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» MH17: ? »  DSB JIT »  DSB 13.10.15: Article MH 17 Crash Appendix V-Consultation Part A


DSB 13.10.15: Article MH 17 Crash Appendix V-Consultation Part A

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2

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State /
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Russian
Federation /
FATA

Ukraine /
NBAAI

Ukraine /
NBAAI

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7

39

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Summary

Summary

2.9.1

Text to be corrected (frst... last word)

The in-flight disintegration of the airworthy aeroplane
operated by a licensed and qualifed flight crew was
the result of the detonation of a 9M314-model warhead
containing pre-formed fragments.
Other possible scenarios that could have led to the
disintegration and crash of the aeroplane were
considered, analysed and excluded

The 9M314-model warhead was launched from a Buk,
Buk-M1 or Buk-M1-2 surface-to-air missile system in an
area of about 250 km2 south of Snizhne, Ukraine, which
was controlled, at that time, by the illegal armed
groups.

Air Traffc Services for flight MH17 were provided by air
traffc controllers of Lviv, Kyiv and Dnipropetrovsk
ACCs. UKSATSE air traffc controllers are licensed,
qualifed and accordingly trained. The regulations and
procedures of air traffc service provision are based on
ICAO Standards and Recommended Practices.

Argumentation / substantiation

Proposed text:
1. Here and further in the text of the report it is worthwhile indicating the
exact name of the type of weapon which hit the aircraft.
2. Replace 9M314 with 9H314, as the one corresponding to the
warhead of 9M38 air-to-ground rocket.
3. The second sentence (25 - 26 lines) shall be reworded as follows: There
exist other scenarios that could lead to in-flight break-up of the aircraft.
Argumentation:
1. The report does not provide any suffcient substantiation that the
aircraft was hit by a ground-to-air rocket with 9H314 warhead. The
characteristic pre-formed fragments i.e. butterfly or bow-tie are only
part of 9H314M warhead of the ground-to-air 9M38M1 rocket.
The report does not contain any suffcient data refuting the scenario of
hitting the aircraft with an air-to-air rocket.
2. Based on the investigation results, the report does not provide
suffcient substantiation that the rocket was launched from the area of
Snezhnoye.
The investigation does not take account of the data provided by AlmazAntei.
The respective substantiation is provided in the cover letter and
comments to the related parts of the draft fnal report

Territory de-facto was at time of the accident by the effective control of
illegal armed groups, which needs to be mentioned in the report.

The (following) text should be added as general information regarding the
air traffc service provision of flight MH17 in Ukrainian airspace.

Dutch Safety Board response

General:
The summary has been amended in a number of places to reflect the
comments.
Points 1 and 2 to this comment:
Work by the Dutch Safety Board, NLR, TNO and JSC Concern Almaz-Antey
regarding the identifcation of the weapon used resulted in the following:
The warhead identifed as the only one having bow-tie shape fragments
is the 9N314M (in Cyrillic text, the 9H314M).
The 9N314M warhead uses the 9M38M1 missile but it is known that it
also uses the 9M38 missile. The 9M38 can be launched from the TELAR
of the Buk and Buk M1 system, while the 9M38M1 can be launched from
the Buk M1 and Buk M1-2.
For readability the generic term Buk is used in the report.
Point 3 to this comment. The comment is not adopted as it is correct to
state that the other scenarios are all excluded.
See also the information described in the Dutch Safety Boards report
About the investigation and its Appendix L.

The Dutch Safety Board does not provide any political interpretation of the
conflict and strives to use politically neutral terms as much as possible.
Interpretations by other parties are those parties responsibilities

As the training an qualifcations of the air traffc controllers have not been
included in the investigation, the matter will be addressed in a similar
manner to that of the cabin crew.

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NBAA

Russian
Federation /
FATA

Page

40

48

Section /
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2.9.4

2.9.5.3

Text to be corrected (frst... last word)

along the border with Crimea administrative border of
the Autonomous Republic of Crimea

According to ICAO Annex 11 Air Traffc Services,
paragraph 6.4.1 Automatic recording of surveillance
data, States are required to automatically record
surveillance data from primary and secondary radar
equipment systems for use in accident and incident
investigations, search and rescue, and air traffc control
and surveillance systems evaluation and training. These
recordings shall be retained for a period of at least
thirty days and for accident and incident investigation
for a longer period until it is evident that they will no
longer be required.
As the accident had occurred outside Russian
Federation territory, the Federal Air Transport Agency
of the Russian Federation stated that no radar data was
saved nor was it required to be so by national
regulations. It was confrmed that had the event
occurred in Russian Federation territory, the data
would have been saved according to Russian
Federation regulations. The Russian Federation was
requested to provide its national regulations. As to
date these regulations have not been received.
It is noted that the provisions in ICAO Annex 14
paragraph 6.4.1 are not restricted to States
boundaries. Due to the national regulations from the
Russian Federation being different to the standard in
ICAO Annex 14 paragraph 6.4.1, ICAO requires that this
difference between the national version of a specifc
standard and ICAOs text be reported to ICAO. The
Russian Federation has not fled a difference to this
paragraph with ICAO

Argumentation / substantiation

Crimea is the internationally recognized territory of Ukraine, which was
additionally confrmed by UN General Assembly Resolution 68/262 On
territorial integrity of Ukraine)

Proposed text:
Delete this text and replace it with the following:
The Russian Federation has requirements for automatic recording of
surveillance data in the national legislation that are fully compliant with
ICAO Annex 14. The explicit explanations and extracts from the national
regulations were sent to the investigator in charge on May 6, 2015. ICAO
Annex 14 does not specifcally say that raw data must be saved. The
Russian Federation saved the necessary surveillance data in the format of
a video fle thus fully complying with the requirements of ICAO Annex 14.
Argumentation:
In accordance with the item 3.6.8 of the Federal Aviation Rules Air Traffc
Management the radio exchange between ATS units and aircraft pilots,
voice exchange between ATS unit controllers, weather briefngs of pilots
and ATC controllers, pre-flight inspections, weather data transmitted on
radio channels as well as radar and flight data shall be recorded by special
equipment. The recorded data must be kept and used for the purpose of
ATS within 14 days if using analogue recording equipment and within 30
days if using digital recording equipment.
The ICAO documents do not provide any defnition of the term ATS
surveillance system. Pursuant to item 8.1.2. of the ICAO Doc 4444, the
surveillance system comprises integration of all data necessary for air
traffc services. In this regard, the video fle with the air situation from the
radar screen provided by the Russian Federation can be qualifed as
surveillance data, which retention is required by the item 6.4.1.1 Annex 11
to the Chicago Convention.
The Russian Federation is in full compliance with the requirements of the
item 6.4.1.1 of Annex 11 to the Chicago Convention. All data at disposal of
the Russian side was properly made available to DSB and used in the
course of the investigation.

Dutch Safety Board response

The Dutch Safety Board has chosen to use a neutral term; Crimea.

The text in ICAO Annex 11, paragraph 6.4.9 refers to automatic recording.
The Dutch Safety Boards position is that this includes the recording of all
data, including raw data.
ICAO was consulted on this matter and ICAO concurs with the Dutch
Safety Boards position.
The reports text has been modifed to better state the Dutch Safety
Boards conclusion.

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Ukraine /
NBAAI

Ukraine /
NBAAI

Page

50

59

Section /
Paragraph

2.11.1

2.11.7

Text to be corrected (frst... last word)

On 21 July 2014, the recorders were handed over to a
Malaysian offcial in Donetsk by representatives of the
illegal armed group controlling the area. No evidence
or indications of manipulation of the recorders were
found

NATO AWACS aeroplanes did not have information
pertinent to the investigation. NATO AWACS
aeroplanes detected the signal of an anti-aircraft
system (SA-3 type of surface to air missile) at a range of
several hundred kilometres from the site of the
accident

Argumentation / substantiation

It would be useful to know whether there has been any verifcation of this
statement (that no evidence or indications of manipulation of the recorders
were found) by expert reports.
The armed groups operating in certain areas of Donetsk and Luhansk
Regions of Ukraine that are not controlled by the government do not have
any legal status.

On page 59 line 17-20, there is a reference to a fact that the AWACS
aeroplanes detected the signal of an anti-aircraft system at a range of
several hundred kilometres from the site of the accident. This signal was
automatically classifed by the AWACS aeroplanes as an SA-3 type of
surface to air missile. It is unclear why this fact has not been taken into
account. There is nothing in the report to suggest that this fact is not
accurate or does not relate to the accident, except the statement from the
NATO specialist that there is no data from the AWACS which would be
relevant to the investigation of the crash.

Dutch Safety Board response

The Dutch Safety Board does not provide any political interpretation of the
conflict and strives to use politically neutral terms as much as possible.
Interpretations by other parties are those parties responsibilities.

This letter to the German parliament that the comment refers to makes use
of material that cannot be verifed or further clarifed by the Dutch Safety
Board. The response from NATO to the Dutch Safety Boards questions
contains suffcient explanation. Consequently, the extract of the letter has
been withdrawn from the report.

