MH17: ?

, ! .


» MH17: ? »  DSB JIT »  DSB 13.10.15: MH17 About the investigation


DSB 13.10.15: MH17 About the investigation

1 30 97

1

2

1

MH17

MH17 About
the investigation

https://b.radikal.ru/b29/1908/bb/1f95e4ae9823.png

3

2

MH17 About
the investigation

The Hague, October 2015
The reports issued by the Dutch Safety Board are open to the public.
All reports are available on the Safety Boards website safetyboard.nl.
Source photo cover: Dutch Safety Board

4

3Dutch Safety Board
The aim in the Netherlands is to limit the risk of accidents and incidents as much as
possible. If accidents or near accidents nevertheless occur, a thorough investigation into
the causes, irrespective of who are to blame, may help to prevent similar problems from
occurring in the future. It is important to ensure that the investigation is carried out
independently from the parties involved. This is why the Dutch Safety Board itself selects
the issues it wishes to investigate, mindful of citizens position of dependence with
respect to authorities and businesses. In some cases the Dutch Safety Board is required
by law to conduct an investigation.
Dutch Safety Board
Chairman: T.H.J. Joustra
E.R. Muller
M.B.A. van Asselt
Associate members
of the Board: B.J.A.M. Welten
A.P.J.M. Rutten
General Secretary: M. Visser
Visiting address: Anna van Saksenlaan 50
2593 HT The Hague
The Netherlands
Postal address: PO Box 95404
2509 CK The Hague
The Netherlands
Telephone: +31 (0)70 333 7000 Fax: +31 (0)70 333 7077
Website: safetyboard.nl

NB: This report is published in the English and Dutch languages. If there is a difference in
interpretation between the English and Dutch versions, the English text will prevail.

5

4

CONTENTS

Foreword                                                                                                                       6
List of Abbreviations                                                                                                        8
1 The Dutch Safety Boards Working Method                                                                    10
1.1 Why this report about the investigation? .............................................................    10
1.2 Which subjects did the investigation look into?....................................................11
1.3 Legal framework................................................................................................... 12
1.4 Conducting the investigation............................................................................... 17
2 Preliminary Repor................................................................................................... 28
2.1 Introduction.......................................................................................................... 28
2.2 Provisions of Annex 13 ......................................................................................... 28
2.3 Publication of the preliminary report ................................................................... 28
2.4 Erratum................................................................................................................. 29
3 Crash: Cause                                                                                                              30
3.1 Design of the investigation ................................................................................. 30
3.2 Data collection ..................................................................................................... 30
3.3 Analysis and assessment ...................................................................................... 32
4 Crash: Flight Route ..................................................................................................38
4.1 Design of the investigation .................................................................................. 38
4.2 Data collection ..................................................................................................... 39
4.3 Analysis and assessment ...................................................................................... 42
5 Crash: The Occupants .............................................................................................44
5.1 Design of the investigation ................................................................................. 44
5.2 Data collection ..................................................................................................... 45
5.3 Analysis and assessment ...................................................................................... 46
6 Passenger Information............................................................................................ 48
6.1 Design of the investigation ................................................................................. 48
6.2 Data collection ..................................................................................................... 49
6.3 Analysis and assessment ...................................................................................... 51
7 Exceptional Circumstances .......................................................................................52
7.1 Visiting the wreckage area and recovery of the wreckage................................... 52
7.2 Reconstruction of the aeroplane ......................................................................... 58
7.3 International data collection................................................................................. 59
7.4 Concurrence with the criminal investigation ........................................................ 63
7.5 Classifed information .......................................................................................... 65

6

5

Statement by the Board..............................................................................................68
APPENDICES..............................................................................................................69
Appendix A Project team .............................................................................................70
Appendix B Notifcation to the Dutch Safety Board .......................................................71
Appendix C Memorandum of Understanding Ukraine-the Netherlands
with regard to the delegation of the investigation ............................................................72
Appendix D Agreement NBAAI - Dutch Safety Board with regard
to the delegation of the investigation .............................................................................74
Appendix E Confrmation of participation in the investigation
by Australia.................................................................................................................78
Appendix F Invitation to the Russian Federation to participate
in the investigation...................................................................................................... 79
Appendix G Agreements about the recovery of the wreckage........................................... 80
Appendix H Request with regard to recovery of the wreckage............................................82
Appendix I Priority list of wreckage pieces ...........................................................83
Appendix J Request with regard to the removal of the remaining
pieces of wreckage ....................................................................................................91
Appendix K Analysis techniques used........................................................................... 93
Appendix L Response to the comments of the Russian Federation......................................94

