DUTCH SAFETY BOARD Safe flight routes Responses to escalating conflicts 2021 report Safe flight routes Responses to escalating conflicts 2021 report The Hague, June 2021 The reports issued by the Dutch Safety Board are publicly available on www.safetyboard.nl. Cover photo: Dutch Safety Board The Dutch Safety Board When accidents or disasters happen, the Dutch Safety Board investigates how it was possible for these to occur, with the aim of learning lessons for the future and, ultimately, improving safety in the Netherlands. The Safety Board is independent and is free to decide which incidents to investigate. In particular, it focuses on situations in which people’s personal safety is dependent on third parties, such as the government or companies. In certain cases the Board is under an obligation to carry out an investigation. Its investigations do not address issues of blame or liability. Dutch Safety Board Chairman: J.R.V.A. Dijsselbloem M.B.A. van Asselt (until 14 June 2021) S. Zouridis Secretary Director: C.A.J.F. Verheij Visiting address: Lange Voorhout 9 Postal address: PO Box 95404 2514 EA The Hague 2509 CK The Hague The Netherlands The Netherlands Telephone: +31 (0)70 333 7000 Website: safetyboard.nl E-mail: [email protected] N.B. This report is published in the Dutch and English languages. If there is a difference in interpretation between the Dutch and English versions, the English text will prevail. - 3 - CONTENTS Summary .................................................................................................................... 6 Consideration ............................................................................................................10 Recommendations .....................................................................................................13 Abbreviations ............................................................................................................15 1 Introduction .........................................................................................................17 1.1 Background .......................................................................................................... 17 1.2 Focus of the present investigation ....................................................................... 19 1.3 Investigation questions ........................................................................................ 20 1.4 Demarcation ......................................................................................................... 21 1.5 Other investigations and initiatives ...................................................................... 21 1.6 Overview of responsibilities in the selection of safe routes ................................. 22 1.7 Reading guide ...................................................................................................... 24 2 Airspace management ........................................................................................ 25 2.1 Significance .......................................................................................................... 25 2.2 Responsibilities and obligations ........................................................................... 25 2.3 Airspace management worldwide........................................................................ 28 2.4 Airspace management at the time of the crash of flight PS752 ........................... 31 2.5 Conclusions .......................................................................................................... 38 3 Information sharing and state guidance ..............................................................39 3.1 Significance .......................................................................................................... 39 3.2 Responsibilities and obligations ........................................................................... 40 3.3 Information sharing and state guidance for Dutch airlines .................................. 42 3.4 State guidance globally ........................................................................................ 52 3.5 Information sharing prior to and after the PS752 crash ....................................... 56 3.6 Conclusions .......................................................................................................... 65 4 Airline decision-making and accountability ........................................................ 68 4.1 Significance .......................................................................................................... 68 4.2 Responsibilities and obligations ........................................................................... 69 4.3 Decision-making and accountability for Dutch airlines ........................................ 76 4.4 Decision-making at the time of the PS752 crash.................................................. 81 4.5 Conclusions .......................................................................................................... 91 - 4 - 5 Conclusions ..........................................................................................................94 6 Recommendations ................................................................................................98 Appendix A .............................................................................................................. 99 Appendix B .............................................................................................................104 - 5 - SUMMARY On 17 July 2014, flight MH17 crashed in Ukraine, following the detonation of a surface- to-air missile outside the aircraft’s cockpit. All 298 persons on board lost their lives in the crash. The Dutch Safety Board investigated the crash and published a final report (in 2015) and a follow-up report (in 2019) about the risks of flying over conflict zones. Less than six years later, on 8 January 2020, flight PS752 was also shot down by a surface- to-air missile, shortly after taking off from Teheran Airport in Iran. All 176 persons on board were killed. This crash once again raised concerns about the decisions taken in respect of flying over or near conflict zones. Despite the fact that there was no Dutch involvement in the crash of flight PS752, the Dutch Minister of Infrastructure and Water Management requested the Dutch Safety Board to reflect further on the implementation of the recommendations from the MH17 Crash report. This request was focused on possible improvements to the national, European and global system for better managing the risks involved in flying over conflict zones. In response to this request, the Dutch Safety Board decided to start an additional follow-up investigation into the safety of flight routes. The aim of this investigation is to provide insight into what airlines and states do in practice to manage the risks of flying over conflict zones. Based on these insights, the Dutch Safety Board identified any shortcomings and possibilities for improvement. The cause of the crash of flight PS752 was not part of this investigation as the accident investigation into the cause of the crash was led in accordance with international standards by the Aircraft Accident Investigation Board of the Civil Aviation Organization of Iran. In its investigation, the Dutch Safety Board reconstructed the information available to Dutch airlines and the Dutch government in the period leading up to the crash of flight PS752, and the decisions they took in respect of overflying Iran and Iraq. The report integrates relevant findings from previous investigations by the Dutch Safety Board (2015 and 2019) with new findings about current practice in airspace management, the sharing of information and decision-making on flight routes. Until the crash of flight MH17, the risks to civil aviation of overflying conflict zones were insufficiently recognized. Until that moment, within civil aviation, it was assumed that whenever airspace was open, it was safe to fly there. Since that time, important steps have been taken within civil aviation to improve the management of risks of flying over and near conflict zones. In the follow-up report published in 2019, the Dutch Safety Board concluded that airlines have become more aware of the risks above and near conflict zones. Awareness has also increased among states and international organizations, which is reflected amongst others in new ICAO standards and the EU Integrated Aviation Security Risk Assessment process. At national level, the sharing of threat information between government and airlines has improved, as a result of a covenant between the Dutch state and airlines. - 6 - Airspace management by states with a conflict in or near their territory is of the utmost importance, as a crucial step in protecting civil aviation. As in its follow-up investigation in 2019, the Dutch Safety Board once again concludes that the majority of states with a conflict on or near their territory still do not close or restrict their airspace, and that they do not share information about the conflict relevant to airlines. Although closure of the airspace as a precaution would offer the best protection, this means is rarely employed. Even when the conflict between Iran and the United States escalated rapidly in January 2020, the Iranian airspace remained open, and Iran did not to publish a NOTAM (an aeronautical publication) about the ongoing conflict. Although in theory airspace management in conflict zones is an effective safety barrier, in