Crash 2 Operational facts and background 7 Recovery of the wreckage 10 Reconstruction 12 MH17 Investigation into flight routes 14 About the investigation 19 About the Dutch Safety Board 20 Credits 20

Introduction The crash of flight MH17 on 17 July 2014 shocked the world and caused hundreds of families much grief. In the first few days after the crash the first expla­ nations for the cause of the crash began to appear. The question was also raised as to why the flew over the conflict zone in the eastern part of . On board flight MH17 there were 298 occupants, of which 193 passengers with the Dutch nationality. On Friday 18 July 2014, the Dutch Safety Board received a formal MH17 Crash notification from Ukraine that flight MH17 had crashed and that an investigation into the causes of the crash was already underway. The same Investigation into the Main conclusions Passenger information day, the Board sent three investigators crash of flight MH17 Causes of the crash - The crash A second, independent who arrived in Kyiv in the evening. The Dutch Safety Board has of the investigation was conducted into extensively investigated the 777-200 was caused by the the gathering and verification of A few days later, the investigation was delegated to the Dutch Safety Board. crash of flight MH17. The first detonation of a model 9N314M passenger information and The Dutch Safety Board was determined part of the investigation focused warhead, fitted to a 9M38-series informing the relatives of the to answer the questions of how this on the causes of the crash. missile that was fired from a Buk Dutch victims of the crash of accident could have happened and what The Board has aimed at surface-to-air missile system. flight MH17. This investigation caused it on the basis of factual informa­ providing an accurate picture of has been published in a separate tion. Such an investigation requires the course of flight MH17 on None of the 298 occupants report and corresponding time, but I hope that our conclusions 17 July 2014 and the causes of survived the crash. brochure. answer questions that have preoccupied the crash. The second part of the the relatives since 17 July 2014. investigation focused on the Flight routes - None of the Tjibbe Joustra, chairman questions of why the aircraft was parties involved adequately Dutch Safety Board flying over the eastern part of identified the risks to civil aviation Ukraine and how, in general brought about by the armed terms, flight routes over conflict conflict in the eastern part of zones are determined. Ukraine. Crash Airspace restrictions From mid-March 2014, parts of the airspace over the eastern Air traffic: part of Ukraine were regularly route and closed for brief periods of time or their use was restricted. altitude Civil air traffic was not permitted In order to conduct air traffic to fly there, but military aircraft in an orderly, safe and were. The restrictions were efficient fashion, a system of related to the activities of the airways is used. On the basis Ukrainian Air Force. This subject of these airways, the is discussed in more detail in operator sets out a route the chapter dedicated to flight and makes a flight plan routes (see page 14). containing, among other things, information on Airspace restrictions are navigation, times and announced in a so-called altitudes. This flight plan is Notice to Airmen (NOTAM, see submitted to the air traffic box on page 16). On 17 July control prior to the flight. 2014, various were in Flight MH17 on force with regard to different In the air, aeroplanes are 17 July 2014 parts of the airspace over the separated by flying in At 12.31 Dutch time (10.31 UTC), On the day in question the eastern part of Ukraine, four of different headings and at flight MH17 departed from Gate aeroplane headed southeast, in them relevant to flight MH17. different altitudes. These G3 at Airport the direction of Germany. After Fo example, since 14 July 2014, altitudes are expressed in Schiphol heading for Kuala crossing the German and Polish civil aviation was not permitted flight levels (FL). Lumpur International Airport in , the aero­plane entered to fly below FL320 (circa For example, an aeroplane Malaysia. On board the aeroplane Ukrainian airspace. The 9,7 kilometres). On 17 July, flight can be flying at FL330, were 298 people, 283 of which aeroplane would then have MH17 was in an authorised area, which represents a flight were passengers. The crew continued its flight, flying over flying at an authorised altitude of altitude of 33,000 feet consisted of four pilots and Russia and Asia, to its final FL330 (circa 10.1 kilometres). (10.1 kilometres). eleven cabin crew members. destination of .

Time zones The aviation sector uses a universal time zone called Coordinated Universal Time (UTC). During the summer, the local time in the is two hours ahead of universal time (UTC+2), while in Ukraine it is three hours ahead (UTC+3). To avoid any confusion, times are specified in universal time (UTC), unless explicitly stated otherwise.

The planned route of flight MH17 on July 17, 2014.

2 - Dutch Safety Board Time Callsign Means Spoken text Translation (UTC) Last contact 13.19:49 DNP (S4) RAD Malaysian one seven, due traffic proceed direct to point ROMEO At around 13.19, the aircraft was NOVEMBER DELTA above the eastern part of Ukraine, near the border with 13.19:56 MH17 RAD ROMEO NOVEMBER DELTA, Malaysian Russia. At this point, the one seven aeroplane received permission to fly directly to the Russian 13.20:00 DNP (S4) RAD Malaysian one seven, and after point ROMEO NOVEMBER DELTA expect Federation. The crew confirmed direct to TIKNA this notification at 13.19:56. Up until that moment the flight had 13.21:10 DNP (S4) RAD Malaysian one seven, how do you read progressed as normal. A few me? seconds later, gave permission for the next DNP (S4) RAD Malaysian one seven, Dnipro part of the route. This permission 13.21:36 DNP (S4) RAD Malaysian one seven, Dnipro Radar was not confirmed, however, and no more signals were received 13.22:02 DNP (S4) RAD Malaysian one seven, Dnipro Radar from the crew of flight MH17. 13.22:05 RST TEL Слушаю, Ростов Listening you, its Rostov