7

6

FOREWORD
Aviation disasters shock the world. In todays society an incredible amount of information
regarding the circumstances, the possible causes and who could be responsible is shared
immediately after a crash. This instantly reveals the extent and the impact of the crash to
the world, but brings uncertainties with it as well. A thorough investigation determines
exactly the causes of a crash, presents the facts and removes the distress of speculations.
This can contribute to aviation safety and also provides clarity to the relatives of the
victims.
The Dutch Safety Board is appointed by law to investigate aviation accidents. Because of
the large number of victims with Dutch nationality, the Dutch Safety Board was ready to
contribute to the investigation into the crash of flight MH17. Therefore, when Ukraine
requested that the Netherlands take over the investigation into the causes of the crash,
the answer could only be positive.
Right from the start, the investigation applied four principles: maintaining independence;
aiming for high quality; focusing on determining the causes as accurately as possible in
order to exclude other scenarios; aiming to achieve as much international acknowledgment
as possible for the investigation.
The investigation was carried out under exceptional circumstances. The Dutch Safety
Board was not blind to the geopolitical implications of the crash but in the investigation
deliberately kept its distance from international politics. The facts were leading in the
investigation and the views of parties were evaluated against those facts, a proven
protocol that is used worldwide for aircraft accident investigations under the guidelines of
the International Civil Aviation Organization (ICAO). The Dutch Safety Board has
endeavoured to complete the investigation in the shortest possible time, without
compromising on content quality. Within ffteen months, it has completed the investigation
into four different subjects regarding the crash of flight MH17.
Immediately after the crash of flight MH17, initiatives were taken at international level to
further improve aviation safety, which is a complicated diplomatic process. Now that the
recommendations of the Dutch Safety Board are available, they can be included in the
initiatives for improvement.
The relatives of the victims have the right to know the answers to their questions. What
happened, why did the aeroplane fly over that area, were the passengers aware of
anything and why did it take two to four days to confrm who were on board? Those
were questions that arose immediately after the crash, but could only be answered
after thorough investigation that required time. In the meantime, the relatives of the
victims were confronted with all kinds of stories in the media. The conclusions in the
Dutch Safety Boards reports regarding the crash of flight MH17 are based on facts,

8

7

originating from several sources. I hope that these reports will answer questions of the
relatives and society at large and that the recommendations will help prevent a repeat
of this tragedy.
T.H.J. Joustra
Chairman, Dutch Safety Board

9

8

LIST OF ABBREVIATIONS
AAIB                Air Accidents Investigation Branch
ACI                  Airports Council International
AIVD               General Intelligence and Security Service (Algemene Inlichtingen- en Veiligheidsdienst)
AWACS            Airborne Warning and Control System azM Maastricht University Hospital (Academisch Ziekenhuis Maastricht)
CANSO            Civil Air Navigation Services Organisation
CTIVD             Dutch Review Committee on the Intelligence and Security Services
                      (Commissie van Toezicht betreffende de Inlichtingen- en Veiligheidsdiensten)
EASA               European Aviation Safety Agency FL flight level
HCSS              The Hague Centre for Strategic Studies
IAC                 Interstate Aviation Committee
IATA                International Air Transport Association
ICAO               International Civil Aviation Organization
IIC                  Investigator-In-Charge
JIT                  Joint Investigation Team
KNMI              Royal Netherlands Meteorological Institute (Koninklijk Nederlands
                      Meteorologisch Instituut)
LTFO               National Forensic Investigation Team (Landelijk Team Forensische
                      Opsporing)
MIVD              Military Intelligence and Security Service (Militaire Inlichtingen- en Veiligheidsdienst)
NATO              North Atlantic Treaty Organization
NBAAI             National Bureau of Air Accidents Investigation of Ukraine
NCC                National Crisis Centre (Nationaal CrisisCentrum)
NCTV              National Coordinator for Security and Counterterrorism (Nationaal
                      Coördinator Terrorismebestrijding en Veiligheid)