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State /
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Ukraine /
NBAA

Ukraine /
NBAAI

Page

60

60

Section /
Paragraph

2.12.1

2.12.1

Text to be corrected (frst... last word)

Additional sentence:
Ukrainian side was unable to provide immediate, safe,
secure and unrestricted access to the crash site and the
surrounding area for the appropriate investigating
authorities, including the Dutch Safety Board experts,
after the crash, because this area was controlled by
illegal armed groups.

permission from local authorities illegal armed groups

Argumentation / substantiation

An additional sentence needs to be added considering the current
situation in the feld at that particular moment

It is unclear what kind of local authorities gave the permission. If it is (most
probably) about the illegal armed groups - it should be properly indicated.
If it is Ukrainian local authorities - it should be made clear as well.

Dutch Safety Board response

The Dutch Safety Board does not provide any political interpretation of the
conflict and strives to use politically neutral terms as much as possible.
Interpretations by other parties are those parties responsibilities. The
brief description of the situation contained in the report is therefore
deemed to be adequate.

The Dutch Safety Board does not provide any political interpretation of the
conflict and strives to use politically neutral terms as much as possible.
Interpretations by other parties are those parties responsibilities.

State /
Organisation

Russian
Federation /
FATA

Russian
Federation /
FATA

Page

76

76

Section /
Paragraph

2.16.1

2.16.2

Text to be corrected (frst... last word)

In total 72 selected objects were further examined; 16
foreign objects found in the bodies of the flight crew
members and one passenger, together with 56 foreign
objects recovered from the wreckage

2.16.2 Examinations of the selected objects.

Argumentation / substantiation

Proposed text:
1. Insert the following text after this text:
There were found two foreign objects in the shape similar to butterfly
or bow-tie. However, the analysis of these objects in relation to weight
and dimensions does not provide suffcient basis for attributing them to
the warhead 9N314M pre-formed fragmentation known as bow-tie of
9M38M1 rocket.
2. Insert the specifcation (table, diagram or similar) of all found highenergy objects with indication of their characteristics (shape, size, steel
grade).
Argumentation:
1. The report does not specify the number of butterfly or bow-tie shape
fragments found. The report neither indicates from which locations in
the aircraft structure (bodies of pilots, passengers or other) they were
extracted. It is also necessary to indicate who, where and when found
the high energy objects providing the inventory of the supporting
documentation.
The reported ratio of the high energy objects of various fractions
extracted from the aircraft structure does not correspond to the
expected results for 9N314M warhead of 9M38M1 rocket. The expected
ratio of the three fractions is as follows:
0,238 Bow-tie 13 x 13 x 8,2 mm;
0,238 Filler 6 x 6 x 8,2 mm;
0,524 Square 8 x 8 x 5 mm.
2. The report does not analyze the characteristics of the foreign objects
(by shape, steel grade and quantity), which does not provide suffcient
substantiation to conclude that the fragments extracted from the
aircraft structure belong to 9H314M warhead of 9M38M1 rocket

Proposed text:
1. This section shall be complemented with information on the steel grade
used in the discovered high-energy objects.
2. This section shall also consider the testing results of various types of
warheads provided by Almaz-Antei.
Argumentation:
1. The investigation did not identify the steel grade from which the preformed fragments were manufactured. Such analysis was absolutely
necessary for each type of fragments in particular because 9M38 and
9M38M1 rocket warheads use different type of steel grades for preformed fragments of different fractions (light and heavy).
It is impossible to state that the pre-formed fragments belong to the
same warhead type until steel grades of each type of pre-formed
fragments (two light and one heavy fractions) are identifed and
substance residue on all entry holes in different locations of the aircraft
structure is compared.
2. During the investigation of the high energy objects, there were
identifed no fragments of light fraction - parallelepiped
(Filler 6 x 6 x 8,2 mm). Given that in the course of the investigation, NFI
did not identify the steel grade of pre-formed fragments of light
fraction - parallelepiped (Square 8 x 8 x 5 mm) and heavy fraction
(Bow-tie 13 x 13 x 8,2 mm) it is impossible to ultimately identify the
warhead typ

Dutch Safety Board response

The Dutch Safety Board partially agrees with point 1 of the comment. As a
result, texts in Sections 1.13, 1.16 and 2.5 have been improved to include
more details on the fragments expected in a 9N314M warhead and the four
distinctly shaped fragments recovered.
However, the reported ratios between the different shapes cannot be
correlated with those fragments recovered as it is not possible to recover
all of the fragments from a detonation at an altitude of 10 km. In addition,
JSC Concern Almaz-Antey indicated that the actual number of pre-formed
fragments differs slightly from one warhead to another during
manufacture, making the ratios in the comment an approximation and not
an exact set of fgures.
Regarding point 2 of the comment. Whilst four pre-formed fragments were
recovered in a form close to their original shape, size and mass, many of
the fragments found were not in their original form (i.e. bow-tie, fller or
square). This was the result of abrasion, break-up, chipping and shattering
of the fragments after penetrating the aircraft skin and passing through
the aeroplanes internal structure and the cockpits interior.
Studying the detailed chemical composition of the steel is not relevant to
the investigation as the high-energy objects are usually made from lowgrade metal (unalloyed steel) originating from different batches, different
sources, different manufacturing locations and over different periods of
time. Matching the fragments found with reference material from an intact
warhead would not be possible because of these differences.
Considering changes due to deformation, abrasion, chipping and
shattering on explosion and impact, the bow-tie fragments found in the
wreckage originally had the shape, size and mass of the fragments used in
the 9N314M warhead. These fr

Point 1 to this comment:
Studying the detailed chemical composition of the steel is not relevant to
the investigation as the high-energy objects are usually made from lowgrade metal (unalloyed steel) originating from different batches, different
sources, different manufacturing locations and over different periods of
time. Matching the fragments found with reference material from an intact
warhead would not be possible because of these differences.
Point 2 to this comment:
Considering changes due to deformation, abrasion, chipping and
shattering on explosion and impact, the bow-tie fragments found in the
wreckage originally had the shape, size and mass of the fragments used in
the 9N314M warhead. These fragments are very distinct and they are
found in this type of warhead

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Russian
Federation /
FATA

Russian
Federa

Page

78

78

Section /
Paragraph

2.17

2.18

Text to be corrected (frst... last word)

2.17 Organisational and management information
Factual information and its analysis relating to the
decision making processes around the flight routes is
contained in the separate Dutch Safety Board report
entitled Flight MH17 and flying over conflict areas.
In that report, the following subjects relevant to this
accident were investigated:
the selection of flight routes by Malaysia Airlines,
with particular attention to the route across Ukraine;
the oversight by the Malaysian authorities, and - the
management of airspace in Ukraine, with particular
attention to the restriction of airspace made by the
Ukrainian authorities

2.18 Additional information
This paragraph contains a number of relevant subjects
that have not been addressed elsewhere in Section 2.
These relate to:
a description to two different aeroplane systems;
cabin pressurisation and cabin emergency oxygen
system;
background information on possible external
sources of damage, and
the preventative actions taken following the
accident

Argumentation / substantiation

Proposed text:
Add the following information to this section:
The Ukrainian authorities did not ensure the appropriate coordination
between the military authority and Air Traffc Service unit for the purpose
of advance introduction of flight restrictions over the armed conflict zone
due to the intensifcation of Ukraine Air Defense activities (introduction of
BUK-M1 anti-aircraft weapon systems to the conflict zone).
On the date of the accident, Dnepropetrovsk FIR was unable to use
primary radar data. The data from primary radars of Ukraine Armed Forces
were neither available. This situation was creating additional risks, nonaccountable by Ukraine authorities in case of possible disruptions on the
ground or onboard the aircraft flying over the armed conflict zone.
The adoption of the decision on the continuation of flights over the armed
conflict zone with the lack of use of all the capabilities of the ground CNS
facilities in case of possible disruptions, witnesses to the fact that the
Ukrainian authorities did not take necessary actions to ensure flight safety
over the armed conflict zone considering the recommendations of ICAO
Doc 9554.
Argumentation:
1. This section was compiled scholastically and did not reflect many
important conclusions made in the draft fnal report Flight MH17 and
flying over conflict areas.
2. Annex 13 to the Chicago Convention does not provide for issuance of
two reports on the results of the investigation separating the
consideration of causes which lead to the same accident. It is therefore
suggested to move all information related to the crash from Flight
MH17 and flying over conflict areas report to the fnal report.

Proposed text:
It is suggested to add the following subsection to this section Russian
Federations information on the movement and activity of Ukraine Air
Defense Forces in the conflict zone as follows:
Pursuant to the information of the Russian Ministry of Defense presented
at the offcial briefng on July 21, 2014, on the date of Boeing 777 crash, the
Ukraine Air Defense command in the vicinity of Donetsk had at least three -
four divisions of BUK-M1 anti-aircraft weapon systems which were capable
of hitting targets at the range of 35 kilometers and at heights of up to
22 kilometers. By July 17, 2014 the activity of Ukraine radar stations 9S18
Kupol-M1 of BUK-M1 anti-aircraft weapon systems was at maximum. Thus,
if on July 15, 2014 there were 7 active stations, then on July 16 there were 8
and on July 17, 2014 there were 9. Starting from July 18, 2014 the activity of
these radar stations sharply decreased and equaled to 2-3 per day.
According to the satellite pictures, presented by the Russian Ministry of
Defense, on July 17, 2014 there was identifed a Ukrainian BUK-M1 battery
in the area of Zaroshchenskoye village (8 km south of Shakhtersk).
The proposed text shall be complemented with respective satellite
pictures. The briefng materials are available at:
http://www.mid.ru/brp_4.nsf/newsline/f6 … 1d00203ccf
Argumentation:
1. The report should consider the risk of hitting the Boeing 777 (MH17) by
a Ukrainian BUK anti-aircraft weapon system present in the conflict zone.
2. The Russian Federation is the only State providing the objective data on
the movement and activity of anti-aircraft weapon systems on the crash
date and the preceding period.

