La Malaisie a donc publié le 2 juillet 2018 son rapport final sur la disparition du vol MH 370 et vous avez le dossier complet de 445 pages ci-dessous.

MH 370 rapport final anglais

C’est en anglais et un peu indigeste et je pense que pas grand monde le lira en totalité. J’en ai donc tiré une quintessence en extirpant les 4 pages des conclusions ( pages 440 à 443) qui forment un résumé convenable du contenu général, pour aboutir à une courte phrase finale lapidaire :

« En conclusion, la Commission n’est pas capable de déterminer la cause réelle de la disparition du MH  370 ! »

Résumé des conclusions

Après la perte de fonctionnement de l’ACARS et des transpondeurs, les différentes prises de cap de l’avion avant de prendre une trajectoire vers l’Océan indien ne peuvent résulter SEULEMENT d’une anomalie de fonctionnement des systèmes. Des essais au simulateur ont montré que l’avion était en pilotage manuel et non pas sur pilote automatique (NDLR : sauf pour la trajectoire vers l’Océan indien où on pense que le PA fonctionnait.)

Les contrôleurs aériens de Kuala Lumpur et du Vietnam ont signalé avec retard la disparition de contact, ce qui a retardé les recherches.

Les pilotes étaient à jour de leurs licences et rien ne suggère qu’ils aient eu des difficultés ou change récents dans leur relationnel ou de conflit entre eux. Il n’y a pas eu de stress financier ou de changement de comportement et ils ne manifestaient aucune anxiété dans leurs communications.

La maintenance de l’avion était respectueuse des procédures et réglementations, excepté la batterie de l’enregistreur de paramètres FDR, dont la validité avait expiré.

Il est vraisemblable que la perte de communication VHF, HF, ACARS et Transpondeurs est due à une manipulation manuelle pour les mettre sur OFF. La VHF et la HF n’ont pas été utilisés intentionnellement ou pour une autre raison. La Commission n’a pas pu exclure l’hypothèse d’une intervention d’une tierce personne dans ces déconnexions.

Le SATCOM indique que l’avion est resté plus de 7 heures en vol et suggère que le pilote automatique fonctionnait dans ses fonctions basiques, pour que l’avion vole un temps aussi long.

La durée du vol montre que les systèmes essentiels de l’avion fonctionnaient et qu’il n’y a pas eu de problème mécanique avec la structure de l’avion, ses systèmes de contrôle, de pétrole ou moteurs.

L’avion a émis par le SATCOM 7 « pings » qui ont permis de le situer au-dessus de l’Océan indien.

La perte de ce signal à 0019UTC résulte probablement de la perte des deux poussées de moteurs par manque de fuel. L’épave n’a pas été retrouvée malgré 4 années de recherches dans le sud de l’Océan indien.

Le flaperon retrouvé est bien une part de l’avion ainsi qu’un morceau de de volet. L’examen des pièces montre que le volet était probablement en position retractée et le flaperon au neutre. (NDLR : ce qui exclut un amerrissage piloté)

Il n’y a pas d’informations sur une dislocation en vol ou à l’impact avec l’eau.

L’avion transportait des batteries Lithium-ion dans des conditions de paquetage de façon standard.

La possibilité de l’intervention d’un troisième acteur sur les systèmes ne peut être exclue.

Des mesures doivent être prises pour que puisse être installés des mécanismes permettant de suivre un avion qui dévierait de sa route et que la position des avions soit toujours connue

En conclusion, la Commission n’est pas capable de déterminer la cause réelle pour laquelle le MH 370 a disparu.

Poursuite de l’enquête par la France

Le 8 août 2018, nous apprenons que la section de recherches de la gendarmerie des transports aériens (SR-GTA) française relancera l’enquête sur le vol MH 370, pour vérifier certaines données satellite.

Les autorités françaises n’ont pas encore fait de déclarations officielles concernant la réouverture de l’enquête.

La GTA entend rétablir la trajectoire du Boeing 777 malaisien en vérifiant notamment l’authenticité des données techniques recueillies pendant l’enquête, notamment celle fournies par la société britannique Inmarsat, qui a réceptionné les positions transmises par le Boeing avant sa disparition.

Le système Inmarsat a suivi l’appareil avec la détection des fameux « pings » durant 7 heures, jusqu’à l’Océan indien où il aurait sombré. Mais le premier virage effectué par l’avion alors qu’il se trouvait au large de la Malaisie et du Vietnam, entre deux contrôles aériens, était volontaire.