10

9

NFI           Netherlands Forensic Institute (Nederlands Forensisch Instituut)
NLR          National Aerospace Laboratory (Nationaal Lucht- en Ruimtevaartlaboratorium)
NOTAM      Notice to Airmen
NTSB        National Transportation Safety Board
OSCE        Organization for Security and Cooperation in Europe
SES          State Emergency Service
STAMP      Systems-Theoretic Accident Model and Processes
STEP        Sequentially Timed Events Plotting
TF RCZ     Task Force on Risks to Civil Aviation arising from Conflict Zones
TNO         Netherlands Organisation for Applied Scientifc Research (Nederlandse
               organisatie voor Toegepast Natuurwetenschappelijk Onderzoek)
UN           United Nations
Wiv 2002 Intelligence and Security Services Act 2002 (Wet op de inlichtingen- en
               veiligheidsdiensten 2002)

11

10

1 THE DUTCH SAFETY BOARDS
WORKING METHOD

1.1 Why this report about the investigation?
On 17 July 2014, a Malaysia Airlines passenger aeroplane crashed in the eastern part of
Ukraine. All 298 people on board the Boeing 777-200 lost their lives. Flight MH17 had
taken off from Amsterdam Airport Schiphol in the Netherlands for a flight to Kuala Lumpur
International Airport in Malaysia.
The National Bureau of Air Accidents Investigation of Ukraine (NBAAI) instituted an
investigation into the crash, in which the Dutch Safety Board was asked to participate. In
addition to the Ukrainian investigation into the causes of the crash, the Dutch Safety
Board decided on 18 July 2014 to launch its own investigation into the decision-making
related to flight routes over conflict areas and the availability of passenger information
following the crash.
On Wednesday 23 July 2014, Ukraine delegated the execution of the investigation into
the causes of the crash to the Netherlands. As the accident investigation authority of the
Netherlands, the Dutch Safety Board was effectively put in charge of the investigation.
From that moment, the Dutch Safety Boards objective was to obtain an accurate picture
of the crash and the relevant circumstances within the shortest time frame possible. This
included the decision-making related to the flight route and the availability of passenger
information. In a later stage, the question of what happened to the occupants of the
aeroplane became subject of investigation as well.
When the investigation was delegated to the Netherlands, it was clear that the investigation
into the crash of flight MH17 would take place under exceptional circumstances. Soon after
the crash, which received a great deal of international media attention, suspicions circulated
that the crash of flight MH17 could not be attributed to a technical defect or pilot error, but
that the aeroplane had been shot down. Wreckage of the aeroplane was scattered over a
large area, spanning a total of approximately 50 km2 in the Dnipropetrovsk region - an area
where, at the time, there was an armed conflict. Because of regular fghting, the safety
situation in the area initially did not allow the investigation to be conducted at the crash
site. The scenario that the aeroplane had been shot down meant that it was of great
importance for the investigation to be conducted in an independent manner. There were
calls for an independent investigation into the causes and the circumstances of the crash of
flight MH17, underlined by a UN Security Council Resolution.1 The geopolitical dimension
meant that it was even more important to substantiate the fndings of the investigation
with as many sources as possible, so that the answer to the question of what happened to
flight MH17 will be totally indisputable.