Dutch Safety Board response

The text in Section 2.17 is a summary of that part of the investigation that
is contained in the newly added Part B of the Final Report.

The report does not address the location and availability of weapons
systems in the feld; it only seeks to identify the causes of the crash. Issues
regarding which parties were in possession of which weapon systems and
the missile launching location are issues for the criminal investigation.

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Federation /
FAT

Russian
Federation /
FAT

Page

86

106

Section /
Paragraph

2.19.

3.4.8

Text to be corrected (frst... last word)

At the second progress meeting with the international
investigators on 6 and 7 May 2015, the Russian
Federation presented work performed by the Russian
organisation Almaz-Antey on the impact damage on
the wreckage of flight MH17 and its possible source.
Almaz-Antey determined the weapon system that was
used in its simulation on the basis of public information
and its own sources within the Russian military and its
suppliers.

3.4.8 Weapon systems

Argumentation / substantiation

General comment on section 2.19.4 High-energy object analysis of
the report:
Almaz-Antei provided the data that did not identify the type of weapon
system but rather characterized the damage and rocket trajectory if this
rocket had indeed belonged to BUK anti-aircraft weapons system.
The data on the aircraft structure damage was analyzed by Almaz-Antei on
the basis of BUK performance data which were not publicly available and
consequently not considered in the simulations accomplished by NLR and
TNO. Unfortunately after receiving the information from Almaz-Antei, the
data used by DSB (NLR and TNO) were neither considered nor amended.
As a result, the warhead detonation and damage models used by DSB
(NLR and TNO) are not taking into account the full coverage area of the
fragment spay. The models were using the source data acceptable for
evaluation of effciency of battle applications. Such models evaluate only
the damage on the outer skin (about 70 % of the surface) and damage
degree of the most vital aircraft structure parts. The main result of such
simulation is the probability of hitting (terminated/damaged/did not
terminate). Meanwhile, the full objective picture of the damage on the
whole of the outer skin is not provided (up to 30 % of damage is not
considered) as well as the damage to the inside cockpit equipment and
aircraft structure bodywork.

Proposed text:
Subsections 3.4.8.1 and 3.4.8.2 shall be reworked on the sequence of
conclusions through the damage analysis, characteristics of high-energy
objects, determination of weight and detonation point of the warhead and
then determination of the type of rocket.
Argumentation:
In general, the version of hitting the aircraft with air-to-air rocket is
practically not presented in the report.
The approach to the analysis of the circumstances surrounding the hitting
of the aircraft presented in this section is incorrect and insuffciently
substantiating the reasons of hitting due to the following:
1. The report lists the conditions of aircraft hitting which more or less shall
coincide with BUK type anti-aircraft rocket weapon system.
2. When considering air-to-air rockets, the report beforehand highlights
only those used by Russia and Ukraine. The possibility of using rockets
with fragmentation warheads manufactured by other States is not
considered at all. The selection of rockets listed in Table 15 is made
without a prior weight determination of the rocket warhead which hit
the Boeing 777-200 (MH17).

Dutch Safety Board response

t is noted that the presentation made by the Russian Federation was not
intended to identify the weapon used. However, the new information on
the characteristics of the warhead that JSC Concern Almaz-Antey provided
the Dutch Safety Board with, was used by both TNO and NLR in their
simulation models.
In addition, it is a well known fact in the study of terminal ballistics of
fragments that a fragment hitting a plate at an oblique angle (not
perpendicular to the plate) changes its direction of travel after
penetration. The initial angle is typically reduced after penetration. This
change in angle is dependent on several factors and can be as small as
several degrees or as large as the original oblique angle. As a result, it is
usually not possible to obtain accurate data on the direction of travel of
fragments outside the structure by studying parts inside the structure.
The presentation by JSC Concern Almaz-Antey that was contained in the
Appendices to the draft Final Report has been withdrawn from the
defnitive version.

Reference is made to other weapon systems that are common in the
region. The text of the report has been amended to only introduce the
Buk system when evidence of its missiles is presented. Air-to-air weapons
are, based on the evidence, adequately addressed in the report.
Only weapon systems that are common in the region are addressed
because the Dutch Safety Board understood that there was very little
likelihood that weapons from other parts of the world were in the
inventory of any party in the region.
The Dutch Safety Board is not aware of any evidence that suggests that
other weapon systems both capable of causing the crash and containing
the distinct pre-formed fragments were present in the region

State /
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Russian
Federation /
FATA

Russian
Federation /
FATA

Page

108

109

Section /
Paragraph

3.4.8.2

3.4.8.2

Text to be corrected (frst... last word)

As none of the air to air missile that have fragmentation
warheads include butterfly or bow-tie shaped fragments,
these missiles cannot have caused the damage to flight
MH17. In addition, for an air to air missile with a
fragmentation warhead to have been responsible for
causing the damage found, another aeroplane would
have to have been displayed on, at least, the primary
radar data. The analysis in Section 3.3 of this report
shows that no military aeroplanes were in the vicinity of
flight MH17 at the time of the accident.

The high-energy object damage was not caused by an
air to air missile because:
there was no military aircraft in the area of flight
MH17 to launch such a missile;
no air to air missile warheads have butterfly or bowtie shaped fragments, and
an infra-red guided missile would have caused
damage to the aeroplane nearer the engines.

Argumentation / substantiation

Proposed text:
After this text, add the following text:
Meanwhile the use of air-to-air rocket shall not be ruled out. The modern
short-range air-to-air rockets are ftted with fragmentation warheads with
pre-formed fragments and seekers (passive, radar, lock on active radar or
infrared homing with pixel waveband. They are capable of engaging the
aircraft both from the rear (engine nozzle) or the front (most sensitive areas
such as cockpit, nose radar etc) and inflicting the damage similar to the
one observed on the front part of fuselage skin .
Argumentation:
Considering the air-to-air rocket performance as well as the method of
their delivery (by air), such rockets could have been used in the conflict
zone in Eastern Ukraine.

Proposed text:
Delete this text from the report as non-substantial and unproved.

Dutch Safety Board response

n addition to the response to the comment regarding paragraph 3.4.8
above, it should be noted that analysis performed by TNO demonstrated
that the damage pattern observed on the wreckage could not be
reproduced when a 40 kg warhead (typical of an air-to-air weapon) was
simulated.

The air-to-air missile scenario was investigated and rejected with valid
arguments that are discussed in the report. Most importantly, there is no
known air-to-air missile that contains bow-tie shaped fragments. The text
has been improved.

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Federation /
FATA

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112

Section /
Paragraph

3.4.8.3

3.4.9

Text to be corrected (frst... last word)

3.4.8.3 Surface to air missile fre

3.4.9 Buk surface to air weapon system
Considering the location of the accident, all of the
weapons considered were constructed by Soviet /
Russian Federation companies. The Buk (beech tree in
Russian) surface to air weapon system is the most
common weapon in this region and is the only weapon
system that contains pre-formed high-energy objects in
the shape of a butterfly or bow-tie in its warhead.

Argumentation / substantiation

General comment to Section 3.4.8.3 Surface to air missile fre:
This section includes the theoretical data and oversimplifed information
on the performance principle of a rocket with a fragmentation warhead.
The data contained in this section can be equally applicable to both air-toair and ground-to-air rockets.
The conclusion that air-to-air rocket can only target engine is incorrect.
Thus the information provided in this section does not give the
substantiated answer as to why we are considering only ground-to-air
rocket further in the report.
This section shall not refer to ground-to-air rockets only.

Proposed text:
Delete this text from the report.
Argumentation:
1. The conclusion is made that BUK type anti-aircraft systems are using
rockets with butterfly or bow-tie fragmented warheads. It is not
considered though that BUK can use both 9M38 rocket (with 9N314
warhead containing fragments of two fractions without butterfly or
bow-tie shape fragments) and 9M38M1 (with 9N314M warhead with
fragments of three fractions including butterfly or bow-tie).
2. During the investigation, there was made no analysis of the ratio
between the extracted fragments of various fractions from the aircraft
structure. The absence of data on the steel grade of the high energy
objects in the report does not provide any substantiation for the
conclusion on the warhead type of the rocket.

Dutch Safety Board response

The text referred to in the 2nd and 3rd paragraph is corrected. See also
responses on paragraph 3.4.8.2 above (page 108 and 109).

See the response to the comment made regarding paragraph 2.16.1
above.

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3.4.9

3.4.10

Text to be corrected (frst... last word)

The 9N314-model warhead contains butterfly or bowtie, so-called fller and square shapes (see Figure 32
for a sample image).

