By Holly Maher
On March 8, 2014 Malaysia Airline flight MH370 took off from Kuala Lumpur heading for Beijing, China. The aircraft had 239 passengers and crew aboard. Less than 1 hour into the flight, communication and radar contact was lost with the aircraft. Forty-nine days later, the location and fate of the aircraft is still unknown despite a massive international effort to locate the missing airliner. The search effort has dominated the news for the last month and the question is still out there: how, with today’s technology, can an entire aircraft go missing?
Since we may never know what happened to flight MH370, this analysis is intended to understand why we can’t find it and identify the causes required to produce this effect. This will allow us to identify many possible solutions for preventing it from happening again. We start by asking “why” questions and documenting the answers to visually lay out all the causes that contributed to this incident. The cause-and-effect relationships lay out from left to right.
In this example, the Customer Service Goal is impacted because we are missing 239 passengers and crew. This is caused by the fact that we can’t locate Malaysia Airline MH370. The inability to locate the airline is a result of a number of causes over the 49 day period. One reason is that 3 days were initially spent looking in the wrong location, along the original flight path from Kuala Lumpur to Beijing, in the Gulf of Thailand and the South China Sea. The reason 3 days were mistakenly spent looking in this location is that the airline had left the original flight path and officials were unaware of that fact. Why the aircraft left the original flight path is still unknown, but we can look at some of the causes that allowed the flight to leave the original flight path undetected.
One of the reasons the aircraft was able to leave the original flight path undetected was that air traffic control was unable to track the airplane with radar. The transponder onboard the aircraft, which allows the ground control to track the aircraft using airspeed and altitude, was turned off less than one hour into the flight. We don’t know the reason the transponder was turned off; however, the fact that it is designed to be turned off manually is a cause of the transponder being turned off. It is designed to be manually turned off to reduce risk in the event of failure or fire, and to reduce radio traffic when the airplane is on the ground. After 9/11, when 3 out of the 4 hijacked airplanes had transponders that had been turned off, the airline industry debated the manual on/off design of the transponder, but aviation experts strongly supported the need for the pilots to be able to turn off the transponders, as needed, for the safety of the flight.
Another reason the aircraft left the original flight path undetected was because the flight crew outside the cockpit did not communicate distress or change of route. This is because all communications from the airplane come from/through the cockpit. The aircraft is not currently equipped to allow for communication, specifically distress communications, from outside the cockpit.
Days into the investigation, radar data was identified which showed the change of course of the aircraft. This changed the area of the search away from the original flight path. However, this radar detection was not identified in real time, as the plane was moving away from the original flight path. This is also a cause of the aircraft being able to leave the flight path undetected.
Once the search area moved west, the size of the potential search area was incredibly large, another cause of being unable to locate the aircraft. At its largest, the search area was 2.96 million square miles. This was based on an analysis of how far the flight could have gotten with the amount of fuel on board. Further analysis of satellite data, or “handshakes” with the computer framework on board the aircraft, continued to refine the search area.
Many people have asked why no one on the flight made cell phone calls indicating distress (if this was an act of terrorism). The reason no cell phone calls were made was because cell phones do not work over 2000 ft. That is because there is no direct line to a cellular tower.
Another cause of being unable to locate MH370 is being unable to locate the black box. The black box is made of aluminum and is very heavy, designed to withstand significant forces in the event of a crash. This causes the black box to sink, instead of float, making it difficult to locate. The depth of the ocean in which the search is occurring ranges from 4,000-23,000 ft, adding to the difficulty of finding the black box. Acoustic pings were last detected from the black box on April 8, 2014, 32 days into the search. This is because the battery life on the black box is ~30 days. This had been the battery design life criteria prior to the Air France Flight 447 crash in 2009. It took over 2 years to locate the black box and wreckage from flight 447, therefore the design criteria for the black box battery life was changed from 30 days to 90 days. This would allow search crews more time to locate the black box. Malaysia Airlines Flight MH370 still had a black box with a battery life of 30 days.
Once the analysis has broken down incident into its causes, solutions can be identified to mitigate the risk a similar incident in the future.
To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.