1 UN Security Council, Resolution 2166 (2014), S/res/2166 (2014), 21 July 2014

12

11

The course of the investigation into flight MH17 could not be delineated prior to the
investigation. The Dutch Safety Board always acted according to circumstances within
the national and international legal frameworks. Its principle was that what the legal
frameworks have in common: to conduct an impartial and thorough investigation based
on learning that helps prevent similar accidents from recurring in the future, without
apportioning blame or liability. These last issues are addressed in the international
criminal investigation (see Section 7.4).
In this document the Dutch Safety Board explains how the investigation into the crash of
flight MH17 was conducted and the choices that were made. The Dutch Safety Board
wants to provide insight into the working method that was adopted and to explain how it
arrived at its conclusions. This report about the investigation entails the entire investigation,
from the moment that it was known that flight MH17 had crashed in the eastern part of
Ukraine up until the moment that the Dutch Safety Board concluded the reports for
publication.
1.2 Which subjects did the investigation look into?
Under the Chicago Convention,2 the causes of any civil aviation incident must be
investigated. The investigation, which in principle is conducted by the state in which the
accident occurred, must at least include the technical condition of the aircraft, the history
of the flight, the flight crews actions, the circumstances encountered during the flight
and all relevant background information. This is stipulated in Annex 13 to the Chicago
Convention; Aircraft Accident and Incident Investigation.
Apart from this Annex 13 investigation, the Dutch Safety Board had decided to conduct
an investigation into the decision-making related to the flight routes over conflict areas
and into the availability of passenger information, even before it took over the
investigation from its Ukrainian sister organisation. This decision by the Dutch Safety
Board was prompted by astonishment at the fact that Malaysia Airlines and other airlines
were flying over the conflict area, and the fact that passenger information was not
immediately available. In the course of the investigation the question arose to which
extent the occupants of the aeroplane were aware of the crash. Victims relatives felt the
need to know if their loved ones had experienced the crash consciously. The Dutch
Safety Board decided to also include this aspect in its investigation and also devote
attention to the transportation of the human remains to the Netherlands.
During the investigation, the Dutch Safety Board decided to publish the fndings with
regard to these four subjects simultaneously in two investigation reports. The causes of
the crash of flight MH17, the decision-making related to the flight route and what
happened to the occupants, are discussed in one report. The investigation into the
availability of passenger information makes up a separate report. Given the fact that
there is an enormous international as well as national interest in the investigation, the
Dutch Safety Board has published the reports in English and in Dutch.


2 Convention on International Civil Aviation, ICAO Doc 7300, 7 December 1944

13

12

1.3 Legal framework
The provisions of Annex 13 to the Chicago Convention are followed for investigations
into civil aviation accidents. The position, working method and authority of the Dutch
Safety Board are stipulated in the Kingdom Act Dutch Safety Board. Annex 13 and the
Kingdom Act Dutch Safety Board have the same objective: to conduct an impartial,
thorough, learning based investigation that helps prevent similar accidents from recurring
in the future, without apportioning blame or liability.
As previously pointed out, the Dutch Safety Board had already started its own
investigation, based on the Kingdom Act Dutch Safety Board, into the decision-making
related to flight routes and the availability of passenger information when it took over the
investigation from its Ukrainian sister organisation. This meant that the investigation had
to be conducted within a legal framework consisting of two regimes.
This section explores specifc provisions of Annex 13 and the Kingdom Act Dutch Safety
Board, and explains the choices made in the investigation. It also deals with the agreements made between Ukraine and the Netherlands when the international investigation
was delegated.
1.3.1 Chicago Convention
Article 26 of the Chicago Convention provides for investigations into civil aviation
accidents. Ukraine and the Netherlands, as well as the other states involved in this
investigation, have ratifed this Convention.

Article 26. Investigation of accidents
In the event of an accident to an aircraft of a contracting State occurring in the
territory of another contracting State, and involving death or serious injury, or
indicating serious technical defect in the aircraft or air navigation facilities, the State
in which the accident occurs will institute an inquiry into the circumstances of the
accident, in accordance, so far as its laws permit, with the procedure which may be
recommended by the International Civil Aviation Organization. The State in which
the aircraft is registered shall be given the opportunity to appoint observers to be
present at the inquiry and the State holding the inquiry shall communicate the report
and fndings in the matter to that State.

Annex 13 to the Chicago Convention provides Standards and Recommended Practices
for the investigation of accidents. Some relevant aspects are explained below.
According to Annex 13 investigations into civil aviation accidents should focus exclusively
on preventing future incidents. Article 3 of the Annex reads as follows: The sole objective
of the investigation of an accident or incident shall be the prevention of accidents and
incidents. It is not the purpose of this activity to apportion blame or liability. To this end,
the Annex establishes that states should have an independent accident investigation