The examination by the NFI of the high-energy objects
found in the bodies of the flight crew members found
that the objects were made of unalloyed steel
consisting of iron with some silicon, manganese,
copper, chromium and cobalt. One high energy objects
consisted of a low alloy steel having an elemental
composition of iron with some silicon, chromium and
nickel. On the high-energy objects of unalloyed steel,
aluminium, glass and other material was present in the
form of thin layers or loose particles. On a number of
high-energy objects layers of both aluminium and glass
were found. The glass layers are considered to be
cockpit glass due to their zirconium content. The layers
of aluminium are considered to be from the aeroplanes
aluminium structure. This indicates that metal parts
passed through the cockpit windows and hit the pilots
at high speed and with high temperatur

Argumentation / substantiation

Proposed text:
Delete this text from the report.
Argumentation:
This statement is not correct: the warhead with pre-formed fragments of
three fractions are only used in 9H314M warhead of 9M38M1 rocke

Proposed text:
1. In the frst sentence after the high-energy objects found in the bodies
of the flight crew members add in brackets the number (quantity) of
high energy objects found in the bodies of flight crew members.
2. In the second sentence after One high energy object add in
brackets the characteristics of the high energy objects i.e. (shape,
weight, steel grade).
Argumentation:
No evaluation of high energy objects has been done to identify the steel
grade of which they had been manufactured. The provided data contain
only general conclusions on the chemical composition of the material,
which was used for making high energy objects.
It is impossible to state that all fragments belong to the same warhead
before determining the steel grade of all types of high energy objects
(light and heavy fractions).

Dutch Safety Board response

The warhead identifed as the only one having bow-tie shape fragments is
the 9N314M (in Cyrillic text, the 9H314M). This warhead is intended to be
carried by the 9M38M1 missile but it is known to be also installed on the
9M38M. Therefore, the report refers to the 9N314M warhead and the
9M38M or 9M38M1 missile as launched by the Buk surface-to-air missile
system.

Text has been improved to include more details on the fragments expected
in a 9N314M warhead and the fragments recovered from the bodies of the
crew members. However, the reported ratios between the different shapes
cannot be correlated with those fragments recovered as it is not possible to
recover all of the fragments from a detonation at an altitude of 10 km. The
fragments found are not in their original form (i.e. bow-tie, fller or square)
due to abrasion, break-up, chipping and shattering of fragments after
penetrating the aircraft skin and the surfaces on the inside. In addition, JSC
Concern Almaz-Antey indicated that the actual number of pre-formed
fragments differs from one warhead to another during manufacture.
Studying the detailed chemical composition of the steel is not relevant to
the investigation as the high-energy objects are usually made from lowgrade metal (unalloyed steel) originating from different batches, different
sources, different manufacturing locations and over different periods of
time. Matching the fragments found with reference material from an intact
warhead would not be possible because of these differences.
Considering changes due to deformation, abrasion, chipping and
shattering on explosion and impact, the bow-tie fragments found in the
wreckage originally had the shape, size and mass of the fragments used in
the 9N314M warhead. These fragments are very distinct and they are
found in this type of warhead

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3.4.10

Findings

Text to be corrected (frst... last word)

The high-energy object found in the wreckage of flight
MH17 as described in 2.16 and shown in fgure 33 is
consistent with the fragments found in the 9N314-
model warhead carried on the 9M38-series of missiles
as installed on the Buk, Buk-M1 or Buk-M1-2 surface to
air missile system. Due to the absence of reference
material from the mentioned 9N314-model warhead
pre-formed fragments a metallurgical link could not be
made.

The number, shape and size of the high-energy objects
found in the wreckage of flight MH17 are consistent
with the pre-formed fragments in the 9N314-model
warhead carried on the 9M38-series of missiles as
installed on the Buk, Buk-M1 or Buk-M1-2 surface to air
missile system.
High-energy objects found in the aeroplane and the
bodies of the flight crew were mainly of unalloyed steel
some of which showed evidence of having passed
through the aeroplanes skin and cockpit windows. The
material composition of these objects could not be
matched to a 9N314-model warhead due to the
absence of reference material from the pre-formed
fragments in such a weapon

Argumentation / substantiation

Proposed text:
Delete this text from the report.
Argumentation:
1. It is inappropriate to list all known modifcations of BUK anti-aircraft
weapon systems such as BUK, BUK-M1, BUK-M1-2 as pre-formed
fragments like butterfly or bow-tie are used only in 9M38M1 rockets.
The reference to the lack of data on 9N314 warhead is also
inappropriate as Almaz-Antei has provided the necessary data on the
composition of 9N314 and 9N314M warheads. Almaz-Antei was not
asked to provide any additional data.
2. The butterfly or bow-tie shaped fragments showed on the photos in the
report did not coincide with warhead fragments of BUK M1 rocket by
weight, shape and geometrical dimensions.
During the frst meeting in February 2015, one bow-tie fragment was
weighed and turned out to be 5.5 grams. JSC Almaz Antei ran a test
which showed that after penetrating a 5 mm steel obstacle a bow-tie or
butterfly fragment should weigh at least 7.2 grams.
The evaluations showed that under such a degree of deformation the
actual shape of the BUK M1 warhead fragment should differ from the
one provided in the report.

Proposed text:
Delete this text from the report.
Argumentation:
1. It is inappropriate to list all known modifcations of BUK anti-aircraft
weapon systems such as BUK, BUK-M1, BUK-M1-2 as pre-formed
fragments like butterfly or bow-tie are used only in 9M38M1 rocket

Dutch Safety Board response

Point 1 to this comment:
The warhead identifed as the only one having bow-tie shape fragments is
the 9N314M (in Cyrillic text, the 9H314M). This warhead is intended to be
carried by the 9M38M1 missile but it is known to be also installed on the
9M38M. Therefore, the report refers to the 9N314M warhead and the
9M38M or 9M38M1 missile as launched by the Buk surface-to-air missile
system.
Point 2 to this comment:
Considering changes due to deformation, abrasion, chipping and
shattering on explosion and impact, the bow-tie fragments found in the
wreckage originally had the shape, size and mass of the fragments used in
the 9N314M warhead. These fragments are very distinct and they are
found in this type of warhead.
Regarding the comment in general:
JSC Concern Almaz-Antey provided the Dutch Safety Board with new
information on the characteristics of the warhead. This information was
used independently in different simulation models.
The test performed by the Russian Federation/JSC Concern Almaz-Antey
was not announced beforehand. So, formally it could not be a part of the
international investigation into the crash of flight MH17, since the Dutch
Safety Board and the other States did not have the opportunity to validate
the test.
It is necessary to inform the State that is conducting the investigation in
advance and to send an invitation to that State and possibly to the other
participating States to obtain suggestions for the conduct of the work and/
or to be present at these tests or simulations. Nevertheless, the Dutch
Safety Board seriously considered the input of the Russian Federation into
the investigation.
See also the information described in the Dutch Safety Boards report
About the investigation and its Appendix L.

See the response to the comment made regarding paragraph 2.16.1
above.

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3.7.1

3.7.1

Text to be corrected (frst... last word)

In order to establish the path through the air of the
high-energy objects prior to them penetrating the
aeroplane, the Dutch Safety Board requested NLR and
TNO to analyse the damage as described in Section
2.12 against the 9N314-model warhead and 9M38-
series of missiles as installed on the Buk, Buk-M1 or
Buk-M1-2 surface to air missile system as found in
paragraphs 3.4.8.3 and 3.4.9.

The area that would be exposed to high-energy objects
was calculated by using the dynamic primary
fragmentation pattern described in paragraph 3.4.8.3
and applying that data to the known speed of flight
MH17 and a 3D model of a Boeing 777. This created a
simulation of the location and the boundaries of the area
exposed to high-energy objects on the Boeing 777

Argumentation / substantiation

Proposed text:
Replace this text with the following:
In order to accurately determine the trajectory of high energy objects, it
is necessary to make a mock-up of the aircraft structure (both primary i.e.
outer skin and secondary obstacles i.e. seats, floor etc. If such
investigation is not done, this may lead to a great error in determining the
blast point and approach direction of the rocket to the aircraft. The correct
determination of a blast point will allow identifying the characteristics of
the warhead and establish the type of the weapon.
Argumentation:
The part of the report similarly to section 3.4.8 lists the predetermined
conditions of aircraft hitting which more or less shall coincide with BUK
type ground-to-air rocket weapon system.

Proposed text:
Replace this text with the following:
In order to evaluate the characteristics of the high energy objects which
caused damage to the front part of the fuselage, it is necessary to
investigate the damage in the damage area of the fuselage, including the
characteristics of the area of the aircraft exposed to high energy objects.
Further, these evaluations are necessary in order to link the high energy
objects found inside the aircraft structure to the holes in the aircraft outer
skin (by steel grade, size and shape).
Argumentation:
When selecting the model for static detonation of the warhead, there were
used the sources that did not correspond to the real warhead design. The
reference to Figure 27 (Figure 51 in Appendix P) and Figure 28 (Figure 52
in Appendix P) section 3.4.8.3 is inappropriate because the performance
of BUK warheads has a signifcant difference:
1. The warheads of 9M38 and 9M38M1 rockets have an individual angular
area of a meridional angle of fragment fly-out.
2. The model uses meridional angles of fragment fly-out between 72 and
109 degrees, which corresponds to the evaluation model for battle
damage. The angle ranges between 68 and 72 degrees and 109 and
124 degrees are not considered at all which does not allow simulating
the full area exposed to the fragment spray

Dutch Safety Board response

The Dutch Safety Board has made a reconstruction of the forward part of
the aeroplane. It is a well known fact in the study of terminal ballistics of
fragments that a fragment hitting a plate at an oblique angle (not
perpendicular to the plate) changes its direction of travel after
penetration. The initial angle is typically reduced after penetration. This
change in angle is dependent on several factors and can be as small as
several degrees or as large as the original oblique angle. As a result, it is
usually not possible to obtain accurate data on the direction of travel of
fragments outside the structure by studying parts inside the structure.