Mon commentaire sur ce rapport

Les ayants-droits se sont offusqués de ce rapport, mais que pouvaient-ils en espèrer, eu égard au fait que l’enquête n’a pas pu amener de réponses aux questions que tout le monde se posait, malgré les centaines de millions de dollars dépensés. Deux semaines après le crash, j’avais écrit que « les chances de retrouver l’épave étaient infimes ».

Je pense que l’analyse de ce vol dramatique que j’ai faite dans le Power Point diffusé sur ce blog le 22 juin 2018 donne plus d’éléments de réflexion que ce rapport final malaisien.

Après ce rapport, tous les scénarios de ce drame restent donc envisageables et notamment celui que j’ai émis d’un incendie dans la soute électronique ou au cockpit qui amène à une perte de pressurisation de l’avion et à la perte de conscience des pilotes, qui prennent un cap approximatif vers Kuala Lumpur, avant de sombrer en hypoxie, comme toute chose vivante à bord, l’avion poursuivant sa route au dernier cap affiché, jusqu’au crash à cours de carburant.

On notera que le rapport estime qu’il est difficile d’attribuer les changements de trajectoires constatés seulement à des défaillances de systèmes. Un essai au simulateur a montré que le virage de retour a vraisemblablement avec un pilotage manuel de l’avion.

Concernant l’ouverture d’une enquête judiciaire par le pouvoir politique français par saisie de la Gendarmerie du Transport aérien, on est surpris de la voir surgir après la sortie du rapport, alors que les données de la société Inmarsat sont connues depuis l’été 2014 et que peu de transparence a été déployée pour expliquer concrètement l’existence de ces fameux « pings ». Cette démarche contraste avec le silence religieux de ce pouvoir politique durant toute l’enquête, alors qu’il y avait 4 français à bord.

Le MH 370 était équipé de ce du Satellite Detector Unit (SDU), placé entre les deux ailes en soute et donc protégé d’un incendie éventuel en soute électronique. Il sera intéressant que la Gendarmerie étudie le fonctionnement de ce SDU sur d’autres avions, pour voir si on retrouve ces « pings » dans des conditions de vol similaires. A ma connaissance, aucune investigation en ce sen n’avait été menée.

                                                           À suivre….. !

Extrait du rapport final du vol MH 370

SECTION 3.2 – Conclusions

 On 08 March 2014, MH370, a scheduled passenger flight from Kuala Lumpur to Beijing, operated by MAS went missing soon after a routine handover from the Malaysian ATC to Viet Nam ATC. Communications with the aircraft were lost after it passed waypoint IGARI, less than 40 minutes after take-off. The aircraft operating the flight was a Boeing 777-200ER, registered 9M-MRO. On board the aircraft were 12 crew and 227 passengers (239 persons in total).

Evidence shows that Flight MH370 diverted from the Filed Flight Plan route. The aircraft’s transponder signal ceased for reasons that could not be established and was then no longer visible on the ATC radar display. The changes in the aircraft flight path after the aircraft passed waypoint IGARI were captured by both civilian and military radars. These changes, evidently seen as turning slightly to the right first and then to the left and flying across the Peninsular Malaysia, followed by a right turn south of Penang Island to the north-west and a subsequent (unrecorded) turn towards the Southern Indian Ocean, are difficult to attribute to anomalous system issues alone. It could not be established whether the aircraft was flown by anyone other than the pilots. Later flight simulator trials established that the turn back was likely made while the aircraft was under manual control and not the autopilot.

KL ATSC operation was normal with no significant observation until the handover to Viet Nam ATC. Being the accepting unit, HCM ACC did not notify the transferring unit (KL ATSC) when two-way communication was not established with MH370 within five minutes of the estimated time of the transfer of control point (Establishment of Communications, page 11 of Operational LOA between DCA Malaysia and Vietnam Air Traffic Management effective 1 November 2001). Likewise, KL ATSC should have taken action to contact HCM ACC, instead, relied on position information of the aircraft provided by MAS Flight Operations. By this time, the aircraft had left the range of radars visible to the KL ATSC. It is noted that about one minute elapsed from the last transmission from MH370 and the SSR being lost from the radar display. The Air Traffic Controllers of both Centres did not initiate the various emergency phases as required then, thereby delaying the activation of the alerting and Search and Rescue operations.

The PIC and FO held valid airman licences and medical certification. There is no evidence to suggest that the PIC and FO experienced recent changes or difficulties in personal relationships or that there were any conflicts or problems between them. All the flight and cabin crew were certified fit to fly and were within duty-time limits at the time of the flight and were adequately rested. There had been no financial stress or impending insolvency, recent or additional insurance coverage purchased or recent behavioural changes for the crew. The radio-telephony communications conducted by the PIC and the FO with the Air Traffic Controllers conformed to the routine procedure and no evidence of anxiety or stress was detected in the communications.