14

13

authority that decides on the investigations format and implementation. In the
Netherlands, the Dutch Safety Board has been appointed as the accident investigation
authority.
According to Annex 13 the investigation shall at least include the gathering, recording and
analysing of all available relevant information about the accident or incident and that this
must be reported. If possible, the investigation determines causes. If appropriate, safety
recommendations may be issued as well.
The Annex also stipulates how international cooperation is organised in the event of a
civil aviation accident. In principle, the accident investigation authority of the State of
Occurrence (the state in the territory of which an accident or incident occurs) conducts
the investigation. However, it may delegate the investigation. After receiving notifcation
about the investigation, certain states must provide relevant information as quickly as
possible. This concerns the following states:
the state on whose register the aircraft is entered (the State of Registry);
the state in which the operators principal place of business is located or, if there is no
such place of business, the operators permanent residence (the State of the Operator);
the state having jurisdiction over the organisation responsible for the type of design
(the State of Design);
the state having jurisdiction over the organisation responsible for the fnal assembly
of the aircraft (the State of Manufacture).
These states have the right, through appointment of an accredited representative, to
participate in the investigation. This includes among others visiting the scene of the crash,
examining the wreckage, interviewing witnesses and viewing investigation material.3
In addition, other states also have the responsibility, if requested, of providing all
information, facilities or expertise relevant to the investigation that they have. In that
case, they may, also through designation of an accredited representative, participate in
the investigation. But the state that conducts the investigation may restrict the
participation of these accredited representatives to those matters about which they were
requested information. States having suffered fatalities have more restricted rights.
Among other things, they have the right to visit the crash site and to receive information
about the progress of the investigation. They may designate an expert to that end.
The compilation of the investigation report and the consultation thereof is also addressed
in Annex 13. The state conducting the investigation can either incorporate the comments
of the reviewing states in the defnitive report or include them in an appendix.
1.3.2 Delegation of the international investigation to the Netherlands
In accordance with Annex 13, the State of Occurrence shall institute an investigation into the
circumstances of the accident and is responsible for conducting the investigation. Annex 13
offers the possibility of delegating the investigation in part or full, with mutual arrangement


3 See Article 5.25 of Annex 13

15

14

and consent, to another state. Ukraine made use of this option and, a few days after the
crash, asked the Netherlands to conduct the investigation into the crash of flight MH17.
The delegation of the investigation by Ukraine to the Netherlands, which took place in
consultation with the International Civil Aviation Organization (ICAO), was laid down in
two agreements, being a Memorandum of Understanding between the Ukrainian and
the Dutch Ministers of Foreign Affairs and an agreement between Ukraines NBAAI and
the Dutch Safety Board. Both documents are included as appendices to this report
(Appendices C and D). As from 23 July 2014, the Dutch Safety Board was effectively in
charge of the international investigation into the causes of the crash.
The preamble to the Memorandum defnes the objective of the investigation: to
ensure that the investigations [] will be conducted with the maximum impartiality and
objectivity that will meet the expectations of the international community. The
Memorandum and agreement therefore stipulate that the investigation into the crash of
flight MH17 is conducted in accordance with Annex 13 to the Chicago Convention.
1.3.3 The Kingdom Act Dutch Safety Board
The tasks, responsibilities and authorities of the Dutch Safety Board are defned in the
Kingdom Act Dutch Safety Board. The Dutch Safety Boards statutory task is to explain
how an accident or incident could have occurred, how to prevent a similar accident from
happening in the future or how to limit its impact. In relation to this, the legislator
considers that an investigation performed by the Dutch Safety Board can help alleviate
public unrest caused by an incident.4 The Kingdom Act Dutch Safety Board stipulates that
the Dutch Safety Board must refrain from statements that apportion blame or liability.
The Kingdom Act Dutch Safety Board provides for the Dutch Safety Boards independent
position, which allows it to decide autonomously whether to conduct an investigation
without taking into account the interests of the parties concerned, political offcials or
other stakeholders.5 This concerns independence from parties that are involved in an
accident or incident as well as independence from the (central) government. Members of
the Dutch Safety Board are appointed, suspended and dismissed by Royal Decree, after
consultation with the Board. The members sitting on the Board are not bound by a
mandate. The way in which the Dutch Safety Board is funded, does not offer any
possibility for exercising influence over the organisation.
The Kingdom Act Dutch Safety Board and the subordinate regulations include provisions
related to the investigation process and the way in which the Dutch Safety Board must
handle investigation material. In brief, these provisions give the Dutch Safety Board
extensive authority to request data and information that it needs for its investigations, or
to request that parties cooperate with the investigation. Statements made to the Dutch


4 Parliamentary Paper II, 2003/2004, 28 634, no. 3. p. 6.
5 In certain circumstances, the Dutch Safety Board is obliged to conduct an investigation. Certain political offcials
can also request the Dutch Safety Board to conduct an investigation. However, the Dutch Safety Board does not
have to respond to these requests.