For the calculations of the spray angles (fragment fly-out), JSC Concern
Almaz-Antey provided the Dutch Safety Board with new information on the
characteristics of the warhead. This information was used independently in
different simulation models. The new results of these simulations are
included in the report.

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3.7.2

3.7.2

Text to be corrected (frst... last word)

3.7.2 Physical measurements

n addition to the main high-energy object impact
damage on the cockpit there are two further areas
where impact damage is observed; the left engine
cowling lip ring and the left wingtip. The left engine
cowling lip ring is a hollow structure consisting of an
aerodynamically shaped curved front and a flat plate
rear. A number of objects have penetrated both parts
of this structure. The size of most of this damage is
signifcantly larger than the impact damage on the
wreckage of the cockpit. On the upper surface of the
left wingtip damage is observed from the front to the
back, moving outwards as it moved rearward.

Argumentation / substantiation

General comment to this section:
When determining the penetration directions of the high energy objects,
there were used only entry holes in the aircraft outer skin.
There was made no matching of the damages on the outer skin and inside
damages (cockpit structure, floor, ribs etc).
The report shall be added with information on the nature of damage in the
cockpit floor, control columns, captains and frst offcers seats as well as
ribs in the front part of the fuselage.

Proposed text:
Add the following text after this text:
The damage of left engine cowling lip ring allows drawing a conclusion
that the left engine was inside the main fragment area i.e. these damages
are not secondary. A similar conclusion can be made on the nature of
damage on left wingtip and left part of the stabilizer.
Argumentation:
The damage evaluation of left engine cowling lip ring, left wing tip (slats)
and front part of the left side of the stabilizer was done rather causally.
It is necessary to add the detailed description of the damage on left
engine cowling lip ring, left wing tip (slats) and front part of the left side of
the stabilizer.

Dutch Safety Board response

The Dutch Safety Board has made a reconstruction of the forward part of
the aeroplane. It is a well known fact in the study of terminal ballistics of
fragments that a fragment hitting a plate at an oblique angle (not
perpendicular to the plate) changes its direction of travel after
penetration.
The initial angle is typically reduced after penetration. This change in
angle is dependent on several factors and can be as small as several
degrees or as large as the original oblique angle. As a result, it is usually
not possible to obtain accurate data on the direction of travel of fragments
outside the structure by studying parts inside the structure.

The Dutch Safety Board has performed an in-depth evaluation of the
damage. Although there were a number of perforations noted, there was
no large scale damage found on the engine cowling lip ring and the left
hand wing that was caused by high energy fragments in the primary
fragmentation spray.

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3.7.3

3.7.4

Text to be corrected (frst... last word)

3.7.3 NLR projection
Using the dynamic primary fragmentation pattern
described in paragraph 3.4.8.3, the known speed of the
aeroplane and a 3D model of a Boeing 777, a
simulation model of the location and the boundaries of
the fragmentation on the fuselage of the Boeing 777
was constructed. Light was used to visualise the area of
the fuselage exposed to the dynamic primary fragment
spray of the warhead. This fragmentation visualisation
model was used to match the observed high-energy
object damage on the cockpit with the calculated
fragment spray of the warhead from the point of view
of location, boundary and impact angle. The best
match for a detonation location of the warhead was
obtained to the left and above of the cockpit, travelling
at a high speed in the opposite direction to the
direction of flight of the aircraft, coming slightly from
below and from the right with respect to the aircraft
forward axis.

A complex, so-called flyout simulation, was used to
analyse the missiles fnal speed and attitude (based on
the damage patterns) to try and calculate the surface
launch location. Multiple iterations of this process were
performed. It was calculated that a missile launch was
from a location ahead and to the right of the aeroplane

Argumentation / substantiation

Proposed text:
Delete this text from the report.
Argumentation:
1. The model used to NLR to simulate the area of the aircraft exposed to
the fragment spray-out requires serious corrections. The area exposed
to fragment spray obtained though a light method does not explain all
damages on the outer skin of the front part of the aircraft, ribs (holes at
the angle of nearly 90 degrees) and multiple damage on left engine
cowling lip ring, left wing tip (slats) and front part of the left side of the
stabilizer.
2. The simplifed model of fragment spray used for preparation of the
draft fnal report does not consider the actual area of fly-out either.
The actual fragment spray created during the detonation of 9M38M1
rocket warhead in motion (considering the rocket speed of around 730
m/s) is a complex rotating fgure.
3. The distribution pattern of 9H314M warhead (9M38M1 rocket) fragment
spray is optimized with a functional delay. Given the summarized
speeds of the rocket and the target in the range of 1000 - 1200 m/s, the
main spay of fragments (over 40 % from the fragment mass) at the
maximum speed of 2100-2300 m/s is directed perpendicularly to the
rocket movement vector at the angles of 70-90 and 260-280 degrees.
This peculiarity allows identifying individual features of target hitting by
a warhead of a certain typ

Proposed text:
Delete this text from the report.
Argumentation:
It appears that during the simulation no consideration was given to the
specifcs of the proximity fuse. The main feature of the proximity fuse of
9M38 and 9M38M1 rockets is that on receiving the required number of
response impulses by the reception antenna, a functional delay is
activated.
The time of the functional delay is optimized on such condition that when
fring at head-on courses the detonation point would be at least 3 to
5 meters from the front part of the aircraft in the direction of the tail unit.
The delay may change only in case the response signal of the proximity
fuse disappears. (when a target is flying on crossing courses). In this case
an immediate detonation of the warhead occurs. The distribution of
fragment spray is optimized with a functional delay. Given the summarized
speeds of the rocket and the target in the range of 1000 - 1200 m/s, the
spay of fragments will be directed perpendicularly to the rocket movement
vector.
Thus, in the case of the encounter conditions between the aircraft and the
rocket, described in section 3.7.4, the detonation point of the rocket
warhead should have been 3-5 meters further from the front part of the
aircraft towards the tail unit.

Dutch Safety Board response

In addition to responses elsewhere in this document, the following is
noted:
The NLR Fragmentation Simulation Model does explain the damage
caused by the warheads fragments on the front part of the aeroplane.
Using this model, missile end conditions (position, angles, speed) were
obtained that resulted in a match with the damage on the wreckage in
terms of its location, boundaries and impact angles. The motion of the
warhead due to missile speed is taken into account in the NLR
Fragmentation Simulation Model. In this model, the fragment spray
visualised by light is a complex rotating fgure.
The NLR Kinematic Fragment Spray Pattern Simulation expands on that by
taking into account the influence of the deceleration due to aerodynamic
drag of the fragments. The model used by TNO expands on that further
by simulating the trajectory of all individual fragments.
The results of all these models are consistent with each other.
The comments regarding the damage to the aeroplanes structure
whereby the perforation holes are almost parallel to the direction (at the
angle of 90 degrees) address an aircraft part that was photographed but
was not recovered by the Dutch Safety Board. A photo of the part is shown
in paragraph 2.12.2. The image contradicts the notion that the perforation
holes are at an angle of nearly 90 degrees.
The justifcation for point 3 is noted. However, the information regarding
the operation of the detonation device that JSC Concern Almaz-Antey
provided to the investigation, following a request by the Dutch Safety
Board, was included in the simulations performed by NLR / TNO. This
confrmed the validity of the simulations performed.

On request of the Dutch Safety Board, Almaz-Antey delivered information
about the operation of the detonation device. On the basis of this
information, NLR concluded that the operation of the proximity fuse
coincided with the calculated detonation point from NLR / TNO. The
damage matching process did not include design and function of the
proximity fuse but was based on the actual damage caused to the
aeroplane. The Dutch Safety Board was not provided with information on
the warheads fusing logic but does note that the detonation point
calculated matches the evidence found.

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3.7.4

3.7.4

Text to be corrected (frst... last word)

Using the fragment initial velocities and aerodynamic
calculations, the deceleration due to aerodynamic drag
of the various fragments was modelled and calculated.
The results of these calculations were used to perform
a complete kinematic simulation of the fragment spray
pattern. This simulation includes missile speed, speed
of the Boeing 777, initial fragment speeds and
fragment deceleration and was used to validate the
results obtained from the fragmentation visualization
model. Both the location, the attitude and the airspeed
of the warhead at the time of detonation of the
fragmentation visualization model could be validated
with this kinematic fragment spray pattern simulation.
To visualise these results slow-motion movies of the
simulation results were made. Figure 72 shows several
frames of this simulation in a top down view. The red
cylinder represents the fastest fragments and the
yellow cylinder the slowest.

The fragment spray pattern cloud is in between these
cylinders.
In reality, the weapon disintegrates on detonation and
would not be visible as it is in the lower two frames of
fgures 43 and 44.
Extrapolating the missile trajectory in the kinematic
fragment spray pattern simulation shows that the
secondary fragmentation caused by this disintegration
(i.e. parts of the missile other than the warhead)
impacts the engine and the wing. This secondary
fragmentation damage is consistent with the damage
noted on the left engine cowling ring and the left
wingtip.

