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MH370 final report wash-up - Clive's view...  

From the Daily Beast; via MSN:  

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Flight MH370 Becomes the Cold Case That Nobody Wants to Solve

By Clive Irving
 
1 day ago

© Provided by The Daily Beast Photo Illustration by The Daily Beast
Editor’s note: The opinions in this article are the author’s, as published by our content partner, and do not represent the views of MSN or Microsoft.

Could this disaster happen again?

In the case of Malaysia Airlines Flight 370 the answer is we don’t know. And that is a dangerous answer because it’s a religion with air crash investigators never to quit until they have the answer.

And yet, as we saw this week, the Malaysians have peremptorily shuttered their investigation into the disappearance of their Boeing 777 with 239 aboard without being able to explain what happened.

That is contrary to the diligence expected of every investigation. There is an obligation to discover whether a crash revealed a flaw, either human or mechanical (or a combination of both) that could recur.

Why is this so important? Because flying has only become as remarkably safe as it is because over many decades this question has been successfully answered in an unforgiving process. One crash after another has been relentlessly scrutinized until its cause could be explained beyond any reasonable doubt. 

This is what makes the case of MH370 so disturbing.

Nearly five years after the flight disappeared without trace it has now joined a gallery of ghosts. It has assumed a new cultural dimension, moving from the tangible to the invisible under the marquee title of The World’s Greatest Aviation Mysteries. In the future this will attract numerous narratives, from the rational to the insane

Obviously, this is not a happy place to be. Nobody wants to be part of this kind of enduring mystery story. The list of victims stretches back into the earliest days of flight and includes many names long since forgotten and one that is never forgotten, Amelia Earhart.

Most of these are all the ghosts of a time when aviation safety was on a steep and sometimes wobbly learning curve. The machines were relatively primitive. The risks taken were often reckless. Many parts of the process of flying were fallible. The science was slow in evolving – and matured only by learning from many deaths.


© AP FILE - In this March 6, 2016, file photo, a Malaysian child has his face painted with MH370 during a remembrance event for the ill fated Malaysia Airlines Flight 370 in Kuala Lumpur, Malaysia. An independent investigation report released Monday, July 30, 2018, more than four years after Malaysia Airlines Flight 370 disappeared highlighted shortcomings in the government response that exacerbated the mystery. (AP Photo/Joshua Paul, File)

No other form of transportation produced such spectacularly shocking ways of dying in the course of its growth. The sudden, apparently arbitrary and violent nature of air crashes gave them an impact on public awareness that made air travel seem a greater peril than it actually was – road accident death rates were always much higher in aggregate but nobody ever coined the phrase “fear of driving.”

It is a mark of how much has changed since then that the level of risk acceptable in commercial aviation during its first five decades would be unthinkable now. Every year more than four billion passengers board a scheduled commercial flight across the world with an almost complete certainty that no risk is involved.

Indeed, 2017 was the first year on record when nobody died on a commercial jet worldwide. Statistically the chance of a fatal accident is one in every 16 million flights.

Survivability in a crash has become a big factor in this improvement of safety. A few days ago this was demonstrated when an Aeromexico jet crashed just after takeoff from Durango, Mexico. The Embraer 190 was loaded with fuel and the impact was violent yet all 103 people aboard survived. Everybody was evacuated before the cabin was consumed in fire. Evacuation was made easier because the Embraer cabin has only two seats each side of the aisle, not three, and also because the cabin crew were exemplary in how they handled the emergency.


© Reuters A family member reads an MH370 briefing report before a closed door meeting in Putrajaya, Malaysia July 30, 2018. REUTERS/Sadiq Asyraf

Set against this background of a vastly improved safety record, MH370 is an anomaly – and, as a mystery, intolerable. In some way the highly sophisticated system that has given us an all but impeccable safety culture has failed. And we still have no idea which part or parts of that system, either singly or in combination, failed.

In every air crash there is a rush to assign blame. In the course of covering this story from the beginning I have seen the urge to assign blame surface, as it always does, from a variety of motives, from those anxious to escape responsibility to the anguished families who lost loved ones.

There seemed plenty of blame to go around when confronted with the serial incompetence of the Malaysian authorities. And, understandably, deep in their own irremediable grief, the families of the victims, frequently treated by the Malaysians as an unwanted nuisance, were handed a good target to blame.