16

15

Safety Board may not be used as evidence in legal processes. With this provision, the
legislator aims to encourage the persons involved to provide full disclosure, since they
do not have to fear (criminal) legal repercussions.
1.3.4 Using the legal framework in the investigation
Crash: Causes
An important objective of the investigation was to provide the international community
and the victims relatives with an accurate and truthful picture of the causes of the crash
of flight MH17 on 17 July 2014. Another objective of the Dutch Safety Board was to draw
lessons for the future, based on the fndings of the investigation.
The investigation into the causes of the crash of flight MH17 was conducted in accordance
with the provisions of Annex 13 to the Chicago Convention by an international investigation team in which, after the initial phase, the following states were represented by an
accredited representative:6

State

Explanation

The Netherlands

The state that conducted the investigation and that supplied the investigatorin-charge (IIC).

Ukraine

The state in which the incident occurred.

Malaysia

The state in which the aeroplane was registered and in which the operator is
based.

United Kingdom

The state in which the manufacturer of the engines is based.

United States

The state in which the aircraft manufacturer is based.

Australia

The state that provided information at the request of the Dutch Safety Board,
such as photos of the wreckage in the wreckage area.

Russian Federation

The state that provided information at the Dutch Safety Boards request, such
as radar and communication data and weapons information.

Apart from these states, representatives of various states and international organisations
were present in Ukraine or assisted Ukraine in other ways during the initial phase of the
investigation when the Netherlands was not yet conducting the investigation.7
Crash: Flight route
The fact that two judicial regimes apply, namely the Kingdom Act Dutch Safety Board and
Annex 13 to the Chicago Convention, was especially noticeable in the investigation into
how the decision-making related to the flight route of flight MH17 was organised, and how


6 After a request to the Russian Federation for radar information, the Dutch Safety Board asked the Russian
Federation to participate in the investigation. This invitation is included as Appendix F. The confrmation that
Australia assigned an accredited representative is included as Appendix E to this report.
7 This involved France, Germany, Italy, the European Aviation Safety Agency (EASA), the International Civil Aviation
Organization (ICAO) and the Interstate Aviation Committee (IAC).

17

16

decisions about flying over conflict areas are made in general. For the investigation into
flying over conflict areas, the Dutch Safety Board approached various parties in and outside
the Netherlands to request their cooperation in the investigation. It was not always clear to
these parties whether the Dutch Safety Board requested them to cooperate on the basis
of Annex 13 to the Chicago Convention, or on the basis of the Kingdom Act Dutch Safety
Board. These parties, such as sister organisations and airlines, provided information to the
Dutch Safety Board and cooperated with this part of the investigation anonymously and on
a voluntary basis.
During the investigation it became increasingly clear that parties all over the world attach
great value to improving the safety of civil aviation regarding flying over conflict areas.
This was demonstrated, for example, by a joint declaration (on 29 July 2014) from ICAO,
the international branch organisations of airlines (IATA), airports (ACI) and air navigation
service providers (CANSO). Following the crash, various international initiatives were
taken with the aim of reducing the chance of an accident, such as that involving flight
MH17, occurring in the future. In August 2014, for example, ICAO set up a task force to
advise on adapting roles and procedures focused on limiting risks that conflict areas
pose to civil aviation.8 On 27 October 2014, ICAO also adopted a resolution advocating
for the investigation into the crash of flight MH17 to be used to improve international
standards and to share best practices for the safety of civil air traffc flying over conflict
areas.9 The subject was also on the agenda of the ICAO High Level Safety Conference in
Montreal in February 2015. Flying over conflict areas and MH17s flight above the eastern
part of Ukraine was a recurring theme in the media too.
In the investigation into the decision-making related to flight routes, the Dutch Safety
Board attempted to do justice to these international developments and included them in
its investigation where possible. In addition, because of the international importance of
the investigation into flight routes, the Dutch Safety Board followed the provisions of
Annex 13 to the Chicago Convention as closely as possible. The Dutch Safety Board
involved representatives of sister organisations where possible and when necessary for
the investigation. The investigation into the general decision-making related to flying
over conflict areas made it possible to place the outcomes of the investigation into flight
MH17s route in an international perspective and created the opportunity to learn deeper
and broader lessons from this disaster.
Crash: Occupants
According to Annex 13 to the Chicago Convention the investigation should include the
injuries suffered by the victims, medical and pathological information and their chances
of survival, depending on the circumstances of the accident. The provisions of Annex 13
do not primarily focus on answering questions that relatives may have about what the
occupants may have experienced of the accident. The Dutch Safety Board decided to
conduct a more thorough investigation into the consequences of the crash for the
occupants than is customary on the basis of Annex 13. Apart from the aspects listed
there, the Dutch Safety Board attempted to answer the question as to what conditions


8 Task Force on Risks to Civil Aviation arising from Conflict Zones (TF RCZ).
9 ICAO Council Resolution on Malaysia Airlines Flight MH17, Destroyed over Eastern Ukraine on 17 July 2014.
27 October 2014.