DNP (S4) TEL Ростов, а вы малазийца семнадцатого Rostov, do you observe the Malaysian наблюдаете по...по ответу? seventeen by… by the transponder? Air traffic RST TEL Да нет. Что то начала разваливаться No. It seems that its mark has started to control метка его. break Virtually every country in the world has its own air traffic DNP (S4) TEL Ну у нас тоже. И на вызовы не Well, we have the same. And it’s not control service provider отвечает responding for our calls too controlling the air traffic above its territory. RST TEL И не отвечает на вьізовьі, да? He is not responding to the calls, is he? Throughout a flight, the cockpit crew maintain DNP (S4) TEL Да. И не видим пока его. То-есть ему No. And we don’t see it yet. So we gave him a contact with the air traffic дали отворот, он подтвердил и ... turn, he confirmed and… control of the country over which the aircraft is flying at RST TEL И все, да? And that was all, yes? that time. This contact involves, among other things, DNP (S4) TEL Да и исчез. Yes, and it disappeared coordinating the flight route and altitude, and making RST TEL Сейчас, подожди, я попрошу. Wait now, I’ll ask requests to deviate from the original route (for practical DNP (S4) TEL В пассиве там ничего у вас не In primary don’t you observe anything either? reasons). The air traffic наблюдается? control services of bordering RST TEL No, no, no, nothing. We see nothing. areas are also in contact with Не не не ничего. Ничего не видим. each other to coordinate the handover of flights and to DNP (S4) TEL Ну хорошо, сейчас мы зовем их сюда. Ok then, we are calling them here now discuss any special circumstances. DNP (S4) RAD Malaysian one seven, Dnipro Radar Transcript (extract) of the conversation between flight MH17 and air traffic control services and between air traffic controllers.

MH17 Crash - 3 Impact At 13.20:03 the aircraft was penetrated by hundreds of high- energy objects that originated from a warhead, model 9N314M, fired from a Buk surface-to-air missile system. This has been established on the basis of, among other things, the altitude at which the aircraft was hit, the damage pattern on the wreckage and the particles found in the wreckage and in the bodies of three of the crew Combination sketch of the calculated areas. The Russian Federation, at the Dutch Safety Board’s request, calculated a members. A number of the possible launch area without confirming the use of a 9N314M warhead, a 9M38-series missile or a Buk surface-to-air missile particles showed traces of system. (Source: Dutch Safety Board) aluminium and glass. This is material originating from the aeroplane that melted when it These matched the paint The investigation revealed that number of fragments from the was hit and thus was deposited samples from the missile parts the missile approached the warhead were found in their on the particles. A number of recovered from the wreckage aircraft almost head-on, in the bodies. fragments were found in the area. No scenario other than the direction of the upper left-hand wreckage of the aeroplane that one described above, involving a side of the aeroplane. The Recorder data were not from the aeroplane. Buk surface-to-air missile system, warhead exploded to the left of The recording on the Cockpit Samples of paint were taken can explain this combination of the cockpit. This is evident from Voice Recorder ended abruptly from two of these fragments. facts. the aeroplane’s damage pattern, at 13.20:03. A high-energetic which shows the highest number sound wave lasting 2.3 milli­ of impacts on the left-hand side seconds was detected in the of the cockpit. final 20 milliseconds of the recording. This sound wave It is not possible to determine originated from outside the the exact position and angle aeroplane, above the upper left- from which the missile was fired, hand side of the cockpit. This is the speed at which this occurred consistent with the position of and the local circumstances at the warhead at the moment of that moment. Based on the the explosion. impact pattern, the impact angle and other data a calculation was Further analysis of the recorders Not to scale made to determine the missile’s revealed that no warning signals trajectory, which originated in an were activated. The recordings area spanning approximately on the Flight Data Recorder 320 square kilometres in the ended abruptly and at the same eastern part of Ukraine. time as those on the Cockpit Voice Recorder. At this point, the As a result of the impact and the electrical power of the aeroplane ensuing pressure wave, the three was disrupted, causing both crew members in the cockpit recorders to stop recording. were killed instantly. A large Simplified representation of the volume of space of the warhead detonation location according to three independent simulations (Source: Dutch Safety Board)