But blame without information is a blunt instrument. And that applies particularly to the pilots involved. When I began covering air crashes 20 years ago, a veteran air-crash investigator cautioned: “Always remember, blame has no place in an investigation. Pilot error, for example, is a symptom of other problems and not a cause of accidents. Errors happen all the time.

“It is absolutely vital to get behind the error and ask what contributed to that person making the mistake. Was it the design? The training? The procedures? Most errors are part of being human.”

Related: MH370: new revelation in the case of the airplane that was never found! (StarInsider)

MH370: new revelation in the case of the airplane that was never found!

As it happens, that wisdom was later to be borne out by the disaster that, in some ways, is a direct precursor to the loss of Flight MH370.

In 2009 Air France Flight 447 from Rio to Paris disappeared in the south Atlantic, taking 228 souls with it. This was the first loss of a modern jet over an ocean where its final resting place was elusive: it took two years to locate the wreckage.

Once the wreckage was examined and the flight data recorders disclosed the final fatal minutes of the flight, an alarming picture emerged that combined a flawed technology with a poor response from the pilots. An instrument that recorded the air speed had fed wildly erratic data into the computers that directed the airplane’s autopilot system (the system normally flying the Airbus A330 at cruise as this was).

The computers, confused, began to shut down. The two pilots were unprepared to recover control from the computers and, because of the false air speed readings, were just as confused as their instruments. If they had correctly recognized the problem they could – and should – have flown themselves out of trouble. Instead, their handling errors magnified the jet’s instability and it fell rapidly into the ocean.

The original fault with the air speed instrument had been caused by icing in unusual climatic conditions. The decisively lethal fault was human. As a result, pilots now get regular training in simulators for the specific skill required, “upset recovery.” And the instrument was redesigned so that icing would not take it out.


© Getty PUBLIKA, KUALA LUMPUR, KL, MALAYSIA - 2018/03/03: A MH370 poster seen at the 4th Annual MH370 Remembrance event. Hundreds of people had gathered at the Remember MH370? Its Not History, Its Our Future is the 4th Annual MH370 Remembrance event organised by VOICE370 the MH370 Family Support Group held at Publika, Kuala Lumpur on 3rd March 2018. The purpose of the event is to gather the people to stand in solidarity and commemorate 4 years since tragedy of MH370 disappeared from the blue sky with the loss of 239 lives on 8th March 2014. (Photo by Faris Hadziq/SOPA Images/LightRocket via Getty Images)

So the case of Air France Flight 447 began as a preventable disaster but concluded as a classic exercise in how to learn from a crash and make flying safer.

But one vital lesson of that disaster remained unheeded: it should not take two years to find the remains of a jet lying at the bottom of the ocean. Most people were shocked to discover that in many parts of the world there was no effective way of keeping track of an airliner over oceans. French investigators vigorously demanded a remedy, but were ignored – until Flight MH 370 vanished over water.

In truth, this reveals a scandalous example of recidivism on the part of those charged with overseeing airline safety, both the regulators and the airlines themselves.

To prevent an airliner disappearing when beyond radar range over water, and to know in an emergency what had gone wrong, needed two measures to be taken, both readily available. The first was flight tracking, a secure automatic system that kept constant track via satellites of where the airplane was at all times. The second was a data streaming system that could be triggered in an emergency to describe what was happening to the airplane’s systems.

The failure to take these steps after such a clear red flag was raised by Air France 447 was partly psychological and partly venal. The airlines simply believed that this had been a one-off combination of errors that would never happen again. (The errors of piloting were, in any case, being remedied.) And, because of that, they decided that it wasn’t worth spending the money to provide dependable tracking and monitoring.

That same complacent mindset is, incredibly, apparent in the response to the loss of the Malaysian 777. But it’s even worse.


© Getty A woman walks past a banner bearing solidarity messages for passengers of the missing Malaysia Airlines flight MH370, during a memorial event in Kuala Lumpur on March 3, 2018 ahead of the fourth anniversary of at the ill-fated planes disappearance. / AFP PHOTO / Manan VATSYAYANA (Photo credit should read MANAN VATSYAYANA/AFP/Getty Images)

Flight MH370 has now become, uniquely in the history of modern air travel, a cold case that nobody wants to solve. They just can’t be bothered. That is, I believe, because once more the aviation industry’s attitude is that this was a freak event with its own peculiarcauses that cannot possibly bother us again. Not worth spending any more money to pursue.

