The release of the MH370 "Safety Investigation Report" at the end of July marked the culmination of a four-year fruitless search for the missing airliner. The search began as if looking for a needle in the haystack that is the South China Sea, before Malaysia dramatically revealed that it was the wrong haystack. The search finally ended in the Southern Indian Ocean, to which the term "haystack" does not even begin to describe.
Just as the original search served as a blame game between the various states involved, a game of "security competition by proxy" as interstate rivalry was evident within the supposed cooperative search, the release of the report was more of the same, with an extra element of infighting Malaysian bureaucratic politics thrown in for good measure.
In a major admission of the ineptitude of the various bureaucracies involved, Malaysia's Chief of Civil Aviation Authority resigned a day after the report came out. The report singled out a range of "significant issues" that contributed to delays in initiating the search and rescue efforts. This list of issues included "Malaysian and adjacent air traffic management", cargo screening, air crew medical certification, the flight monitoring system, "quick reference for operations control", and the effectiveness of the emergency locator transmitter.
Malaysia's civilian and military radar capabilities were revealed to have tracked MH370 as it turned westward from its last reporting "checkpoint". Tragically, this information was not collated and passed on to the relevant authorities co-located at Kuala Lumpur Air Traffic Services Centre (ATSC).
Additionally, the report pointed out that Malaysia Airlines' own operations centre was receiving automated tracking information from MH370 up to half an hour after the airline had dropped off the Kuala Lumpur (KL) Area Control Centre (ACC) radar. This operations centre, however, could not verify if its queries related to MH370 were received, leading to greater confusion over the whereabouts of MH370.
Therefore, the Rescue Coordination Centre (RCC) was activated nearly four hours late.
Noting these failings highlighted by the report, the new Malaysian Transport Minister, Anthony Loke Siew Fook announced that the ministry will "conduct a thorough investigation and take action against any misconduct committed based on the findings under the existing provisions of the law".
Furthermore, in his remarks announcing the publication of the Safety Investigation Report on MH370, Malaysia's Chief Investigator, Kok Soo Chon, commented that "The answer [to MH370's disappearance] can only be conclusive if the wreckage is found...as far as our team is concerned, we have done our job... We do not deal with search. Search is not our area. You have to ask the people responsible for the search. I can only answer your question relating to the investigation". The Australian media interpreted this to mean that Kuala Lumpur was adroitly parcelling out some responsibility for the lack of tangible outcomes from the four-year search to Canberra.
Not only that, the report established that Indonesian military radar and Bangkok ACC had both tracked MH370 up to the point where it was to be handed over to the supervision of Ho Chi Minh ACC. Nonetheless, there was no communication of this to Kuala Lumpur ACC or Ho Chi Minh ACC, especially once there was confusion over the location of MH370 between the two.
One bone of contention between the KL and HCM centres thus lay in whether an official alarm should have been raised when there was automated radar tracking without voice verification from the pilots. According to the report, this caused twenty minutes of delay in either initiating a radar scan towards MH370's alternative trajectories or a full-scale search and rescue effort.
The report also found that Ho Chi Minh ACC may have suffered from linguistic difficulties in raising the alarm to Kuala Lumpur faster and earlier, thus recommending that Vietnam's civil aviation authority "observe the requirement of language proficiency".
The upshot of all this is that disaster management needs to tackle that perennial bane of civil service bureaucracies worldwide: snags, unrehearsed emergency communication pathways, and outright miscommunication among disparate bureaucratic cultures, especially across state boundaries. These lessons are applicable to managing man-made and natural disasters around the world.
This "final" MH370 report is thus a wake up call -- that aviation bureaucracies can still improve on their professionalism in practicing scrupulous observance of procedure, especially with increasing air traffic. On another level, bureaucratic appointees must also be encouraged to exercise reasonable discretion and initiative in making the tough call for initiating search and rescue.
This is the very least the international aviation community owes to the memory of MH370's passengers and crew, and better than any memorial ever could.
Alan Chong is associate professor, and Jun Yan Chang is an associate research fellow, in the S Rajaratnam School of International Studies (RSIS) in Singapore.