4 - Dutch Safety Board Consequences of the impact Buk surface-to-air missile system and high-energy The Dutch Safety Board had a digital simulation made of the objects impact and the pressure wave that followed the explosion of A Buk surface-to-air missile system is an air altitude of 33,000 feet (approximately the warhead. The pressure wave defence system that consists of different 10.1 kilometres) at which flight MH17 was caused damage to the front components in various models and flying. section of the aircraft, up to configurations. The installation can comprise a 12.5 metres from the nose of the number of vehicles carrying the launch and The particles found in the aeroplane and in the fuselage. As a result of the radar systems, but there are also launching bodies of three of the crew members explosion and the impact, the systems that work autonomously. The consisted of unalloyed steel. The particles are aeroplane broke up in mid-air: warheads of this weapon system are filled with cube and bow-tie shaped. The number of the cockpit and the floor of the an explosive charge surrounded by two layers impacts, the distribution pattern and the tore away from of preformed fragments. shape of the high-energy objects that were the fuselage almost instantly and found are consistent with the pre-shaped crashed. The rest of the A Buk surface-to-air missile system can reach fragments in the warhead of the 9N314M aeroplane continued to fly for an altitude of 80,000 feet (approximately model. approximately 8.5 kilometres in 24.4 kilometres). This altitude far exceeds the an easterly direction. Sections of the upper side of the aeroplane were torn off as air currents, moving at a speed of approximate 900 kilometres per hour (480 knots), took hold of the damaged aeroplane. Both wingtips broke away and the rear section of the fuselage fractured, causing the tail section to detach itself from the centre section.

From the moment the forward section of the aircraft was struck, it took about 1 to 1.5 minutes until the rest of the aeroplane hit Left: example of a 9N314M-warhead. Middle: The different shaped particles in the warhead. Right: 3D-print of the the ground. arrangement of the pre-formed particles.

Radar data The radar images from Ukrainian Radome/ Wings Fins/Control Surfaces and Russian air traffic control Nose section Seeker/ Guidance unit show that MH17 was flying level at FL330 (10.1 kilometres) until 13.20. For a few moments, the Warhead Engine/Propulsion Unit Russian air traffic control’s radar images showed pieces of Antenna Autopilot/ Control Unit wreckage falling down as the Body/Outer skin Engine aircraft was breaking up. Generic form of a surface-to-air missile. Nozzle

MH17 Crash - 5

Radome/ Wings Fins/Control Surfaces Nose section Seeker/ Guidance unit

Warhead Engine/Propulsion Unit

Antenna Autopilot/ Control Unit Body/Outer skin Engine Nozzle Crash site The aircraft’s wreckage ended The area where the pieces of aeroplane were the first to break which came to rest upside down. up in several sites around the wreckage came down covered a off and crash. Initially the centre A fierce fire broke out at the site villages of Hrabove, Rozsypne total surface area of and tail sections of the fuselage where the centre section and the and Petropavlivka in the Donetsk approximately 50 square remained intact and ended up a engines hit the ground. As a region in the eastern part of kilometres. Within this area, six few kilometres further eastwards, result, the centre section of the Ukraine. On 17 July 2014, a crash sites can be identified near the village of Hrabove aeroplane was almost completely conflict was being fought where debris came to rest. (crash sites 4, 5 and 6). The destroyed. between armed groups and the distribution of the wreckage Ukrainian authorities. The wreckage that was found across these three eastern crash The crash caused a great deal of near the villages of Rozsypne sites shows that the end section damage in the crash area. There and Petropavlivka (crash sites 1, of the fuselage, the wings and were no casualties among the 2 and 3) shows that the cockpit the tail section came down next, local population. and the front section of the followed by the centre section,

Site 1 Site 4 Site 2 Site 5 Site 3 Site 6

600 m  N

Hrabove

Petropavlivka

Rozsypne

Last FDR point

earth

6 - Dutch Safety Board Operational MH17 recorders The Cockpit Voice Recorder and alarms or warnings and the the Flight Data Recorder of the conversation among the flight facts and flight MH17 aircraft were read crew indicated no abnormalities. out by the investigation team The Flight Data Recorder data and contained recordings that did not record any technical background could be used in the malfunctions or warnings in investigation. The Cockpit Voice relation to this flight. Recorder did not register any

Recorders (black boxes)

Every large transport aeroplane is fitted with two types of recorders, also known as ‘black boxes’.

• The Flight Data Recorder records all key flight data, such In addition to the direct causes there were no known technical as information of the crash, operational facts malfunctions that could affect pertaining to the and backgrounds were also the safety of the flight. There engines, altitude, investigated. By investigating was no known damage and there speed, course, etc. the aeroplane, the crew, and were no incorrectly performed Some recorders can other factors that can affect a repairs or engine malfunctions record up to a flight, other potential causes that could have caused the thousand different flight details over the preceding 25 flying could be excluded. aeroplane to crash. hours. All information is stored in binary form (i.e., in ones and zeros). This is one reason why the painstaking process of Crew, aeroplane and cargo The aeroplane took off with reading out and analysing the recorders takes a great deal of The cockpit crew of flight MH17 283 passengers, 15 crew time. consisted of two Captains and members, 17,751 kg of baggage two First Officers. All pilots were and cargo and 96,500 kg of fuel • The Cockpit Voice authorised and qualified to be on board. The aeroplane’s Recorder records flying a -200. weight and centre of gravity conversations and Malaysia Airlines company were within the prescribed limits. sounds in the directives prescribe that there There were no hazardous cargo cockpit. This must be two pilot teams - each or explosive materials on board. includes consisting of one Captain and conversations one First Officer - on board the Flight preparations between the pilots, aeroplane for flights with a The flight plan was prepared in conversations with duration of approximately twelve the prescribed manner and air traffic control and sounds in the cockpit such as warning hours. submitted to air traffic control. signals. The purpose of the Cockpit Voice Recorder is to enable The crew received an investigators to better investigate civil aviation incidents. As On departure from Amsterdam operational flight plan, relevant the recorder registers all pilot conversation, including private Airport Schiphol the aeroplane NOTAMs and information about ones, it was internationally agreed that the recorder data can was in airworthy condition and the cargo and the weather. be used in investigation but will never be made public in full.