Argumentation / substantiation

Proposed text:
Delete this text from the report.
Argumentation:
Under the encounter conditions between the aircraft and the rocket
considered in the report, the high energy objects with maximum
concentration, speed and kinematic energy should move in the direction
of the right side of the aircraft.
Considering the actual characteristics of the 9M38M1 rocket warhead, the
cockpit will be exposed to three sprays of high energy objects. The frst
and second are in the range of 270 - 290 degrees with the speed of 2000-
2400 m/s and the third one is in the range of 273-278 degrees with the
speed of 1400-1900 m/s.
The impact of the three spays of high energy objects would create through
penetration holes in the outer skin of the cockpit right side and break-up
of right side cockpit windows. These damages are not present on the front
part of the fuselag

Proposed text:
Delete this text from the report.
Argumentation:
The draft fnal report shows only one damage on left engine cowling lip
ring on Figure 27 (Front side engine cowling impact damage) and Figure
28 (Back side engine cowling impact damage). The conclusion is that this
damage has been caused by secondary fragments (break-up of the nose
part of the rocket).
Nevertheless, the analysis of the number and shape of damage on the left
engine cowling lip ring assumes that it has been caused by warhead
fragments of various fractions and is the result of primary damage.
Considering the distance of more than 20 meters from the detonation
point the damage density of the left engine confrms that the left engine
was within the main area of fragment spray.
The similar conclusions can be made about the left wing tip and left part
of the stabilizer.

Dutch Safety Board response

With the warhead detonating at a point within the volume of space that
was calculated (see paragraph 3.8.5 of the report), it is not expected that
the right hand side of the cockpit would be perforated. The complex
construction of the fuselage including its furnishing, instruments,
equipment and the occupants in the cockpit all form barriers that reduce
the speed of the fragments and prevent perforation, from the inside out,
on the aeroplanes right hand side.
The fact that hundreds of fragments were found in the bodies of the three
crew members in the cockpit illustrated that the path of the fragments was
affected.

Although the Dutch Safety Board has concluded that the majority of the
damage mentioned was secondary damage, some primary damage may
have been caused to the parts mentioned. The Final Report has been
amended accordingly.
The missile fragment that was recovered from inside in the left wing tip
illustrated that this area, near the left engine, was exposed to secondary
fragments. See paragraph 2.16.3.

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Paragraph

3.7.4

Text to be corrected (frst... last word)

Figure 44 shows several frames of the movie with a
perspective 1 view from the left hand side. The location
and the boundaries where the fragments impact the
fuselage match the damage to both left hand front
window and the side panel ahead of the forward
passenger door on the left hand side of the fuselage

Argumentation / substantiation

Proposed text:
Delete this text from the report.
Argumentation:
In the case of the encounter conditions between the aircraft and the
rocket, described in section 3.7.4, the detonation point of the rocket
warhead should have been 3-5 meters further from the front part of the
aircraft towards the tail unit

Dutch Safety Board response

The NLR Fragmentation Simulation Model does explain the damage
caused by the warheads fragments on the front part of the aeroplane.
Using this model, missile end conditions (position, angles, speed) were
obtained that resulted in a match with the damage on the wreckage in
terms of its location, boundaries and impact angles. The motion of the
warhead due to missile speed is taken into account in the NLR
Fragmentation Simulation Model. In this model, the fragment spray
visualised by light is a complex rotating fgure.
The NLR Kinematic Fragment Spray Pattern Simulation expands on that by
taking into account the influence of the deceleration due to aerodynamic
drag of the fragments. The model used by TNO expands on that further
by simulating the trajectory of all individual fragments.
The results of all these models are consistent with each other.
At the request of the Dutch Safety Board, JSC Concern Almaz-Antey
delivered information about the operation of the detonation device. On the
basis of this information, NLR concluded that the operation of the proximity
fuse coincided with the calculated detonation point from NLR / TNO.
The damage matching process did not include design and function of the
proximity fuse but was based on the actual damage caused to the
aeroplane. The Dutch Safety Board was not provided with information on
the warheads fusing logic but does note that the detonation point
calculated matches the evidence found.

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3.7.4

3.7.4

Text to be corrected
(frst... last word)

The primary and the secondary damage on the
wreckage of the aeroplane is consistent with the fnal
missile speed and direction of a medium to large sized
surface to air missile launched from a surface location
ahead of the aeroplane.

The weapon approached the aeroplane from a near
head-on position, to the aeroplanes left hand side and
was in a slig

The size of the penetration damage on the wreckage of
the cockpit is consistent with the size of the fragments
of the 9N314-model warhead.
The type of damage on the wreckage of the
aeroplanes fuselage, left engine and left wingtip is
consistent with the type of damage caused by a preformed fragmentation warhead; a 9N314-model
warhead carried on the 9M38-series of missiles as
installed on the Buk, Buk-M1 or Buk-M1-2 surface to air
missile system.
The bow-tie fragments found in the wreckage of the
cockpit are consistent with the bow-tie fragments used
by the 9N314-model warhead.

Argumentation /
substantiation

Proposed text:
Delete this text from the report.
Argumentation:
Considering the damage to the aircraft structure and the specifcs of the
actual spay pattern of 9M38M1 rocket warhead fragments, Almaz-Antei
(BUK design bureau) ran a simulation and obtained different results: based
on the source data shown in the report, 9M38M1 rocket should cross the
aircraft heading at 72-78 degrees horizontally and at 20-22 degrees
vertically.

Proposed text:
Delete this text from the report.
Argumentation:
1. The report incorrectly lists all known modifcations of BUK, BUK-M1,
BUK-M1-2, which have different characteristics.
2. The conclusion about the warhead of 9N314 series is incorrect as this
warhead does not use butterfly or bow-tie fragments.
3. The butterfly or bow-tie shaped fragments showed on the photos in the
report did not coincide with warhead fragments of BUK rocket by
weight, shape and geometrical dimensions.
During the investigation, one bow-tie fragment was weighed and turned
out to be 5.5 grams. JSC Almaz Antei ran a test which showed that after
penetrating a 5 mm steel obstacle a bow-tie or butterfly fragment should
weigh at least 7.2 grams.

Dutch Safety Board
response

The NLR Fragmentation Simulation Model does explain the damage
caused by the warheads fragments on the front part of the aeroplane.
Using this model, missile end conditions (position, angles, speed) were
obtained that resulted in a match with the damage on the wreckage in
terms of its location, boundaries and impact angles. The motion of the
warhead due to missile speed is taken into account in the NLR
Fragmentation Simulation Model. In this model, the fragment spray
visualised by light is a complex rotating fgure.
The NLR Kinematic Fragment Spray Pattern Simulation expands on that by
taking into account the influence of the deceleration due to aerodynamic
drag of the fragments. The model used by TNO expands on that further
by simulating the trajectory of all individual fragments.
The results of all these models are consistent with each other.
At the request of the Dutch Safety Board, JSC Concern Almaz-Antey
delivered information about the operation of the detonation device. On the
basis of this information, NLR concluded that the operation of the proximity
fuse coincided with the calculated detonation point from NLR / TNO.
The damage matching process did not include design and function of the
proximity fuse but was based on the actual damage caused to the
aeroplane. The Dutch Safety Board was not provided with information on
the warheads fusing logic but does note that the detonation point
calculated matches the evidence found.

Text has been improved to include more details on the fragments
expected in a 9N314M warhead. The fragments found are not in their
original form (i.e. bow-tie, fller or square) due to abrasion, break-up,
chipping and shattering of fragments after penetrating the aircraft skin
and the surfaces on the inside. In addition, JSC Concern Almaz-Antey
indicated that the actual number of pre-formed fragments differs from one
warhead to another during manufacture.
Considering changes due to deformation, abrasion, chipping and
shattering on explosion and impact, the bow-tie fragments found in the
wreckage originally had the shape, size and mass of the fragments used in
the 9N314M warhead. These fragments are very distinct and they are
found in this type of warhead.

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3.7.5

3.8

Text to be corrected
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The warheads position at detonation takes into
account the time between detonation of the warhead
and the impact of the fragments. Table 15 shows the
warhead position as stated according to NLR and TNO.
The differences between the two calculated positions
are small.