18

17

the occupants were exposed to during the crash and what the influence of this was on
their bodies, consciousness and awareness. In addition, the Dutch Safety Board has
investigated how the human remains were handled following the crash. The investigation
into these questions was conducted on the basis of the authority provided by the
Kingdom Act Dutch Safety Board.
Passenger information
The investigation into passenger information looked into the time needed to provide the
relatives of the Dutch victims of flight MH17 with offcial confrmation that their loved
ones were on board the aeroplane. This investigation was conducted fully within the
authority granted to the Dutch Safety Board by the Kingdom Act Dutch Safety Board.
On the basis of this authority, the Dutch Safety Board can conduct an investigation into
the way the Netherlands has managed the consequences of incidents abroad of which
the impact extends to the territory of the Netherlands.10
1.4 Conducting the investigation
The Dutch Safety Board conducts its investigations within the applicable legal framework
respecting its core values: independent - professional - transparent. In this section, the
Dutch Safety Board explains how these terms in general are put into practice and what
this meant for the investigation into the crash of flight MH17.
1.4.1 Independence
The Dutch Safety Boards objective in conducting its investigations is to provide a defnite
answer about what happened and how, and to draw authoritative conclusions and lessons
from this. From that objective, it is important that the Dutch Safety Board is able to
formulate its own autonomous opinion about the facts and their interpretation. In this
respect, the legal framework offers several guarantees.
In the context of an accident investigation, independence is not absolute. Firstly, there is
always a certain interdependency between the investigator and the subject of the investigation, because parties directly involved have knowledge of unique facts and circumstances that are necessary for understanding the incident. Although the Dutch Safety
Board benefts from legal powers it can use to enforce cooperation with its investigation,
that does not totally eliminate the type of dependency referred to above. Secondly, due
to the scope of its feld of work, the Dutch Safety Board will always depend on the
expertise of others to effectively conduct its investigations. Thirdly, to be able to arrive at
authoritative conclusions it is important that the Dutch Safety Board also takes account
of the views and interests of others.
The Dutch Safety Board therefore cannot and does not wish to wholly isolate itself in
conducting its investigation. It is rather a matter of the Dutch Safety Board guarding its
conclusions against the disproportionate influencing by other parties while ensuring


10 Article 4, second paragraph, under a, Kingdom Act Dutch Safety Board.

19

18

observance of the aforementioned dependencies. The Dutch Safety Board must at all
times be able to formulate an autonomous and impartial perspective, fed by the
perspectives of others.
The investigation into the crash of flight MH17 took place in an extraordinary context. The
large number of victims, the considerable media attention and the public involvement in
the crash, the simultaneous occurrence of an international criminal investigation and the
geopolitical interests involved, made it even more important for the Dutch Safety Board
to safeguard its independence. To this end measures were taken in the investigation
process, which are explored in more detail in the following part of this section. The way in
which the investigation by the Dutch Safety Board was related to the international criminal
investigation is described separately in Section 7.4.
The Dutch Safety Board would like to state that neither the Cabinet, nor the judicial
authorities nor other parts of the Dutch (central) government at any time attempted to
influence the investigation into the crash of flight MH17. Naturally, the central government,
as well as other interested parties, put forward its requests and expectations with regard
to the subjects to be investigated. The central government was occasionally informed
about the schedule of the publishing of the investigation reports.
Reflection meetings
From the very beginning of the investigation into the crash of flight MH17, the Dutch
Safety Board was aware that the risk of political influence could be higher than usual,
given the tense international relations. To effectively identify and manage this risk, the
Dutch Safety Board held two reflection meetings with experts that have extensive
experience in conducting investigations in a political playing feld. These meetings
focused on obtaining advice about the right strategy for working and interacting with
parties in this context. The meetings also aimed to explore what the Dutch Safety Board
could do to ensure that the results and recommendations of the investigation optimally
matched the expectations of the outside world. The Dutch Safety Board used the results
of these meetings in its decision-making processes throughout the investigation.
Stakeholder analysis
To arrive at independent and authoritative conclusions in a complex array of forces, it is
important that the investigative body has an effective understanding of these forces:
what interests do the various parties have, how could they influence the course of the
investigation and how can the investigative body best deal with those forces? A stakeholder analysis was performed to systematically answer these questions.
International collaboration in aviation accident investigation
Annex 13 to the Chicago Convention provides for the participation of states having a
special interest in the investigation into a civil aviation accident. Depending on the
nature of their involvement in the occurrence, states can participate in the investigation
through an accredited representative or an expert. The rationale behind involving
various states in the investigation is that parties with potentially conflicting interests
have the opportunity to take note of the facts frst-hand and present their views in the