MH17 Crash - 7 Emergency Locator Communications Addressing route; five minutes later the were present in the vicinity of Transmitter and Reporting System (ACARS). aircraft returned to the planned flight MH17 at the time of the In addition to the recorders, This system is used for route. occurrence. All three were under every large transport aeroplane exchanging flight or aircraft data the control of Ukrainian air traffic is fitted with an Emergency between the aeroplane and Radar images of flight control. The nearest aircraft was Locator Transmitter (ELT). This is ground stations. The commu­ MH17 located at a distance of activated if an aeroplane crashes nica­tions run via satellite During the investigation, the 33 kilometres from flight MH17. or when it is switched on by the (SATCOM) or radio frequencies investigators only had the raw No military aircraft were visible crew. Upon activation, the ELT (VHF). data from Ukraine’s air traffic in the radar images provided. transmits a signal to a receiver control’s secondary radar at their station via satellite. This makes At 13.12 the last ACARS message disposal. According to the Excluded causes it possible to determine the from flight MH17 was sent via authorities, the primary radar In addition to investigating the aircraft’s position. VHF. The messages sent from system in Ukraine was not active. causes of the crash, the investi­ the ground to the aeroplane gation also focused on excluding The flight MH17 aeroplane was after this time were not received Russian air traffic control did not alternative scenarios. The fitted with a fixed and a portable by the aircraft. store the raw data from its investigation has demonstrated ELT. The fixed ELT was activated primary or secondary radar that the crash was not caused by automatically upon impact of the Weather because the accident did not metal fatigue, corrosion or warhead; the signal was received The weather forecast indicated occur on Russian territory. existing damage to the around 13.20:36. No signal was that there was a high probability However, Russian air traffic aeroplane. Neither was the crash received from the portable ELT, of thunderstorms in the eastern control did provide a video film caused by an exploding fuel which can only be activated part of Ukraine. This turned out of the radar screen. tank, explosives exploding inside manually. to be true: there were clouds the aeroplane, or a fire on board and thunderstorms. At 13.00, These images show flight MH17 the aeroplane. Events such as a ACARS after consulting air traffic control, up until the moment when the lightning strike or a meteor In addition to a system for radio the crew decided to deviate aeroplane broke up. According impact were also excluded. communications, each modern 6.5 nautical miles (approx. to the radar data from both is fitted with an Aircraft 12 kilometres) from the flight services, three civil aeroplanes

Radar

Two types of radar are used in air traffic:

• Primary radar: this system signal transmitted from the uses reflections of radio ground. In addition to waves off objects. The position and speed, the primary radar provides an secondary radar can display object’s angle and distance, other information about the which are converted into a aeroplane (such as the type position. This can then be of aeroplane, the operator used to calculate the object’s and the destination). speed as well. The raw radar data are received • Secondary radar: in this by air traffic control, which then system a transmitter in the converts it into images on a Sample Ukrainian radar screen display which shows information about the aeroplane responds to a screen. aeroplane and the navigation of flight MH17.

8 - Dutch Safety Board Sources for findings The circumstances of the flight and the The time when the aeroplane was downed The observation that the aircraft was downed position of the aeroplane at the moment of was based on: with a Buk surface-to-air missile is based on: impact were based on: • Flight Data Recorder; • Shape and composition of the particles • Flight Data Recorder; • Cockpit Voice Recorder; that were found; • Cockpit Voice Recorder; • Communications with air traffic control; • The impact damage to the aeroplane • Communications with air traffic control; • Radar data and radar images provided by (impact pattern, spreading of impacts, • Location where Emergency Locator Ukraine and the Russian Federation; angle and location); Transmitter (ELT) was activated; • Final ACARS data that was transmitted • Damage to the aeroplane by the formation • Flight plan and flight preparations. through SATCOM and VHF system; of the pressure wave; • Time at which the Emergency Locator • Injuries of crew members in the cockpit; Transmitter (ELT) was activated; • The missile parts that were found; • Distribution of wreckage on the crash site. • The similarity between the paint samples on the fragments of the missile found in the wreckage and the missile parts recovered from the wreckage area; • Sound peak registered on Cockpit Voice Recorder; • The altitude at which the aeroplane was hit.

It was also examined whether energy objects found, the has revealed that no military • The impact killed the three there had been an aerial attack damage to the aircraft and the aircraft were present within at crew members in the cockpit by a military aircraft. An attack trajectory followed by the high- least a radius of 30 kilometres of instantly and caused structural from the air could not have energy objects. Moreover, the aeroplane. damage to the front section of caused the crash given the high- analysis of the available material the aeroplane fuselage. This Conclusions caused the aeroplane to break up in mid-air, after which the • On 17 July 2014, Malaysia wreckage came down in an Airlines flight MH17, carried area of 50 square kilometres out with an airworthy Boeing near the village of 777-200, registration 9M-MRD, Petropavlivka and the town of was flying at cruising altitude Hrabove in Ukraine. All near the Ukrainian-Russian 298 occupants lost their lives. border under the control of Ukrainian air traffic control and • Alternative scenarios were was being flown by an examined and excluded. authorised and qualified cockpit crew. More information In the first part of the ‘MH17 • At 13.20:03 a warhead Crash’ report you can read all exploded on the outside, to the findings of the investigation the left and above the cockpit. into the cause of the crash of This was a model 9N314M flight MH17. Sample Russian Federation radar screen display which shows flight MH17 and warhead, carried by a 9M38- accompanying details. series missile, fired from a Buk surface-to-air missile system.

