A300B4, and stayed on as First Officer (FO) until March 1990. In July 1990 he was promoted to captain and took his first command on the F50 aircraft.
By the end of 1991 he was promoted to Captain on the B737-400 until December 1996. His next promotion was to the A330-300 and stayed on the fleet until September 1998 when he was promoted to the B777- 200ER fleet until the day of the event. By virtue of his good track record and seniority he was made a Type Rating Instructor (TRI) and Type Rating Examiner (TRE) on this present fleet effective November 2007.
The PIC’s flying record for the last 72 hours and preceding 28 days’ cycle were well within the Company’s specified limits. His last flight as an operating PIC was to Denpasar, Bali, in the Republic of Indonesia on 03 March 2014. This was a daily return flight with a sector time of approximately 3 hours. On the day of the event, he was conducting training for the FO who was functionally checked out.
2) Royal Malaysia Police’s Report on Flight Simulator of PIC
The Royal Malaysia Police (RMP) seized the PIC’s home flight simulator from the residence of the PIC on 15 March 2014.
The RMP Forensic Report dated 19 May 2014 documented more than 2,700 coordinates retrieved from separate file fragments and most of them are default game coordinates.
It was also discovered that there were seven ‘manually programmed’ waypoint4 coordinates (Figure 1.5A below), that when connected together, will create a flight path from KLIA to an area south of the Indian Ocean through the Andaman Sea. These coordinates were stored in the Volume Shadow Information (VSI) file dated 03 February 2014. The function of this file was to save information when a computer is left idle for more than 15 minutes. Hence, the RMP Forensic Report could not determine if the waypoints came from one or more files.
The RMP Forensic Report on the simulator also did not find any data that showed the aircraft was performing climb, attitude or heading manoeuvres, nor did they find any data that showed a similar route flown by MH370.
The RMP Forensic Report concluded that there were no unusual activities other than game-related flight simulations.
___________
4 ‘Manually programmed waypoints’ - Manually programmed waypoints are waypoints that are not published in Airway Charts
Figure 1.5A - Snapshot of Seven Manually Programmed ‘Waypoints’
Source: Royal Malaysia Police
1.5.4 First Officer
The FO was born in the State of Kelantan and had his basic primary education in Segamat, Johor. He completed his secondary Education in Maktab Rendah Sains MARA (MRSM) or MARA Junior Science College, in Taiping, Perak, where he left in 2004 with the Sijil Pelajaran Malaysia (SPM) or Malaysia Certificate of Education, which is equivalent to the UK ‘O’ Level. He was accepted as a MAS Cadet Pilot and completed his flying training at the Langkawi Aerospace Training Centre, Langkawi in 2008.
His first fleet posting was on the B737-400 as a Second Officer until May 2010. He was promoted to FO in May 2010 and was on the fleet until August 2012. Between the end of 2012 to November 2013, he was promoted to the A330- 300 and the B777-200.
On the day of the flight, he was operating his last training flight before he was scheduled to be checked out on his next scheduled flight. His flying record for the last 72 hours and preceding 28 days cycle were well within the Company’s specified limits. His previous flight as a functional FO under Line Training, was to Frankfurt, Germany, on 01 March 2014 and he returned to Malaysia on 02 March 2014. All his required licences and certificates were valid when he was assigned to operate this flight to Beijing.
1) Personal Profile of First Officer
| Sex | Male |
| Age | 27 years |
| Marital Status | Single |
| Date of joining MAS | 23 July 2007 |
| Licence type | Air Transport Pilot Licence (ATPL) |
| Licence number | A3550 |
| Validity Period of Licence | 26 July 2014 |
| Ratings | Boeing B777 |
| Medical Certificate | First Class (valid until 31 October 2014) |
| Aeronautical experience | 2813:42 hours |
| Experience on type | 39:11 hours |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 0:00:00 hours |
| Last 07 days | 28:47:00 hours |
| Last 28 days | 51:17:00 hours |
| Last 90 days | 158:46:00 hours |
| Last line check* | 22 July 2013 (A330) |
| Instrument rating check* | 04 December 2012 (A330) |
| Last proficiency | 26 January 2014 |
| Last promotion | B777 FO (04 November 2013) |
* No record on B777
1.5.5 Summary of Work Schedule for Flight Crew of MH370
A summary of the work schedule for the PIC and the FO, three months prior to the eventful flight, is available in Table 1.5A (below).