Some of this attitude is based on a belief widely held among airline chiefs that the Malaysian pilots were involved. But even the Malaysian officials who were the first to have promoted this theory have now had to conclude that there is no evidence to support it, and never was. In the absence of that theory there is no other credible evidence of deliberate human involvement: no terrorist claim, no evidence of a hijacking and no sinister takeover of the controls by remote means.

At least, steps have finally been taken to equip airline fleets with new flight tracking systems. By November this year all jets carrying 19 or more passengers must be capable of reporting their position every 15 minutes. By 2021 they must be able in an emergency to report every minute.

The cost of not having such a system in place when Flight MH370 took off from Kuala Lumpur on the red-eye run to Beijing that night is enormous – both in money and in human suffering.

The insurance costs and liabilities are in contention because, without knowing the cause, responsibility for the crash cannot be assigned. Soon after the disaster experts at Credit Suisse estimated that the loss of the airplane itself would amount to a cost of $100 million. They also estimated the total liability costs to the relatives of passengers would be around $500 million, but that has turned out to be impossible to calculate. Liability varies according the nationality of the victims and the national laws governing settlements.

According to the Malaysian government, within two years of the disaster 42 families who lost members on the flight had settled for payments of $175,000 for each close relative, as was required by the airline’s legal obligations. But many other claims and lawsuits will drag on. Initially French insurers paid out $750 million to relatives of those lost on Air France 447, but numerous law suits have since been settled without disclosing the amount.

All along, one nation involved in the consequences of the crash has been strangely silent: China. There were 152 Chinese passengers on the flight, by far the largest of any nationality. The Chinese have never publicly voiced any criticism of the way the Malaysians dealt with the aftermath or the lengthy deep sea searches.

China made the smallest contribution to the search costs, $20 million in search equipment and financial contribution. Australia, which had only six passengers aboard, committed $60 million and Malaysia, with 50 passengers aboard, contributed at least $100 million.

Quite clearly, nobody wants to spend another penny with the formal investigation wound up. It’s like a murder mystery without a body to explain it. Or, rather, without 239 bodies that lie somewhere in the dark depths of a distant ocean unable to tell their story, possibly forever. 

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Also via the Senate Estimates thread:

Senate Estimates -  ATSB MH370 related AQON: 

Overdue No
Asked Of Australian Transport Safety Bureau
Proof Hansard Page/Written 58
Portfolio Question Number 246
Question

Mr Hood: There was also a program management board that oversaw the expenditure of the funds, and we had the processes and funds audited by KPMG. In terms of all the audit reports and the moneys in and out, that's certainly available if you'd like that. 
Senator PATRICK: Maybe it's worth tabling the KPMG report. 
Mr Hood: I'll take that on notice to provide that.

Answer
The ATSB’s financial statements are audited annually by the Australian National Audit Office (ANAO). For the financial years 2014–15, 2015–16 and 2016–17 the ANAO gave the MH370 program particular attention. The audit closing letters for each of these financial years is at Attachment A. In the 2016–17 closing letter ANAO specifically references MH370 advising:

We have concluded that ATSB’s revenues and expenses incurred for the search of flight MH370 are materially stated and have been disclosed appropriately in the financial statements.

KPMG, the ATSB’s internal auditor, also completed a ‘Health Check’ of the MH370 program in early 2016. This report is at Attachment B. The report acknowledged the governance structures in place including a Program Board with a representative from the Department of Finance. The report included some business improvement recommendations which were addressed.

Attachments

 Attachment A – ANAO Financial Audit Closing Letters

 Attachment B – MH370 Health-Check Report, KPMG, February 2016
Download question with answer 

Answer Attachment 
183 Attachment.pdf

Answered Date 
06/08/2018

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Overdue No
Asked Of Australian Transport Safety Bureau
Proof Hansard Page/Written Written
Portfolio Question Number 366
Question

1. The ATSB has repeatedly said the satellite data shows MH370 was in a rapid and increasing rate of descent at the end. Larry Vance points out that in such cases, such as Swissair 111, the aircraft gets pulverised into two million smallish parts. How does the ATSB explain the fact that the flaperon and the flap were largely intact; there was nothing big or intact enough to be even recognisable as a flap or flaperon on Swissair 111?
2. Does the ATSB think the flap and flaperon fell off due to "flutter" in a high speed dive?