MH17 Crash - 9 Recovery of the wreckage

For a long time, it was not safe Gilze-Rijen Air Force Base on enough for the Dutch Safety 9 December 2014. In the Board investigators to visit the months following the crash, crash site. The first wreckage local emergency services and recovery mission began on residents collected wreckage 4 November 2014. During a six- parts, which were transported day period that started on to the Nether­lands in the spring 16 November 2014, under the of 2015. Two more recovery leadership of the Dutch Safety missions were conducted in Board, hundreds of wreckage March and April 2015. pieces were collected and taken During one of the recovery to the nearby train station in missions parts of the missile Torez. From there, the wreckage were recovered, which were was transported by train to subsequently­ examined. Kharkiv, where it was subse­ It turned out that the paint quently loaded onto trucks and samples on the missile parts low loaders for transport to the matched those on the Netherlands. The first convoy fragments found in the carrying wreckage arrived at aeroplane wreckage.

10 - Dutch Safety Board An investigation under special circumstances

Normally speaking, an aviation information, the recorders and clear that it would not be situation at the crash site, a investigation will begin at the the radar images. possible to recover the decision was made on which crash site. In the case of this wreckage in the short term due sections of the crash site would investigation, however, this was The Dutch Safety Board’s to the persistent fighting and be searched during the recovery not possible. Due to the objective has always been to repeated negative recommen­ missions, and when. As many persistent fighting and unrest in visit the crash site and recover dations with respect to visiting pieces of wreckage as possible the area, it was not safe for the the pieces of wreckage as the crash site. That is why a list were recovered. While the area investigators to visit the crash quickly as possible. The Dutch was compiled of the pieces of was being searched, it became site and conduct an investigation Safety Board based its actions in wreckage that would be most apparent that a number of for several weeks. Therefore, it this respect on a positive relevant to the investigation. In specific pieces of wreckage were was decided to begin the recommendation from the Dutch November, the recovery mission no longer present. investigation using other authorities. The recovery of started as soon as the conditions available material such as human remains and personal allowed. Using the compiled list photographs, satellite belongings had priority. It was and based on the actual

More information Chapter 7 of the report ‘MH17 About the investigation’ describes all the activities and decisions relevant to the recovery of the wreckage in more detail.

MH17 Crash - 11 Reconstruction After the pieces of wreckage had been investigated, a reconstruction was made of the front section of the aeroplane. In the course of three months, the cockpit and business class section of the aircraft were reconstructed at Gilze- Rijen Air Force Base. For this purpose, a frame modelled on a Boeing 777-200 was built, to which the pieces of wreckage were attached. Due to the fact that many pieces of wreckage were twisted and bent, the frame is slightly larger than the original Boeing 777-200.

The reconstruction shows the consequences of the impact on the aircraft, the angle at which the cockpit was hit and the manner in which the aircraft subsequently broke up.

Righthand side of the reconstruction

Lefthand side of the reconstruction

12 - Dutch Safety Board This reconstructed section of the cockpit clearly shows the impacts of the high- energy objects. Examination of the impact pattern demonstrated that the warhead detonated on the left side, just above the cockpit, and that the particles spread out in a characteristic pattern and penetrated the aeroplane.

This fracture shows the location where the cockpit separated from the aircraft.

The shape and pattern of the impact show that differently shaped particles hit the Front of the aeroplane. reconstruction

MH17 Crash - 13 Investigation into flight routes

Ukraine

Eastern part of Ukraine

The crash of flight MH17 raised flight MH17. The Dutch Safety the question whether the Board therefore conducted an airspace above the eastern part investigation into the flight route The armed conflict in the Organization (ICAO) also issued of Ukraine should have been of flight MH17 and into the eastern part of Ukraine a formal notice regarding the closed due to the armed conflict. decision-making processes An armed conflict was being risks posed by the airspace A second question that was related to flight routes over fought in the eastern part of above . During the period raised is why Malaysia Airlines conflict areas. Ukraine at the time of the crash when the conflict in the eastern selected this particular route for of flight MH17. From the end of part of Ukraine expanded into April 2014, the conflict continued the airspace up to the crash of to expand into the airspace. The flight MH17, foreign authorities investigation revealed that and international organisations Downed Antonov and Sukhoi helicopters and aeroplanes did not issue any specific belonging to the Ukrainian warnings pertaining to the use of On 14 July 2014, three days 6,250 metres. According to armed forces were being shot the airspace above the eastern prior to the crash of flight Ukraine, these aircraft had down ever more frequently. part of Ukraine. MH17, a Ukrainian air force been hit by a more powerful transport aeroplane, an weapon than those that had International attention In diplomatic circles, concerns Antonov An-26, was shot down been used to shoot at military The authorities were expressed about the armed in the Luhansk region. In a aircraft during the period prior issued a general warning to conflict in the eastern part of press release, the Ukrainian to these incidents. The weapon American operators and airmen Ukraine and the shooting down authorities reported that the systems that had presumably concerning the airspace above of military aircraft of the aircraft was hit when flying at been used (a Pantsir surface-to- Ukraine and especially Crimea Ukrainian armed forces. These an altitude of 6,200 to 6,500 air missile or an air-to-air missile) even before the conflict broke concerns mainly arose from metres. On 16 July, a Sukhoi could also reach civil aeroplanes out in the eastern part of military and geopolitical Su-25 fighter jet was shot down at cruising altitude. However, Ukraine. This was done in considerations. However, none which, according to Ukraine, the Ukrainian authorities did response to the unrest in of the politicians, officials or was flying at an altitude of not recognise this risk. Crimea. Early in April 2014, the services made a connection International Civil Aviation between the military develo­p­