The aircraft maintenance records indicated that the aircraft was equipped and maintained in accordance with existing regulations and approved procedures, except for the instance of the SSFDR ULB battery which had expired. The aircraft had a valid Certificate of Airworthiness and was airworthy when released for the flight and there was no record or report of any defect or malfunction in the aircraft that could have contributed to the event. 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 communications (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. No ELT signal from the aircraft was reported by the Search and Rescue agencies or any other aircraft. 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. This in turn suggests that the air and inertial data were probably available to the autopilot system and/or the crew. The inter-dependency of operation of the various aircraft systems suggests that significant parts of the aircraft electrical power system were likely to be functioning throughout the flight. The analysis of the relevant aircraft systems taking into account the route followed by the aircraft and the height at which it flew, constrained by its performance and range capability, does not suggest a mechanical problem with the aircraft’s airframe, control systems, fuel or engines.

Except for the first report, the ACARS reports normally sent every 30 minutes by the SATCOM system were not received. Data from the last seven SATCOM ‘handshakes’ were used to help establish the approximate path of the aircraft over the Indian Ocean. The initial log-on request and the hourly pings have been termed as ‘handshakes’. SATCOM transmissions indicated that a link was available from 1825 UTC on 07 March 2014 to 0011 UTC on 08 March 2014 although not used for any voice, ACARS or other data services apart from two unanswered ground-to-air telephone calls. Two log-ons, at 1825 UTC (07 March 2014) and 0019 UTC (08 March 2014), were initiated by the aircraft most likely due to power interruptions to the SATCOM avionics. The power interruption leading up to 1825 UTC was probably due to power bus cycling, the reason for it being unknown. The power interruption leading up to 0019 UTC was probably due to low fuel at this time resulting in the loss of both engines and their respective generators. There was probably enough fuel for the APU to start up and run long enough for its generator to power the SATCOM avionics to initiate a log-on request.

To date, the main wreckage of MH370 has still not been found despite a 4-year search in the South Indian Ocean. However, items of debris possibly from MH370, have been found as far north as the eastern coast of Tanzania and far south as the eastern coast of South Africa. This is in addition to several islands and island nations off the east coast of the African continent. Of these, the flaperon, a part of the right outboard flap and a section of the left outboard flap were confirmed to be from MH370. A few other pieces of debris were determined to be almost certain from MH370 which included some cabin interior items. Damage examination on the recovered part of the right outboard flap, together with the damage found on the right flaperon has led to the conclusion that the right outboard flap was most likely in the retracted position and the right flaperon was probably at, or close to, the neutral position at the time they separated from the wing. 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. Apart from the above, no other information about in-flight emergencies, aircraft configuration or impact could be inferred from the nature and damage of the debris.

MH370 did not carry any cargo classified as dangerous goods. Two cargo items of interest (the Lithium ion Batteries and Mangosteens) which were carried on MH370 had also been transported via scheduled flights on MAS before and after the event. These items were packed and loaded according to standard operating procedures.

As a result of the identified issues, the investigation has issued safety recommendations to enhance the safety of the aviation system. The recommendations made address the Malaysian and foreign air traffic surveillance systems, cargo scanning, flight crew medical and training records, reporting and following-up of crew mental health, flight-following system, development of a Quick Reference for Operations Control and ELT effectiveness.

It should be recognised that there is a significant lack of evidence available to the Team to determine with any certainty the reasons that the aircraft diverted from its filed flight plan route. However, the change in flight path likely resulted from manual inputs. The lack of evidence includes the exact location and disposition of the main aircraft wreckage and the evidence that it could provide, the information recorded on the Flight Data Recorder, Cockpit Voice Recorder and other recording devices on the aircraft and the absence of any aircraft voice or data transmissions that could indicate why the aircraft flew to the Southern Indian Ocean.

Without the benefit of the examination of the aircraft wreckage and recorded flight data information, the investigation was unable to identify 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. However,

the same lack of evidence precluded the investigation from definitely eliminating that possibility. The possibility of intervention by a third party cannot be excluded either.

The disappearance of MH370 and the search effort are unprecedented in commercial aviation history. Improvements must be undertaken to ensure that this type of event is identified as soon as possible, and mechanisms are in place to track an aircraft that is not following its filed flight plan for any reason.

In recent years, several States have expended significant amounts of funds and resources searching for missing commercial aircraft in remote oceanic locations, including AF447 and MH370. In this technological epoch, the international aviation community needs to provide assurance to the travelling public that the location of current-generation commercial aircraft is always known. It is unacceptable to do otherwise.

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

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