Validity |
||||||
| Pilot-in- Command | 0:00:00 | 07:00:00 | 20:39:00 | 91:04:00 | 303:09:00 | 14 May 2014 |
| First Officer | 0:00:00 | 0:00:00 | 28:47:00 | 51:17:00 | 158:46:00 | 26 July 2014 |
1.5.6 Cabin Crew and Personal Profiles
The cabin crews’ flying experiences spread from 13 years for the most junior member to 35 years for the most senior member. A review of their records in MAS reveals that all certificates, which include Safety Emergency Procedures (SEP) training, Crew Resource Management (CRM), Safety Awareness Programme (SAP), are valid as per the requirement stated in the Company’s document. CRM & SAP incorporate Human Factors as part of the training modules. The flying records which were monitored by the Scheduling Office indicated that all the cabin crew were well-rested before operating the flight.
| Sex | Male |
| Age | 55 years |
| Marital status | Married with 4 children |
| Date of Joining MAS | 19 November 1979 |
| Aircraft Ratings | A330/B777/B747 |
| Crew Performance Appraisal | Rating: 4 |
| Validity period of licence | 28 April 2014 |
| Aeronautical experience | 35 years |
| Medical History | 43 days medical leave including 6 days hospitalisation in 2013 |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 8:00:00 hours |
| Last 7 days | 19:44:00 hours |
| Last 28days | 82:43:00 hours |
| Last 90 days | 305:06:00 hours |
| Last promotion | IFS (27 March 2000) |
2) Chief Steward (CS)
| Sex | Male |
| Age | 49 years |
| Marital status | Married with 2 children |
| Date of Joining MAS | 13 November 1989 |
| Aircraft Ratings | A330/B777/A380 |
| Crew Performance Appraisal | Rating 4 |
| Validity period of licence | 26 June 2014 |
| Aeronautical experience | 25 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 0:00:00 hours |
| Last 7 days | 30:56:00 hours |
| Last 28 days | 124:35:00 hours |
| Last 90 days | 408:32:00 hours |
| Last promotion | CS (06 March 2000) |
3) Chief Stewardess (CSS)
| Sex | Female |
| Age | 49 years |
| Marital status | Married with a child |
| Date of Joining MAS | 02 January 1990 |
| Aircraft Ratings | A330/B777/A380 |
| Crew Performance Appraisal | Rating 5 |
| Validity period of licence | 23 October 2014 |
| Aeronautical experience | 24 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 0:00:00 hours |
| Last 7 days | 30:55:00 hours |
| Last 28 days | 118:02:00 hours |
| Last 90 days | 355:23:00 hours |
| Last promotion | CSS (22 October 2003) |
| Sex | Male |
| Age | 42 years |
| Marital status | Married with 4 children |
| Date of Joining MAS | 05 October 1995 |
| Aircraft Ratings | B737/B777/A380 |
| Crew Performance Appraisal | Rating 4 |
| Validity period of licence | 22 August 2014 |
| Aeronautical experience | 19 years |
| Last 24 hours | 00:00:00 hours |
| Last 72 hours | 10:47:00 hours |
| Last 7 days | 38:38:00 hours |
| Last 28 days | 106:10:00 hours |
| Last 90 days | 365:51:00 hours |
| Last promotion | LS (28 May 2005) |
5) Leading Stewardess (LSS)
| Sex | Female |
| Age | 42 Years |
| Marital status | Married with 2 children |
| Date of Joining MAS | 18 August 1992 |
| Aircraft Ratings | B737/B777/A380 |
| Crew Performance Appraisal | Rating 5 |
| Validity period of licence | 01 November2014 |
| Aeronautical experience | 22 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 11:36:00 hours |
| Last 7 days | 41:27:00 hours |
| Last 28 days | 140:11:00 hours |
| Last 90 days | 443:23:00 hours |
| Last promotion | LSS (09 May 2004) |
| Sex | Female |
| Age | 42 years |
| Marital status | Married with 2 children |
| Date of Joining MAS | 18 January 1992 |
| Aircraft Ratings | A330/B777/A380 |
| Crew Performance Appraisal | Rating 4 |
| Validity period of licence | 27 June 2014 |