14 - Dutch Safety Board ments in the region and the however, did not include any possible risks posed to measures to protect civil air Responsibilities overflying civil aeroplanes. traffic from the weapon systems mentioned by authorities. Identification of the risks The responsibility for the safety of an airspace lies primarily with by Ukraine As a result, on 17 July 2014 civil the state that manages the airspace. However, the operator also The investigation revealed that air traffic was not permitted to has its own responsibility for the safe operation of a flight. Ukraine did not adequately fly below FL320 (circa identify the risks to civil aviation. 9.7 kilometres) in that area. The The state that manages the like to use. To do so, they Ukraine reported that two of airspace above this altitude was airspace submit a flight plan to air their military aircraft had been unrestricted and flight MH17 was Each state has traffic control. In principle, the shot down, at altitudes between flying in the permitted area and over the airspace above its route prescribed by the flight 6,200 and 6,500 metres, with at the permitted altitude in territory. This means that plan is used, but by mutual powerful weapon systems. The accordance with the flight plan. countries may determine how agreement between the systems mentioned by the On that day, until the airspace they use their airspace. captain and air traffic control authorities were also able to was closed, 160 civil aircraft Generally, states receive the actual route may be intercept overflying civil crossed the area. financial compensation from adapted. In some countries, aeroplanes and as such formed a operators using their airspace operators are advised by their threat to civil aviation. According Malaysia Airlines to pay for air traffic control national authorities about the to the Dutch Safety Board these As the operating the services. safety of the airspace in other reports gave enough reason for flight, Malaysia Airlines was countries. Furthermore, in Ukraine to close its airspace as a responsible for safe flight The state an aeroplane is some countries authorities precaution. However, this did not operations. When determining flying over is responsible for can impose a prohibition or a happen. Ukraine did impose the route, Malaysia Airlines assessing the safety of the restriction on resident airline restrictions on civil aviation, but based its decision on information airspace. For safety reasons, a operators on flying over a these were inadequately to that was available to the aviation state can impose certain certain country or area. protect civil aviation from the sector. In doing so, the operator restrictions. Certain routes or mentioned weapon systems. did not perform any separate risk flight levels can be closed, for State of departure However, it turns out that - also assessment for flying over the instance, or the state may Being the state of departure, with respect to other conflict conflict area in the eastern part close the airspace altogether. the Netherlands bears no areas - states hardly ever decide of Ukraine. The way in which Close cooperation between responsibility for the safety of to close their airspace because Malaysia Airlines prepared and civil and military air traffic flight routes used by foreign of an armed conflict. operated the flight complied control is important when operators. Therefore, the with ICAO regulations. assessing safety. In this way, Netherlands was not Airspace restrictions potential risks to civil aviation responsible for advising or From 6 June 2014, civil aviation Flight MH17 was operated by posed by military activities on instructing Malaysia Airlines was not permitted to fly below Malaysia Airlines, but passengers the ground and in the air are on the use of the flight route FL 260 (circa 7.9 kilometres) were also able to book tickets via minimised. that was selected for flight above the eastern part of KLM. Eleven passengers of flight MH17. Moreover, the Ukraine. This restriction was MH17 had booked their ticket Operators Netherlands had no legal intended to enable military air with KLM. This system is called Ultimately operators authority to prohibit Dutch traffic to fly at a greater altitude ‘codesharing’ and is common themselves assess whether or operators - including KLM as in order to protect it from practice in the aviation sector. not a flight route through Malaysia Airlines’ codeshare attacks from the ground. A few A code sharing agreement unrestricted airspace is safe partner - to fly over the weeks later, Ukraine issued a means that the party operating enough. They then decide on eastern part of Ukraine. subsequent NOTAM specifying a the flight is responsible for safe the exact route they would restriction to FL320 (circa flight operations. Malaysia 9.7 kilometres). These NOTAMs, Airlines did not receive any è

MH17 Crash - 15 States When, from the end of April 2014, the conflict in the eastern part of Ukraine expanded into the airspace, not a single state, as far as the Dutch Safety Board was able to ascertain, explicitly warned its operators and pilots that the airspace above the conflict zone was unsafe; nor did they issue a flight prohibition. States that did gather information were focusing on military and geopolitical developments. Possible risks to overflying civil air traffic were not recognised.