  1. If so, why was there no flutter damage to the leading edges?

4. Captain John Cox, a leading air crash investigator, says this of the satellite data when it comes to the speed of descent:The ATSB takes BFO data and derives a vertical profile between the 6th and 7th arc. This is very high (almost too high) indicating a extremely steep descent. However the 7th exchange is a "Power Up" exchange and the vertical information is not as accurate. Looking at the 1st Arc exchange, which was also a "Power Up" exchange the vertical date was determined to be spurious or so inaccurate it was not considered valid. If during a "Power Up" exchange the vertical data is less accurate then the 7th Arc exchange must be viewed with the same concern. Therefore, the vertical BFO derived data is less credible than other data points. This would support Larry's theory and weaken the ATSB position.

1. 1. Is Captain Cox wrong, and if so, why?
      

Answer
1. The ATSB has never performed analysis nor published any information in relation to the speed that the aircraft may have impacted the ocean surface. The analysis performed by scientists from the Defence Science Technology Group (DST Group) of the metadata associated with the final two satellite communications between the aircraft and the Inmarsat ground station concluded that the aircraft was in a high and increasing rate of descent over the eight second time period between the two transmissions.

The analysis by the ATSB and other members of the MH370 Search Strategy Working Group, which includes Inmarsat, Thales, Boeing the Air Accidents Investigation Branch of UK and National Transportation Safety Board of the USA, concluded it is most likely these final two transmissions were triggered by fuel exhaustion of the engines and a restart of the aircraft’s auxiliary power unit and would have occurred when the aircraft was still at an altitude of between 20,000 and 30,000 ft.

Boeing simulations (documented in MH370 – Search and debris examination update available at: http://www.atsb.gov.au/media/5771773/ae-2014-054_debris-update_2nov2016.pdf) of the aircraft’s unpiloted glide behaviour after fuel exhaustion indicated that it is likely that the aircraft performed a series of phugoid motions, with periods of descent at differing rates and periods where the aircraft also gained altitude in the final minutes of the flight. Given the uncertainties associated with the final minutes of the flight it is not possible to conclude a speed at which it is likely the aircraft impacted the ocean surface.

The ATSB has studied many accidents where aircraft have impacted water. The damage to the aircraft and debris resulting from the impact is dependent on many factors including the aircraft’s speed both horizontal and vertical, the attitude of the aircraft at the point of impact and the type, size and construction of the aircraft. Some accidents where there was a high rate of descent led to aircraft debris which was in large sections, including Air France flight 447 which crashed off the coast of Brazil in 2009.

2. The ATSB has never published any analysis suggesting that the flap or flaperon separated from the aircraft due to aerodynamic flutter.

3. The analysis to which Captain Cox refers in this quote was performed by scientists from DST Group and is referred to in the answer to Question 1. A summary of this analysis was included in the ATSB report MH370 – Search and debris examination update (2 November 2016) (http://www.atsb.gov.au/media/5771773/ae-2014-054_debris-update_2nov2016.pdf). A more detailed analysis was published by the DST Group in MH370 Burst Frequency Offset Analysis and Implications on Decent Rate at End-of-Flight (15 January 2018) (Attachment A). The summary in the ATSB report explains that the DST Group analysis accounts for all possible errors in the satellite communication metadata due to system oscillator “warm up” transients and all possible speeds and headings of the aircraft.

The ATSB made contact with Captain Cox at the time his original assessment (quoted in the question) of DST Group’s descent analysis was used in an article in the Australian newspaper and provided him with a copy of DST Group’s full published analysis. He subsequently agreed that his original assessment, used in the newspaper article, was incorrect and the ATSB understands that Captain Cox has asked the Australian newspaper to print a correction.

Attachments

 Attachment A – MH370 Burst Frequency Offset Analysis and Implications on Decent Rate at End-of-Flight, 15 January 2018

Download question with answer 

Answer Attachment 

184 Attachment.pdf

Answered Date 
06/08/2018

MTF...P2