每日航空事故及事故征候(事件)简报(67) 2023.3.8
本系列希望为各位带来最详细的每日航空事故及事故征候(事件)信息(本系列信息全部来源于ASN数据库, 由于数据库更新时间等原因之限制每日简报将报告前一日之内容)
ASN数据库会有信息延迟, 部分事故或事故征候(事件)无法及时(在发生后第二天)出现在简报中, 现决定第一天的中午到晚上发布当天的简报, 第二天上午修改前一天的简报.在发生第二天之后更新至ASN的事故我将不会再次添加至专栏
简报不包括军航事故, ASN资料库简报内会写出事故航班之 "nature", 如此项为"Military"(军事)则该事故不会出现在本简报中
简报最后的"历史上的今天"部分是当天内容, 选取的事故与ASN主页相同部分一样
至文章发出时, ASN已记录2023年事故/事故征候598起
ASN资料库记录2023年3月7日发生之事故/事故症候7起（两起军航事故，另有一起事故确认为重复报告但ASN简报目前并未删除只是标为“Accident Dual Entry”所以仍需算为一起事故但并不会出现在本简报内，ASN简报也应该会在几小时内被删除）, 具体信息如下:
1: ASN事故号:308980
事故时间:0438
机型:Cessna A185F Skywagon
航空器运行及拥有者:私人
航班号:
注册号:N9697Q
制造商序列号:18503788
生产地:
首飞日期:
试飞注册号:
机龄:
机队编号:
引擎:
构型:
总人数: 1
死亡人数:1
非机上人员死亡人数:0
航空器损坏情况: 严重损坏
事故分类: 事故
事故地点:霍莫机场（HOM/KHOM），美利坚合众国
事故发生的飞行阶段: 降落
飞行性质: 私人
起飞机场: 埃尔门多夫空军基地（KEDF），美利坚合众国
目的地机场:霍莫机场（HOM/KHOM），美利坚合众国
具体信息:
2: ASN事故号:308985
事故时间:1400当地时间（1900协调世界时）
机型:Piper J3C-65 Cub
航空器运行及拥有者:Jack Brown's Seaplane Base Inc
航班号:
注册号:
制造商序列号:
生产地:
首飞日期:
试飞注册号:
机龄:
机队编号:
引擎:
构型:
总人数: 2
死亡人数:2
非机上人员死亡人数:2
航空器损坏情况: 损坏无法修复，航空器注销
事故分类: 事故
事故地点:靠近温特哈文斯吉尔伯特机场（GIF/KGIF），美利坚合众国
事故发生的飞行阶段: 巡航
飞行性质: 私人
起飞机场: 温特哈文斯市立机场（GIF/KGIF），美利坚合众国
目的地机场:温特哈文斯市立机场（GIF/KGIF），美利坚合众国
具体信息:
空中相撞，另一架机信息见简报3
3: ASN事故号:308988
事故时间:1400当地时间（1900协调世界时）
机型:Piper PA-28-161 Warrior II
航空器运行及拥有者:Sunrise Aviation Inc
航班号:
注册号:
制造商序列号:
生产地:
首飞日期:
试飞注册号:
机龄:
机队编号:
引擎:
构型:
总人数: 2
死亡人数:2
非机上人员死亡人数:2
航空器损坏情况: 损坏无法修复，航空器注销
事故分类: 事故
事故地点:靠近温特哈文斯吉尔伯特机场（GIF/KGIF），美利坚合众国
事故发生的飞行阶段: 巡航
飞行性质: 训练
起飞机场: 温特哈文斯市立机场（GIF/KGIF），美利坚合众国
目的地机场:温特哈文斯市立机场（GIF/KGIF），美利坚合众国
具体信息:
空中相撞，另一架机信息见简报2
4: ASN事故号:308986
事故时间:0501
机型:Cessna 172M Skyhawk
航空器运行及拥有者:Panair Flying Club Inc.