Other operators In March 2014, before the armed conflict in the eastern part of Ukraine started, one operator decided not to use the airspace above Ukraine anymore. This decision was taken because of the growing unrest in the country. Thereafter, as far as the Dutch Safety Board was able to The flight route and altitude of flight MH17 and the restrictions of airspace over the eastern part of Ukraine. ascertain, no other operators changed their flight routes for safety reasons related to the signals from KLM or other conflict in the eastern part of NOTAM operators that the airspace Ukraine. This situation remained above the eastern part of Ukraine unchanged after it was reported If a restriction or other change altitude, partly closed airspace would be unsafe. that an Antonov and a Sukhoi is applied to air traffic, this is or a runway that is out of use. It had been shot down on 14 and announced in a so-called also indicates the exact period Actions by other parties 16 July 2014 respectively. Notice to Airmen (NOTAM). A of time to which the NOTAM The Dutch Safety Board NOTAM is made available to applies and the type of air ascertained whether other States The Netherlands as state of operators and other users of traffic it concerns. In some and operators gathered departure the airspace via an cases additional background information about the situation The situation in Ukraine was internationally used system. information is provided, but in the eastern part of Ukraine being monitored from the this is not compulsory. The and whether this affected the Netherlands, but when gathering A NOTAM includes a concise Ukranian NOTAMs relevant to decision-making process on the information the focus was on the description of restrictions and flight MH17 did not contain use of the airspace. political balance of forces in changes. This can involve, for additional information. Ukraine and how this was example, a minimum flight influenced by the Russian Federation.

16 - Dutch Safety Board The Dutch ministries and intelligence services did not Recommendations have any information suggesting an actual threat to civil air traffic Passengers should be able to assume Risk assessment using the airspace above the that the operator has done all that is Operators cannot take it for granted eastern part of Ukraine. The possible to operate the flight safely, that an unrestricted airspace above a Dutch authorities therefore had and that states have ensured that the conflict area is safe. For this reason, no reason to issue a warning to airspace is safe and will be restricted or operators should make their own risk operators or to actively inform closed if it is unsafe to civil air traffic. assessment, also of the countries it flies them. over. Operators will have to gather In practice, however, this system does information about conflict areas more Conclusions of the not work as intended. In the opinion of actively and share relevant information investigation into flight the Dutch Safety Board it is therefore on threats with each other. States routes necessary to implement improvements should contribute to this by sharing at three levels. relevant information on the conflict in • None of the aviation parties question. The sharing of information involved adequately Airspace management in conflict should occur at both the national and recognised the risks of the areas international levels and be conducted armed conflict in the eastern States are responsible for the in a structured manner. part of Ukraine to overflying management and safety of their civil air traffic. airspace. However, states dealing with Operator accountability an armed conflict very rarely close their It is not clear which flights pass over • The current system of own airspace. When dealing with an conflict areas. Ideally, operators should responsibilities for armed conflict in its territory, a state actively provide information about safeguarding civil air traffic may find it difficult to ensure the safety routes to be flown by them as well as does not provide sufficient of its airspace. Therefore, the Dutch routes recently flown. That way, means to adequately assess Safety Board thinks it is important that everyone can form a judgement, the risks associated with sovereign states in such situations be thereby increasing public attention for flying over conflict areas. given more incentives and support in this issue. A first step toward this fulfilling this responsibility. In this would be to require operators to • Risk assessments for civil air respect, the following topics require regularly provide public accountability traffic using the airspace over attention: for routes they selected that pass over conflict areas should not only conflict areas. consider actual threats, but • The timely closure of the airspace or also include risks of which the restriction of its use; In the opinion of the Dutch Safety intention or capacity is Board, the International Civil Aviation uncertain. • Providing information (on the armed Organization (ICAO) and the conflict) to other parties to include in International Air Transport Association More information their decision-making process; (IATA) can play an important role in this The second part of the ‘MH17 matter. Crash’ report describes all • Proper coordination between civil findings of the investigation into and military air traffic control the flight route of MH17 and the services. decision-making processes involved related to flight routes over conflict areas.

MH17 Crash - 17 Impact on the occupants

Many of the relatives wonder to what extent factors almost immediately. Depending on occupants died, but it is certain that the the occupants experienced the crash of variables such as the occupants’ location in impact on the ground was not survivable. flight MH17. The Dutch Safety Board the cabin at the moment of impact, the conducted an investigation into the impact factors were not the same for all of the Conclusion of the crash on the occupants. occupants. It is likely that the occupants were barely able to comprehend their situation. In the Physical and mental impact A number of occupants immediately course of the crash, the occupants were The impact was entirely unexpected, which sustained severe injuries as a result of the exposed to extreme factors. means that people were barely able to factors, probably causing death. For others, comprehend the situation in which they the exposure caused reduced awareness or More information found themselves. There was hardly any unconsciousness within moments. It could In Section 2.15, Section 3.13 and Appendix time for a conscious response. The not be ascertained at which exact moment N of the ‘MH17 Crash’ report all findings occupants were exposed to extreme can be read.