| Aeronautical experience | 22 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 9:39:00 hours |
| Last 7 days | 34:22:00 hours |
| Last 28 days | 93:50:00 hours |
| Last 90 days | 327:18:00 hours |
| Last promotion | FSS Wide-body aircraft (18 January 1993) |
| Sex | Female |
| Age | 39 years |
| Marital status | Married with 2 children |
| Date of Joining MAS | 16 April 1996 |
| Aircraft Ratings | A330/B777/A380 |
| Crew Performance Appraisal | Rating 4 |
| Validity period of licence | 11 May 2014 |
| Aeronautical experience | 18 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 0:00:00 hours |
| Last 7 days | 16:12:00 hours |
| Last 28 days | 112:11:00 hours |
| Last 90 days | 323:55:00 hours |
| Last promotion | FSS Wide-body aircraft (01 October 2001) |
| Sex | Male |
| Age | 46 years |
| Marital status | Married with 3 children |
| Date of Joining MAS | 16 April 1996 |
| Aircraft Ratings | B737/B777/A380 |
| Crew Performance Appraisal | Rating 5 |
| Validity period of licence | 24 October 2014 |
| Aeronautical experience | 18 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 11:02:00 hours |
| Last 7 days | 30:58:00 hours |
| Last 28 days | 119:27:00 hours |
| Last 90 days | 429:15:00 hours |
| Last promotion | FS Wide-body aircraft (03 December 2001) |
| Sex | Male |
| Age | 41 years |
| Marital status | Married with 2 children |
| Date of Joining MAS | 13 February 1997 |
| Aircraft Ratings | B737/B777/A380 |
| Crew Performance Appraisal | Rating 5 |
| Validity period of licence | 03 November 2014 |
| Aeronautical experience | 17 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 0:00:00 hours |
| Last 7 days | 30:36:00 hours |
| Last 28 days | 122:22:00 hours |
| Last 90 days | 391:20:00 hours |
| Last promotion | FS Wide-body aircraft (15 February 2002) |
| Sex | Male |
| Age | 34 years |
| Marital status | Married with 2 children |
| Date of Joining MAS | 27 September 2001 |
| Aircraft Ratings | B737/B777/A380 |
| Crew Performance Appraisal | Rating 5 |
| Validity period of licence | 06 February 2015 |
| Aeronautical experience | 13 years |
| Last 24 hours | 0:00:00 hours |
| Last 72 hours | 10:47:00 hours |
| Last 7 days | 26:24:00 hours |
| Last 28 days | 125:01:00 hours |
| Last 90 days | 435:43:00 hours |
1.5.7 Disciplinary/Administrative Actions
There were no major disciplinary records on any of the flight and cabin crew.
However, there were minor disciplinary issues among the cabin crew, where cautionary administrative letters were issued.
1.5.8 Financial Background and Insurance Cover
The PIC held bank accounts, two savings accounts, one current account, two national trust funds (ASB and ASN) and a joint account with his wife. He had a credit card. He was contributing to the Employees Provident Fund (EPF). There is no record of him having secured a life insurance policy. He had 2 houses, one in Shah Alam and the other in Subang Jaya. He had taken a bank loan on one of his houses and had a mortgage insurance policy on this loan. He also had 3 vehicles. His gross monthly income and out-of-pocket expenses indicated nothing unusual.
The PIC also had a trading account with an investment bank. The Central Depository System (CDS) and Trading accounts were opened since 13 February 1998 and 19 March 1998 respectively. The CDS account was inactive whereas the last transaction of the trading account was noted on 03 February 2000.
The FO had two saving accounts and a national trust fund (ASB) account. He contributed to the EPF. He owned two cars and spent money on the upkeep of his cars. He did not have much savings in his bank account. He had a life insurance policy and a mortgage insurance policy for a loan he took for his car.