航班号:
注册号:N64535
制造商序列号:17265291
生产地:
首飞日期:
试飞注册号:
机龄:
机队编号:
引擎:
构型:
总人数: 2
死亡人数:0
非机上人员死亡人数:0
航空器损坏情况:
事故分类: 事故
事故地点:霍姆斯特德，美利坚合众国
事故发生的飞行阶段: 巡航
飞行性质:
起飞机场: 迈阿密行政机场（TMB/KTMB），美利坚合众国
目的地机场:
具体信息:
历史上的今天
2014年3月8日，由马来西亚吉隆坡国际机场飞往中华人民共和国北京首都国际机场的马来西亚航空370号班机在巡航过程中失联，事故班机由9M-MRO执飞，机型为Boeing 777-2H6ER型客机，机上的239人全部失联，马来西亚调查组认定事故发生的可能肇因为：“2014年3月8日，马来西亚航空公司运营的一架从吉隆坡飞往北京的定期客运航班 MH370 在马来西亚空中交通管制局（ATC）向越南空中交通管制总局（ATC）进行例行移交后不久失踪。起飞后不到40分钟，航空器通过IGARI航路点后失去了与其的通信。执飞该航班的飞机是一架波音777-200ER，注册号为9M-MRO。飞机上有12名机组人员和227名乘客（共239人）。
证据表明，MH370航班偏离了提交的飞行计划航线。由于无法确定的原因，飞机的应答机信号停止，然后在ATC雷达上不再可见。飞机通过航路点IGARI后，飞机飞行路径的变化被民用和军用雷达捕捉到。这些变化显然被视为先向右转，然后向左转，然后飞越马来西亚半岛，然后在槟城岛以南向西北方向右转，随后（未记录）转向南印度洋，很难单独归因于异常的系统问题。无法确定飞机是否由飞行员以外的任何人驾驶。后来的飞行模拟器试验证实，折返很可能是在飞机处于手动控制而不是自动驾驶的情况下进行的。
吉隆坡ATSC运营正常，在移交给越南ATC之前没有明显观察。作为接受单位，HCM ACC未在控制转移的预计时间后五分钟内与MH370建立双向通信时通知转移单位（KL ATSC）（2001年11月1日生效的DCA马来西亚和越南空中交通管理局之间的运营LOA第11页，建立通信）。同样，KL ATSC应该采取行动联系HCM ACC，而不是依靠马来西亚航空公司飞行运营部提供的飞机位置信息。此时，飞机已离开吉隆坡ATSC可见的雷达范围。值得注意的是，距离MH370的最后一次发射信号和SSR从雷达上消失大约一分钟。两个中心的空中交通管制员当时都没有按要求启动各种紧急阶段，从而推迟了警报和搜救行动的启动。
PIC和FO持有有效的飞行员执照和医疗证明。没有证据表明PIC和FO最近经历了个人关系的变化或困难，或者他们之间存在任何冲突或问题。所有的飞行人员和机组人员都被证明适合飞行，在飞行时都在值班时间内，并得到了充分的休息。机组人员没有财务压力或即将破产、最近购买的或额外的保险或最近的行为变化。PIC和FO与空中交通管制员进行的无线电电话通信符合常规程序，通信中没有发现焦虑或压力的迹象。
飞机维修记录表明，除了SSFDR ULB电池已过期外，飞机按照现行法规和批准程序进行了装备和维修。该飞机具有有效的适航证书，并且在发布飞行时适航，并且没有记录或报告可能导致该事件的飞机缺陷或故障。尽管根据现有的有限证据，无法最终排除飞机或系统故障是原因，但更可能的是，在改道前通信（VHF和HF通信、ACARS、SATCOM和转发器）的丢失是由于系统手动关闭或电源中断，或者在VHF和高频未使用的情况下，无论是否出于意图。搜救机构或任何其他飞机均未报告飞机的ELT信号。卫星通信数据显示，飞机在空中飞行了7个多小时，这表明自动驾驶仪可能在运行，至少在基本模式下，飞机可以长时间飞行。这反过来表明，空气和惯性数据可能对自动驾驶系统和/或机组人员可用。不同飞机系统运行的相互依赖性表明，飞机电力系统的重要部分可能在整个飞行过程中发挥作用。考虑到飞机所遵循的路线和飞行高度，受其性能和航程能力的限制，对相关飞机系统的分析并不表明飞机的机身、控制系统、燃料或发动机存在机械问题。