Using the study performed by NLR (see paragraph
3.7.4) a launch area was calculated. This location was
derived from the last recorded Flight Data Recorder
position of the aeroplane. Due to a number of
uncertainties the position from where the missile was
fred can only be established in terms of a launch area.
Uncertainties exist in the exact point and angles of
detonation, the exact speed of the missile at
detonation and the launch conditions. Over a grid of
launch locations the launch angles were varied to
obtain the boundary where the missile end speed and
attitude angles would still be within the above
mentioned range.
The area obtained by this boundary is limited by missile
kinematic performance, aerodynamics, seeker limits
and takes into account several uncertainties in
guidance and launch conditions. A missile launched
from within this area can obtain the end speed and
attitude (angles) range at the detonation point derived
from the damage matching of the previous Sections.
Outside this launch area these missile end conditions
cannot be realised. The launch area is about 250 km2
approximately 15 kilometres by 17 kilometres. It is
located to the south of, and including, the village of
Snizhne. Figure 47 shows this launch boundary on the
map together with the flown track and last know Flight
Data Recorder position of flight MH17

Argumentation /
substantiation

General comment to section 3.7.5 of the report Validation of NLR
simulation by TNO:
The detonation point was incorrectly determined and did not match the
traces of impact from warhead fragments and blast wave on the aircraft
wreckage.
The identifed detonation point by the movement direction of high energy
objects as shown on Figure 23, 24 and 30 is not correct. The directions are
not matching on all Figures

Proposed text:
Delete this text from the report and replace it with the following:
Considering that during the last three minutes Boeing 777-200 (MH17)
was flying rectilinearly and evenly, the horizontal projection of the rocket
trajectory was nearly a straight line. The trajectory was possibly twisting in
the range of 2-4 degrees at the initial phase of rocket acceleration and at
the stage of self-homing. In the vertical projection the rocket trajectory is
divided into two stages: the acceleration segment and proportional
approach by the location angle.
As the BUK design bureau, Almaz-Antei has the capabilities to identify the
launch area based on the performance data of 9M38 or 9M38M1 rockets.
The limits of the launch area from west to east are dictated by the
encounter conditions - the crossing angle with the aircraft heading in the
horizontal plane (72-78 degrees) and maximum targeting errors (up to
2-4 degrees). The limits of the launch area from north to south are dictated
by the encounter conditions - the crossing angle with the aircraft heading
in the horizontal plane (20-22 degrees), downrange, and maximum
targeting errors (up to 2-3 degrees).
The simulation of the 9M38M1 rocket targeting process ran by AlmazAntei indicates that crossing of the rocket and aircraft trajectories within
the predetermined conditions is feasible only from the limited area south
of Zaroshchenskoye village..

Dutch Safety Board
response

It is noted that the presentation was not intended to identify the weapon
used. The report is amended accordingly and the presentation by JSC
Concern Almaz-Antey contained in the Appendices to the draft Final
Report is therefore withdrawn.
Regarding the rest of the comment, JSC Concern Almaz-Antey provided
the Dutch Safety Board with new information on the characteristics of the
warhead. This information was used independently in different simulation
models. The results of these simulations are included in the Final Report

The following remarks are made in addition to responses made elsewhere
in this document.
Regarding the possible position from where the weapons flight path could
have commenced, calculations were performed using an advanced six
degrees of freedom missile fly out simulation using reliable tactical and
technical performance data of the 9M38-series missile. The simulation
model accounted for a large number of possible uncertainties in modelling
and launch conditions by varying the relevant parameters within viable
boundaries. This results in the area from within which the missiles flight
path could have commenced, as described in the report. The simulation
model that was used was validated using data provided by JSC Concern
Almaz-Antey and was found to contain no errors or omissions.
The differences in performance between the 9M38 and 9M38M1 missile
have been accounted for. The area from within which the missiles flight
path could have commenced was calculated by the Russian Federation
based on NLR data, for both missile types are inside the area calculated by
NLR in Section 3.8.
The simulation referred to by the Russian Federation was presented by
JSC Concern Almaz-Antey during the second progress meeting upon
request from NLR. Almaz-Antey provided a simulation with the detonation
location as calculated by NLR/TNO.
The three simulations of the calculated areas from which a 9N314M
warhead carried on a 9M38-series missile as installed on the Buk surfaceto-air missile system are based on the observed damage on the aeroplane
and the position of the associated detonation location to that.
The simulation run by JSC Concern Almaz-Antey with a launch area near
Zaroshchenskoye resulted in a fly-past confguration that would create a
damage pattern that did not match the observed damage on the
aeroplane or the associated detonation location.
See also the Dutch Safety Boards response to the comment on paragraph
3.7.3 (page 124).

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3.9

3.13

Text to be corrected
(frst... last word)

The meeting concluded with concurrence by all parties
on the following points:
flight MH17 was struck by a surface to air missile
whilst in flight;
the missile contained a 9N314-model warhead
carried on the 9M38-series of missiles as installed on
the Buk, Buk-M1 or Buk-M1-2 surface to air missile
system.
the point of detonation was on the left hand side of
the aeroplane, above the cockpit and between 1.5
and 4 metres laterally from the aeroplane.

3.13 Recording of surveillance radar data
According to ICAO Annex 11 Air Traffc Services,
paragraph 6.4.1 Automatic recording of surveillance
data, States are required to automatically record
surveillance data from primary and secondary radar
equipment systems for use in accident and incident
investigations, search and rescue, and air traffc control
and surveillance systems evaluation and training. These
recordings shall be retained for a period of at least
thirty days and for accident and incident investigation
for a longer period until it is evident that they will no
longer be required.
As the accident had occurred outside Russian
Federation territory, the Federal Air Transport Agency
of the Russian Federation stated that no radar data was
saved nor was it required to be so by national
regulations. It was confrmed that had the event
occurred in Russian Federation territory, the data would
have been saved according to Russian Federation
regulations. The Russian Federation was requested to
provide its national regulations. As to date these
regulations have not been received.
It is noted that the provisions in paragraph 6.4.1 of
Annex 11 are not restricted to States boundaries. The
Russian Federation had not notifed ICAO of a
difference between their national regulations and
practices and this ICAO Standard requiring the
automatic recording of surveillance data. Such a
notifcation obligation was imposed by Article 38 of the
Convention on International Civil Aviation.
Finding
The Russian Federation had not notifed ICAO of a
difference between their national regulations and
practices and an international ICAO Standard, in
Annex 11, requiring the automatic recording of
surveillance data.

Argumentation /
substantiation

Proposed text:
Delete this text from the report.
Argumentation:
During the second meeting, the representatives of the Russian Ministry of
Defense and Almaz-Antei (BUK design bureau) presented the data and
calculations with conclusions, which were different from the ones
presented by DSB: it was pointed out that the detonation point was
incorrectly determined and the pattern of fragment spay was incorrectly
oriented too, not all damage of aircraft structure by high energy objects
was considered either.
This part of the report does not contain any arguments as to why the data
provided by the Russian experts have not been used.

Proposed text:
Delete this text and replace it with the following:
The Russian Federation has requirements for automatic recording of
surveillance data in the national legislation that are fully compliant with
ICAO Annex 14. The explicit explanations and extracts from the national
regulations were sent to the investigator in charge on May 6. 2015. ICAO
Annex 14 does not specifcally say that raw data must be saved. The
Russian Federation saved the necessary surveillance data in the format of
a video fle thus fully complying with the requirements of ICAO Annex 14.
Argumentation:
In accordance with the item 3.6.8 of the Federal Aviation Rules Air Traffc
Management the radio exchange between ATS units and aircraft pilots,
voice exchange between ATS unit controllers, weather briefngs of pilots
and ATC controllers, pre-flight inspection, weather data transmitted on
radio channels as well as radar and flight data shall be recorded by special
equipment. The recorded data must be kept and used for the purpose of
ATS within 14 days if using analogue recording equipment and within 30
days if using digital recording equipment.
The ICAO documents do not provide any defnition of the term ATS
surveillance system. Pursuant to item 8.1.2. of the ICAO Doc 4444, the
surveillance system comprises integration of all data necessary for air
traffc services. In this regard, the video fle with the air situation from the
radar screen provided by the Russian Federation can be qualifed as
surveillance data, which retention is required by the item 6.4.1.1 Annex 11
to the Chicago Convention.
The Russian Federation is in full compliance with the requirements of the
item 6.4.1.1 of Annex 11 to the Chicago Convention. All data at disposal of
the Russian side was properly made available to DSB and used in the
course of the investigation

Dutch Safety Board
response

It is noted that the presentation was not intended to identify the weapon
used. The report is amended accordingly and the presentation by JSC
Concern Almaz-Antey contained in the Appendices to the draft Final
Report is therefore withdrawn.
Regarding the rest of the comment, JSC Concern Almaz-Antey provided
the Dutch Safety Board with new information on the characteristics of the
warhead. This information was used independently in different simulation
models. The outcome of the simulations was incorporated in the Final
Report.
The Russian Federation has, notwithstanding their previous position
during the frst and second progress meeting, stated that the aircraft was
shot down by a missile that could have been launched from an aircraft as
well as from the surface. The third progress meeting was concluded with
the common conclusion, supported by the Russian Federation that the
aircraft was hit by high energy objects that originated from a missile that
detonated on the left side and above the cockpit.
Abovementioned information is described in the Dutch Safety Boards
report About the investigation

ICAO was consulted on this matter. The text in ICAO Annex 11, paragraph
6.4.9 refers to automatic recording. According to ICAO this includes the
recording of all data, including raw data. The reports text has also been
modifed.

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3.14

4

Text to be corrected
(frst... last word)

3.14 Air Traffc Service
As of the day of the crash Air Traffc Services for flight
MH17 were provided by air traffc controllers of Lviv,
Kyiv and Dnipropetrovsk ACCs. UKSATSE air traffc
controllers were licensed, qualifed and accordingly
trained. The regulations and procedures of air traffc
service provision complied with ICAO Standards and
Recommended Practices.
Finding
Air Traffc Services for flight MH17 could not be the
cause or any contributing factors of the crash

4 CONCLUSIONS

Argumentation /
substantiation

Additional subsection should be added to this paragraph.

