Lessons Learned From MH370 Investigation
Today is the 6th anniversary of the disappearance of MH370. On March 8th, 2014 Malaysia Airlines Flight 370 with 239 people on board departed Kuala Lumpur International Airport in the dark of the night, en route to Beijing, China. About 37 minutes later, Kuala Lumpur Air Traffic Control cleared MH370 to switch to the communication radio frequency of the next control sector, where the pilot would be expected to report in. Less than two minutes later a significant anomaly occurred onboard MH370: the electronic tracking signal from the airplane, transmitted by a radio unit called a transponder, completely disappeared, causing the airplane to disappear from all ATC radar screens.
This was the beginning of what is often called “the greatest mystery in the history of aviation”. Many theories have been proposed to explain what happened.
Despite the efforts of an international investigation team, and millions of dollars spent searching the ocean bottom for the wreckage site, the official investigation has not found the wreckage and did not provide a definitive answer about what happened with MH370. How is this possible?
DISCOVERY OF FLAPERON
My name is Larry Vance and I have been investigating aircraft accidents since 1984. I was a leader in the Swissair 111 investigation, which crashed at high speed into the Atlantic Ocean off the coast of Canada in 1998. I am also the author of Transportation Safety Board of Canada’s Manual of Investigation Operations for which I received the Government of Canada Merit Award.
When the flaperon from the right wing, identified to be from MH370, was discovered in July 2015, I firmly believed that the evidence on the recovered flaperon would guide the official investigators to what caused the disappearance of MH370. The analysis of that recovered flaperon, and the subsequently discovered section of the outboard flap, should lead the investigators to conclude that MH370 ended its flight with the flaps fully extended (down) during a pilot-controlled ditching. Clearly, it was an MH370 pilot who caused MH370 to disappear.
To my great surprise, and I must admit professional disappointment, the official investigation did not come to that conclusion. Instead, they continued to support their theory of an unpiloted airplane. Their belief is that MH370 entered the ocean unpiloted, while in a high-speed diving crash. That belief is simply not true.
DEFICIENCIES IN AIR CRASH INVESTIGATION PRACTICES
As I have shown in my book, MH370: Mystery Solved, the evidence to disprove a high-speed diving crash, and to support a pilot-controlled ditching, is overwhelming. All of the evidence I used to explain what happened to MH370 was available to the official investigation, and yet they failed to uncover it.
The fact that such a high profile investigation failed to uncover and disclose such basic evidence is cause for grave concern. What assurance can we have that future investigations will not suffer from equal ineffectiveness?
Some of the top air safety investigation agencies in the world were involved in the MH370 investigation. According to the authorities, the official accident investigation included experts from Malaysia, Australia, China, United Kingdom, United States, and France.
There was also a criminal investigation side to the investigation, and it had equally impressive international representation, including by Interpol. There were other countries represented in some unofficial capacity.
Despite the availability of all this expertise, the MH370 investigation was clearly deficient. It failed to recognize and properly interpret the evidence that was available. Lessons must be learned about what went wrong, and why it went wrong, and steps must be taken to prevent this from happening again.
The primary purpose of an accident investigation is to discover safety deficiencies. Although MH370 was not an accident, the one overwhelming safety deficiency highlighted by the MH370 event is the inability of those involved in the investigation to find and interpret obvious evidence.
In my work as an investigation consultant, I have opportunities to examine the work of numerous official investigation agencies, including the most highly regarded. I can assure you that the shortcomings in the MH370 investigation are not isolated to that event.
I do not mean to imply that all investigations miss the mark. Some excellent work is being done, and deficiencies are being uncovered, and safety actions are being taken. However, opportunities for safety improvements are being lost because investigators miss or misinterpret evidence.
I believe that an important safety deficiency is apparent. It is a deficiency in the accident investigation capabilities of those who took part in the MH370 investigation, and of investigation agencies generally.
I believe the identification of this deficiency provides an opportunity to assess the readiness of all investigation agencies.
WHAT SHOULD CHANGE?
Every agency should be able to find and analyze the types of evidence which can be seen on the recovered wreckage pieces from MH370. This investigation work should not be beyond the capabilities of any agency that has an investigation mandate. What I have presented in my book is nothing more than basic accident investigation.
The government officials who have a responsibility to maintain an effective accident investigation response capability should make sure that the skills within their agency allow for this type of investigation analysis. If the state of readiness was where it should be in accident investigation, every air safety investigator should not only be able to understand the evidence presented in my book, they should be able to write it. As the MH370 investigation shows, you cannot just assume that the skills are there, even if your agency is recognized as world-class.
The investigators from companies obliged to send experts to assist in an investigation (for MH370, these companies included Malaysia Airlines, Boeing and Rolls-Royce) should have the necessary skills to identify and analyze basic evidence. The appropriate decision-makers must take steps to ensure those skills are in place.
I address the following specifically to those who work as investigators, or who plan to work as investigators. The single greatest attribute for any investigator is curiosity. A burning curiosity should have motivated the MH370 investigators to not be satisfied until they had a complete understanding of every witness mark. They should have obsessed over all the possibilities for how each wreckage piece was created, and figured out how they all combined to tell a story.
All investigators need to be exposed to the investigation basics. Not everyone needs to be a specialist in every aspect of an investigation, but everyone should be able to understand the basics, and be able to contribute (at the very least, to be able to contribute curiosity). It takes a team of investigators with different skills to conduct a successful investigation. Everyone on the team can contribute to ensuring that all the appropriate questions are asked, and to ensuring that no answer is left unchallenged if any doubt about its accuracy remains.
To be effective, you do not need to be the loudest voice in the room. In fact, you should be wary of the loudest voices. Do not assume that those with the most forceful opinions are delivering the most accurate assessments. Seek out and work with those who have the expertise you need to satisfy your curiosity. Then check, and then double-check.
An overactive ego can hurt your ability to find and assess evidence. I have seen this many times, even in myself. As the investigation progresses, it is hard to resist taking your best guess about what happened. You can then fall victim to looking only for evidence to prove yourself right, or to assessing evidence with a bias. You are more likely to do that if you have revealed your best guess to someone else within the team. I believe there were elements of this in the MH370 investigation
Having been involved in air crash investigation for so many years, I find it difficult to believe that some members of the investigation team were not aware of the shortcomings in the evidence being presented by the official investigation.
If some investigators were aware, and if they made their concerns known to the official investigation, their concerns were dismissed or ignored. When you are part of an investigation team, you are expected to express your opinions only within the investigation. You are to argue your positions privately, and never publicly.
As a team member, you agree that only one voice speaks publicly, and that voice belongs to the official investigation. It seems like everyone on the MH370 team has so far lived up to this commitment. In this case, and at this stage where the official investigation has basically run its course, I believe that investigators who were part of the official investigation should abandon the normal protocols for information release. I believe it would be a service to aviation safety if they chose to speak up.
If you are interested in the analysis of the MH370 wreckage pieces and learning more about how the official investigation was deficient (beyond what is covered in this article), check out my book here (available in audio, print and eBook formats).