除第一份报告外，卫星通信系统通常每30分钟发送一次ACARS报告。最后七次卫星通信“握手”的数据被用来帮助确定飞机在印度洋上空的大致路径。初始登录请求和每小时ping被称为“握手”。卫星通信传输表明，从2014年3月7日的1825 UTC到2014年3年8日的0011 UTC，有一条链路可用，但除了两个未应答的地面对空中电话呼叫外，没有用于任何语音、ACARS或其他数据服务。飞机在协调世界时1825（2014年3月7日）和协调世界时0019（2014年4月8日）启动了两次登录，很可能是由于卫星通信航空电子设备断电。1825 UTC之前的电力中断可能是由于电力总线循环，原因不明。直到0019 UTC的电力中断可能是由于此时燃油不足导致两台发动机及其各自发电机的损失。APU可能有足够的燃料启动并运行足够长的时间，以使其发电机为卫星通信航空电子设备供电，从而启动登录请求。
迄今为止，尽管在南印度洋进行了4年的搜索，MH370的主要残骸仍未找到。然而，可能来自MH370的残骸已经被发现，最北至坦桑尼亚东部海岸，最南至南非东部海岸。除此之外，还有非洲大陆东海岸的几个岛屿和岛国。其中，襟翼、一部分右侧外侧襟翼和一部分左侧外侧襟翼被证实来自MH370。其他几块碎片被确定几乎可以肯定来自MH370，其中包括一些机舱内部物品。对右侧外侧襟翼的恢复部分进行的损伤检查，以及在右侧襟翼上发现的损伤，得出的结论是，右侧外侧襟翼最有可能处于缩回位置，而右侧襟翼在与机翼分离时可能处于或接近中立位置。机舱内部碎片的恢复表明，飞机很可能已经解体。然而，没有足够的信息来确定飞机是在空中还是在与海洋碰撞时破裂。除上述内容外，无法从碎片的性质和损坏程度推断出有关飞行中紧急情况、飞机配置或影响的其他信息。
MH370没有携带任何被列为危险品的货物。MH370上搭载的两件引人注意的货物（锂离子电池和山竹）也在事件前后通过马来西亚航空公司的定期航班运输。这些物品按照标准操作程序进行包装和装载。
由于发现的问题，调查已发布安全建议，以加强航空系统的安全性。所提出的建议涉及马来西亚和外国的空中交通监控系统、货物扫描、机组人员医疗和培训记录、机组人员心理健康报告和跟踪、飞行跟踪系统、制定运行控制快速参考和ELT有效性。
应当认识到，调查组缺乏足够的证据来确定飞机偏离其提交的飞行计划路线的原因。然而，飞行路径的变化可能是由人工输入引起的。缺乏证据包括主要飞机残骸的确切位置和处置情况以及它可以提供的证据、飞行数据记录器、驾驶舱语音记录器和飞机上其他记录设备上记录的信息，以及没有任何飞机语音或数据传输可以表明飞机为何飞往南印度洋。
由于没有对飞机残骸和记录的飞行数据信息进行检查，调查无法确定任何可能导致观察到的系统失效、偏离已提交的飞行计划路线和飞机后续飞行路线的飞机或系统故障模式。然而，同样缺乏证据，使调查无法明确排除这种可能性。也不能排除第三方介入的可能性。
MH370的失踪和搜索工作在商业航空史上是前所未有的。必须采取改进措施，以确保尽快识别此类事件，并建立机制，以跟踪因任何原因未遵守其备案飞行计划的飞机。
近年来，一些国家花费了大量资金和资源，在遥远的海洋地点寻找失踪的商用飞机，包括AF447和MH370。在这个技术时代，国际航空界需要向旅行的公众提供保证，即当前一代商用飞机的位置始终是已知的。否则是不可接受的。
结论为，调查组无法确定 MH370 失踪的真正原因。”（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.）