General comment to section 4 of the report Conclusions:
1. The conclusion was subjectively formulated without due regard to the
requirements to the Format of Final Report from Annex 13 to the
Chicago Convention.
This section does not indicate any action, inaction, circumstances,
conditions or their combination (causes) and action, inaction,
circumstances, conditions or their combination, removal, prevention or
absence of which would reduce the probability of the air accident
(contributing factors).
2. The conclusion does not take account of and contradicts to the
conclusions contained in Flight MH17 and flying over conflict areas
report regarding the responsibility of Ukrainian authorities for analyzing
the situation in the conflict zone as well as ensuring proper coordination
between military and civil authorities of Ukraine for the purpose of
timely introduction of necessary restrictions aimed at provision of safety
of civil aviation flights.
3. The proposed Conclusion does not contain any substantiation for the
need to develop actions to prevent similar air accidents in the future.
Thus, the main objective of the investigation established by Standard
3.1 of Annex 13 to the Chicago Convention is not achieved.

Dutch Safety Board
response

As the training an qualifcations of the air traffc controllers have not been
included in the investigation, the matter will be addressed in a similar
manner to that of the cabin crew. There is no evidence that the controllers
did not perform their duties correctly.

The Final Report contains both the investigation into the damage
sustained by the aeroplane and the investigation into the flight route.
The outcome of the results from the investigation does not lend itself to
the layout of Annex 13. The need to exclude other possible causes, for
examples, has lead to an alternative layout for the conclusions.

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Section /
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4.1
4.2

4.1

Text to be corrected
(frst... last word)

4.1 Cause
4.2 Supporting conclusion

Air Traffc Services for flight MH17 was provided by
licensed, qualifed and accordingly trained air traffc
controllers of Lviv, Kyiv and Dnipropetrovsk ACCs. Air
Traffc Services for flight MH17 did not have any impact
on safety to be the reason of the crash.

Argumentation /
substantiation

Proposed text:
Add the following conclusion to this section:
Airspace On 17 July 2014, airspace restrictions were in place for the
eastern part of Ukraine and parts of the bordering airspace in the Russian
Federation from ground level up to FL320. There were no restrictions for
flight MH17 to fly in Dnipropetrovsk Flight Information Region planned
flight levels FL330 and FL350.
Ukraine did not devote enough attention to the risks to civil aviation which
arose from the spreading of the military conflict to the air. The decisionmaking related to Ukrainian airspace was dominated by the military
authorities and the interests of military aviation. The civil aviation authority
and air navigation service provider had insuffcient information to be able
to make an independent assessment of the safety of the airspace for civil
air traffc at cruising altitude. This made it possible that Ukraine did not
close its airspace, even though the fact that the conflict had spread to the
air was reason to do so as a precaution.
Argumentation:
The sections Cause and Supporting conclusions contain a formal
enumeration of certain factors without any conclusions as to why they
became possible.
This section shall be added with the conclusions contained in part b
sub-item 1 section 8 of Flight MH17 and flying over conflict areas report
concerning the lack of appropriate actions on part of Ukraine to ensure
safety of civil aircraft flights over the armed conflict zone

Additional sentences should be added after the Line 11 (ref. protocol of
meeting on 23.07.2014)

Dutch Safety Board
response

Text amended insofar as it addresses the NOTAMs that were in place. The
second paragraph proposed is related to the security of the route and is
addressed in Part B of the Final Report.

As the training an qualifcations of the air traffc controllers have not been
included in the investigation, the matter will be addressed in a similar
manner to that of the cabin crew. There is no evidence that the controllers
did not perform their duties correctly

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4.1

4.2

Text to be corrected
(frst... last word)

The 9M314-model warhead carried by a 9M38-series
missile was launched from a Buk, Buk-M1 or Buk-M1-2
surface-to-air missile system in an area south of
Snizhne, Ukraine, which was controlled, at that time, by
the illegal armed groups.

6. Damage pattern
The location, shape and boundaries of the damage to
the wreckage of flight MH17 and the number and
density of hits on the wreckage was consistent with
fragmentation spray pattern damage of pre-formed
fragments from different shapes and sizes in a 9N314-
model warhead carried on the 9M38-series of missiles
and installed on the Buk, Buk-M1 or Buk-M1-2 surface
to air missile system

Argumentation /
substantiation

At time of the accident, the territory was de-facto controlled by illegal
armed groups, which needs to be mentioned in the report.

Proposed text:
Delete this text from the report.
Argumentation:
1. The report lacks any substantiation that the damage has been inflicted
by BUK type anti-aircraft weapons system (9M38 type rocket with
9H314 type warhead).
2. The report does not unambiguously identify the type of the warhead.
The warhead fragments (high energy objects) are not unambiguously
identifed either (by steel grade, weight, sizes).
3. The report does not consider that 9N314 and 9N314M warheads have
signifcantly different characteristics such as types and quantity of
fragments, spay patterns of fragments under static and dynamic
conditions

Dutch Safety Board
response

The Dutch Safety Board does not provide any political interpretation of the
conflict and strives to use politically neutral terms as much as possible.
Interpretations by other parties are those parties responsibilities.

This comment repeats comments made above. It is handled as per those
comments.
Studying the detailed chemical composition of the steel is not relevant to
the investigation as the high-energy objects are usually made from lowgrade metal (unalloyed steel) originating from different batches, different
sources, different manufacturing locations and over different periods of
time. Matching the fragments found with reference material from an intact
warhead would not be possible because of these differences.
Considering changes due to deformation, abrasion, chipping and
shattering on explosion and impact, the bow-tie fragments found in the
wreckage originally had the shape, size and mass of the fragments used in
the 9N314M warhead. These fragments are very distinct and they are
found in this type of warhead.

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4.2

4.3

Text to be corrected
(frst... last word)

he objects found are consistent with the pre-formed
fragments in the 9N314-model warhead carried on the
9M38-series of missiles as installed in the Buk, Buk-M1
of Buk-M1-2 ground to air missile system

9. Other weapons
a. Air to air gunfre The high-energy object damage
was not caused by air to air gunfre because the
number, the size and type of high-energy objects
impact damage is not consistent with gunfre impact
damage and the trajectories of the high-energy
objects that struck the aeroplane are not parallel but
converge to a single location close to, and above,
the aeroplane.
b. Air to air missile The high-energy object damage
was not caused by an air to air missile because there
was no military aircraft in the area of flight MH17 to
launch such a missile. Air to air missile warheads do
not have butterfly or bow-tie shaped fragments, and
an infra-red guided missile would have caused
damage to the aeroplane nearer the engines.

Argumentation /
substantiation

Proposed text:
Delete this text from the report.
Argumentation:
The conclusion about 9N314 series warhead is not correct as 9N314
does not use butterfly or bow-tie type fragments

General comment on this conclusion:
It is necessary to accurately identify the type of the rocket hitting the
aircraft before drawing such conclusions. The comments to the previous
sections of the report clearly indicate that the conclusions on the use of
BUK type anti-aircraft weapon system again Boeing 777-200 (MH17) are
not substantiated and do not take account of the actual tactical &
technical performace of this type of the weapon system.

Dutch Safety Board
response

Text has been rewritten.
The warhead identifed as the only one having bow-tie shape fragments is
the 9N314M (in Cyrillic text, the 9H314M). This warhead is intended to be
carried by the 9M38M1 missile but it is known to be also installed on the
9M38M. Therefore, the report refers to the 9N314M warhead and the
9M38M or 9M38M1 missile as launched by the Buk surface-to-air missile
system.

The report has been modifed to include more details on weapon systems.
The last sentence in the text is deleted. However, for a weapon system to
be considered as being a potential source of the damage, its warhead
must include the distinctive bow-tie shaped pre-formed fragments that
were recovered.

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4.4

5

Text to be corrected
(frst... last word)

2. Retention of ATC data
The Russian Federation had not notifed ICAO of a
difference between their national regulations and
practices and an international ICAO Standard, requiring
the automatic recording of surveillance data

RECOMMENDATIONS

Argumentation /
substantiation

Proposed text:
It is necessary to exclude this section from the report as not meeting the
objective of Conclusion section of the draft fnal report.
Argumentation:
The Russian Federation is in full compliance with the requirements of the
item 6.4.1.1 of Annex 11 to the Chicago Convention. All data at disposal of
the Russian side was properly made available to DSB and used in the
course of the investigation.
The necessary Argumentation is given in comments to sections 2.9.5.3 and
3.13.

General comment on section 5 of the report Recommendation:
The presented draft fnal report does not contain any recommendations
on flight safety

Dutch Safety Board
response

ICAO was consulted on this matter. The text in ICAO Annex 11, paragraph
6.4.9 refers to automatic recording. According to ICAO this includes the
recording of all data, including raw data. The reports text has also been
modifed.

The proposed recommendations were not included in the draft Final
Report. These were, however, presented during the third progress
meeting. The recommendations are included in the Final Report

State /
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Ukraine /
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Ukraine /
NBAAI

Page

169

219

Section /
Paragraph

Appx. A

Appx. K

Text to be corrected
(frst... last word)

the illegal armed group

the illegal armed group

Argumentation /
substantiation

The armed groups operating in certain areas of Donetsk and Luhansk
Regions of Ukraine that are not controlled by the government do not have
any legal status

The armed groups operating in certain areas of Donetsk and Luhansk
Regions of Ukraine that are not controlled by the government do not have
any legal status

Dutch Safety Board
response

The Dutch Safety Board does not provide any political interpretation of the
conflict and strives to use politically neutral terms as much as possible.
Interpretations by other parties are those parties responsibilities.

The Dutch Safety Board does not provide any political interpretation of the
conflict and strives to use politically neutral terms as much as possible.
Interpretations by other parties are those parties responsibilities


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