Australian Aviation has obtained a recording that reveals how air traffic control missed one of the most serious aviation safety incidents in a generation involving a packed A330.
After failing to respond to the first PAN PAN call for help from the Malaysia Airlines first officer, the controller then didn’t respond when the crew of separate aircraft asked if they’d heard it.
The aircraft took off from Brisbane carrying 215 people with its crucial speed sensors covered up in 2018. Similar incidents in 1996 involving 757s led to fatal crashes that killed more than 200 people.
Significantly, it comes after two separate investigations made claims of a toxic culture at Airservices, which oversees air traffic control.
The first, by a Federal Court QC, argued its culture was so poor it could “endanger the lives of air travellers”, while a second revealed an “unacceptable” atmosphere of bullying, sexual harassment and racism.
Airservices said the earlier investigation’s claims were “false and alarmist” but implemented the recommendations of the second, which it commissioned.
Our recording, obtained under Freedom of Information laws, showcases for the first time how air traffic control initially failed to respond to the incident that was the subject of a four-year probe by air traffic investigators.
The ATSB’s final report said that “no reason could be established” for the controller not hearing the PAN PAN message, adding that there were “no other known distractions or issues that could have interfered with the controller’s perception of the urgency call”.
The controller initially didn’t respond to the alert and then again subsequently when the crew of another aircraft taking off asked if they’d heard it.
It was only after the Malaysian Airlines’ first officer made a second call that he was responded to.
A full breakdown of the conversation from the ATSB is at the bottom of this article.
Airservices told Australian Aviation in response there was “no relationship between the incident referred to in the ATSB report and Airservices’ culture, and the ATSB investigation found no evidence of cultural issues influencing the response to this incident”.
The ATSB said in a statement this year its investigation into the incident was “one of its most substantive and complex” in recent years and also highlighted poor decisions made by Malaysia Airlines pilots and crew, alongside those from other organisations.
The situation took place on 18 July 2018, when the Malaysia Airlines Airbus A330, 9M-MTK, took off from Brisbane bound for Kuala Lumpur in Malaysia, with 14 crew and 215 passengers on board.
Crucially, the ‘pitot probe’ covers, which act as airspeed sensors, were covered up during takeoff.
The covers are necessary at Brisbane airport due to a problem with mud wasps in the area, which can sometimes fly into them.
It was after discovering the problem that the crew’s first officer made the call to air traffic control for help. Only around a minute and a half later was a second call made and responded to.
In 2020, Australian Aviation reported how a fresh investigation into Airservices Australia by a former sex discrimination commissioner lifted the lid on a culture of bullying along with multiple claims of racism, homophobia and gender discrimination.
Elizabeth Broderick’s report interviewed 2,171 employees and found that 37 per cent of women experienced sexual harassment and 50 per cent of all employees bullying, which, she concluded, must be addressed “as a matter of urgency”.
The investigation, commissioned by the business itself, also published numerous claims by employees, including:
- “[My manager said to me once] Why are you staying back at work? Do you want to f**k me? You should wear a dress. We can see your underpants.”
- “I have been here for over 20 years. And I’m worn down. I feel unsafe, vulnerable, scared and anxious. I no longer have the resilience to overcome the constant bullying, nastiness and harassment. No one in a leadership position is willing to stand up for what is right.”
- “The ATCs here make sexualised, racist and homophobic comments. If you call them out, they set you up.”
Airservices accepted the findings in 2020 and pledged to implement all of its recommendations.
In its last annual report, it claimed to have made “significant progress” and said its reforms included the creation of a ‘Culture Reform Board’ and implementation of ‘Safe Place’, which it said was a “specialised team providing essential psychological, wellbeing and investigative support to our people”.
Chief executive Jason Harfield later told Senators that as a result of investigations, “people have left Airservices”.
However, an earlier report by the Anthony North QC, commissioned by the air traffic control union Civil Air, found the culture at the organisation was so poor it could “compromise the safety of passengers”.
It went on to suggest that “management may upon investigation be found to have been primarily responsible” for the “culture of bullying, discrimination and sexual harassment”.
Airservices said it response then that it “unequivocally” rejected the suggestion safety was being put at risk and said there was “no factual basis for these false and alarmist claims”.
In a new statement in relation to the incident, Airservices said it plays a “critical role in Australia’s aviation safety and cultivates a safety-first culture”.
It added, “As the ATSB report notes, the tower controller believed the PAN PAN transmission had come through during a telephone call between the tower and departures from the speakers at the departures controller’s terminal and accordingly did not respond.
“Importantly, the ATSB found that the departures controller provided effective support to the flight crew after take-off, including taking the initiative to provide groundspeed information.”
ATSB analysis of Air Traffic Control correspondence
*Voices in the video have been changed to protect identities
At 2333:04, immediately after the captain’s read back, the FO suggested they call PAN PAN and the FO then immediately transmitted over the tower frequency ‘PAN PAN, PAN PAN, PAN PAN, Malaysian one thirty four, we have unreliable airspeed and request maintain runway track and request climb to six thousand [ft] initially’.
The tower controller did not later recall hearing this call and did not respond to it.
Recorded air traffic control (ATC) data shows that the call was received by the ATC radio on the tower frequency. Other recorded data showed that there were no other transmissions or calls around this time.
The PAN PAN call came about 40 seconds after the end of a coordination telephone call between the tower and departures controllers, in which they also briefly discussed equipment upgrades that were being conducted at the time (the tower controller later reported that the upgrades had no adverse effect on their workload or performance).
About 28 seconds after the end of the PAN PAN call, the flight crew of another aircraft requested take-off clearance from the tower controller. The tower controller responded with the clearance.
Immediately after that clearance was provided, the tower controller received a coordination call from the departures controller, who asked if the Malaysia Airlines aircraft could be transferred to the departures frequency, which is normally done shortly after take-off. The tower controller advised that it had already been done, and that they would ask again.
During that call, as the tower controller was speaking, the flight crew of the aircraft taking off asked over the tower frequency if the controller heard the PAN PAN call.
The tower controller thought that this transmission came through the telephone connection from the speakers at the departures controller’s terminal and, accordingly, did not respond.
The tower controller then asked the flight crew a second time to change frequency, which the FO read back.
Through the above period, the aircraft was passing about 3,800ft. The FO called for the Unreliable Speed Indication procedure. No memory items were called by either flight crew, and the captain proceeded to locate the procedure in the quick reference handbook (QRH).
After changing to the departures frequency, the FO made a second PAN PAN call at 2334:21 (passing 5,800ft), asking to climb to 10,000ft and maintain runway track.
The departures controller acknowledged the PAN PAN and provided the requested clearances.