The cabin crew had bank accounts and loans. However, the gross monthly income and out-of-pocket expenses indicated nothing unusual. There is also no evidence of recent or imminent significant financial transactions carried out.
1.5.9 Significant Past Medical and Medication History
The PIC had received treatment for minor medical ailments and was diagnosed as having osteoarthritis on 05 May 2007. He had a spinal injury on 28 January 2007 in a paragliding event. He sustained a fracture of the 2nd lumbar vertebra and underwent surgery on 30 January 2007 in a private health care facility. He was discharged on 05 February 2007 and went for a follow-up as advised. He was certified fit to fly in mid-2007 and went regularly for his six-monthly medical examinations for his continued licensure as a pilot. For his pain he was noted to have taken analgesics on an irregular basis. Based on available information, he was not on any regular long-term medication for any chronic medical illness.
There was no significant health-related issue for the FO. He went regularly for his yearly medical examinations for his continued licensure to fly.
Based on the medical records from MAS, there were no unusual health- related issues for the cabin crew, except for the in-flight supervisor who had a history of first onset of seizures on 09 June 2013. He was admitted on the same day in a private health care facility and was treated by a Consultant Neurologist. He was discharged on 14 June 2013 and went for a follow-up as advised. He had not experienced any further seizures since his discharge. He was certified fit to fly on 06 August 2013.
1.5.10 Psychological and Social Events
The PIC’s ability to handle stress at work and home was reported to be good. There was no known history of apathy, anxiety, or irritability. There were no significant changes in his lifestyle, interpersonal conflict or family stresses.
Similarly, the FO’s ability and professional approach to work was reported to be good. This was evident with the rapid fleet promotion within 3 years as a professional pilot. There were no reports on recent changes in his behaviour or lifestyle.
1.5.11 Behavioural Events
There were no behavioural signs of social isolation, change in habits or interest, self-neglect, drug or alcohol abuse of the PIC, FO and the cabin crew.
The CCTV recordings at KLIA on 07 March 2014 were evaluated to assess the behavioural pattern of the PIC, and the FO from the time of arrival at KLIA until boarding time.
Three previous CCTV recordings of the movements of the PIC in KLIA were also viewed to see the behavioural pattern and were compared with the CCTV recordings on 07 March 2014.
The PIC’s movement was captured on CCTV at KLIA on the following days:
- 07 March 2014 - To Beijing
- 03 March 2014 - To Denpasar
- 26 February 2014 - To Melbourne
- 21 February 2014 - To Beijing
On studying the PIC’s behavioural pattern on the CCTV recordings on the day of the flight and prior 3 flights there were no significant behavioural changes observed. On all the CCTV recordings the appearance was similar, i.e. well-groomed and attired. The gait, posture, facial expressions and mannerism were his normal characteristics.
The FO’s movement captured on CCTV at KLIA on 07 March 2014 was observed. The FO’s behavioural pattern on CCTV recordings on the day of the flight showed no significant behavioural changes.
1.5.12 Voice Recognition of the Radio Transmissions between MH370 and Air Traffic Control
The radio transmissions made between MH370 and the air traffic control were studied. The Team used pilot friends, family members, and an expert report of objective analysis of the radio transmissions in the voice recognition of the transmissions made between MH370 and air traffic control.
Five sets of audio recordings were analysed starting from Airway Clearance Delivery at 1625:52 UTC [0025:52 MYT] till the last utterance from Lumpur Radar at 1719:30 UTC [0119:30 MYT]. There was a total of 23 utterances as follows:
(MHz) |
||||
| Airway Clearance Delivery (ACD) | ||||
| Lumpur Ground (LG) | ||||
| Lumpur Tower (LT) | ||||
| Approach Radar (AR) | ||||
| Lumpur Radar (LR) | ||||
From the information available, the first 3 sets of audio recordings (ACD, LG, LT), the speech segments are those of the FO before take-off, and the 4th & 5th (AR & LR) sets of the audio recordings originated from the PIC after take- off.