18 - Dutch Safety Board About the 2. Quality 4. International nature The investigation team consisted The investigation into the crash of specialists in different fields, was conducted in an international investigation supplemented where necessary context and in accordance with with the expertise of external ICAO Standards and Best investigators and agencies. Practices (see box). Besides the Guidance committees provided Netherlands, the following states feedback on the reports. The had an accredited representative reports were also assessed for on the international investigation consistency, substantiation and team: Ukraine, Malaysia, the comprehensibility. , the United States, and the Russian 3. Determining the cause Federation. Representatives The Dutch Safety Board was from Belgium and Germany were founded to investigate also included at various points occurrences and establish their throughout the investigation. cause and underlying factors. Where possible, the Dutch Safety More information Board draws lessons to prevent The report ‘MH17 About the similar incidents in future. In this investigation’ provides more respect, the Dutch Safety Board information about the Dutch differs from other investigative Safety Board’s basic principles Major disasters shock the world, International Civil Aviation parties, such as the Joint and the way in which the especially when they involve Organization (ICAO). Based on Investigation Team, which is different MH17 investigations numerous casualties. In today’s these, Ukraine was the party that conducting the criminal investi­ were organised and conducted. society, an incredible amount of would have led the investigation, gation under the leadership of information regarding the but Ukraine delegated this task the Dutch Public Prosecution circumstances, possible causes to the Dutch Safety Board. Service. and responsibilities is shared immediately after a crash. This The Dutch Safety Board adopted Investigations into aviation also causes uncertainties. A four principles in the thorough investigation will investigation: accidents - ICAO Annex 13 determine the cause of a crash When an aircraft crashes, there conduct the investigation, exactly, presenting the facts and 1. Independence are guidelines and rules that which states are entitled to a removing the distress caused by It is important that the Dutch apply to the way in which the role in the investigation, what speculation. That way, an Safety Board is able to form an investigation into the crash this role entails and how an investigation will provide clarity autonomous opinion about the must be conducted and which international investigation to the surviving relatives and facts and interpret them parties are to play a role in the team should be composed. possibly contribute to aviation independently. That is why the process. This was laid down in It also stipulates how the safety. Accident investigations Dutch Safety Board operates Annex 13 of the Chicago international investigation focuses on the cause, not on independently of, and separately Convention of the United team cooperates and how apportioning blame or liability. from, other parties. The Board Nations’ International Civil each party can provide provides public accountability by Aviation Organization (ICAO). information and respond to Investigations into aviation publishing the investigation ICAO’s main objective is to the investigation’s findings. accidents are conducted in reports and the report about of increase the safety of aviation, Annex 13 also describes which accordance with the the investigation. including civil aviation. matters must be investigated internationally established and how the resulting reports standards and provisions of the Annex 13 describes, among must be compiled. other things, which state is to

MH17 Crash - 19 About the Dutch Safety

Board examples would be aviation, rail traffic and shipping, but the Board also investigates incidents in the chemical and petro­ chemical industries, at the armed forces, in the construction sector, in the food industry, in healthcare and with regard to road traffic. Occasionally, the Board will apply its expertise and legal powers to conduct investigations of a more incidental nature in other sectors in response to a serious incident. For example, the Board has investigated digital safety at Credits It has been laid down in Dutch With international occurrences government organisations, the This is a publication of the Dutch Safety law that the Dutch Safety Board the Dutch Safety Board decision making process on gas Board, based on the investigation can investigate serious incidents investigates according to extraction in Groningen and the reports and is published in different and disasters. Its explicit objec­ relevant international laws or safety of asylum seekers who languages. If there is a difference in tive is to establish what has treaties. reside in the Netherlands. texts, the English reports will prevail. happened based on a factual October 2015 investigation, in order to prevent In order to prevent unwanted The Board employs circa seventy similar incidents or disasters interference in its investigations, people, including about forty from happening in future. the Board is independent. Even investigators. Because of the Text contributions though the organisation is funded Board’s multi-modal nature, they Maters & Hermsen In order to provide its investi­ from the central govern­ment’s are able to compare develop­ gators with access to all relevant budget, neither ministers nor any ments in the various sectors and Design and printing information, the Dutch Safety other persons or bodies can apply that know­ledge in their Grapefish Board has extensive legal demand access, or give their investigations as well as the powers to gather such judgement about investiga­tion’s recommendations they make in Photo’s information. Investigators are findings or source materials. This order to enhance safety in the Cover: DCA Malaysia allowed to enter areas, have the enables the Board to reach its Netherlands and beyond. page 2: Google/INEGI power to seize records and own conclusions on the causes page 5: goods, and are able to let an of a major incident and More information about warhead and particles: JSC Concern area where an accident took determine independently which the Dutch Safety Board: Almaz-Antey, place be closed off for the lessons should be learnt from it. www.safetyboard.nl preformed particles: AAIB. investigation. As the Dutch page 7: AAIB Safety Board’s investiga­ tions­ The Dutch Safety Board is a Onderzoeksraad voor page 8/9: UkSATSE en GKOVD never involve matters of blame so-called ‘multi-modal’ board Veiligheid page 10/11: Ministry of Defence and or liability, they are conducted and has legal authority for Dutch Safety Board independently from any criminal conducting investigations in page 12/13: Dutch Safety Board investigations. nearly all fields. Well-known @Onderzoeksraad page 18: Rowin van Diest

20 - Dutch Safety Board