20

19

investigation. The fact that the interests of the states most involved in the investigation
are represented in this manner enables the state that conducts the investigation to
formulate autonomous conclusions based on the various views.
In conducting the investigation into the causes of the crash and the flight route of flight
MH17, various interested states were involved. In a natural manner, this working method
led to counter-arguments, in addition to the usual internal and external assessments of
fndings that the Dutch Safety Board organises for its investigations. By involving people
who view the fndings of the investigation from different angles and with different
interests, critical questions are put forward. Because of the international collaboration,
various perspectives in the investigation arise for discussion, which contribute to the
quality of the analyses.
In international aviation accident investigation, it is customary for the state that is
conducting the investigation to organise progress meetings with the participating states.
The objective is to share relevant information within the team. Holding such meetings is
not required, nor is the number of meetings or their frequency set. The investigator-incharge (IIC) invites the accredited representatives and their advisors. In the investigation
into the causes of the crash of flight MH17, this was done on three occasions. During these
meetings, the Dutch Safety Board explained the state of affairs of the investigation. The
meetings were held in the Netherlands. Due to the circumstances in the eastern part of
Ukraine it was impossible to arrange for a joint visit to the crash site to examine the
wreckage in its original position.
Joint examination of the wreckage frst took place at Gilze-Rijen Air Base during the frst
progress meeting (16 - 25 February 2015). All states in the investigation team were
represented. Also, all states having suffered fatalities were invited, although, of these,
only representatives from Germany and Belgium were present. Lastly, an observer of
ICAO was present.
During this meeting, the fracture surfaces, failure mechanisms and the impact damage
pattern were examined. The meeting was concluded with a plenary meeting during
which all the fndings that had been agreed were recorded, and during which agreements
were made about the matters that required further investigation. It was concluded that
the aeroplane was most likely downed by a missile that was launched from the ground.
The conclusion was endorsed by the accredited representatives of all the states involved.
At the second progress meeting (6-7 May 2015), all of the states in the investigation
team, with the exception of Australia, were represented. During the meeting, the
progress of the investigation into the causes of the crash was discussed, including the
question of which type of weapon could have caused the damage to the aeroplane and
the weapons possible trajectories. Additionally, all participating states were once again
offered the opportunity to examine the wreckage more closely. Furthermore, an
explanation was given of the work on the reconstruction of the aeroplane.
A signifcant part of the meeting was taken up by the presentation of the Dutch National
Aerospace Laboratory (the NLR) that discussed which type of weapon could have caused
the damage to the aeroplane and the possible missile trajectories. In addition, the company

21

20

Almaz-Antey provided a presentation on behalf of the Russian Federation. The results
presented differed on three important aspects from the presentation by the NLR. These
aspects concerned the angle at which the weapon approached the aeroplane, the location
of the detonation relative to the aeroplane and the possible missile trajectories.
The meeting was closed with conclusions, with mutual agreement on the conclusions
that the aeroplane was hit in flight by high-energy objects from a surface-to-air missile,
that the missile concerned was equipped with a warhead as found in missiles installed on
Buk fring systems and that the location of detonation was on the left side of the
aeroplane close to the cockpit. The Russian Federation did not concur with the fndings
about the possible missile trajectories presented by the NLR on behalf of the Netherlands.
During the third progress meeting (11 - 12 August 2015), the fnal state of affairs was
discussed. All states in the investigation team were represented. An observer of ICAO also
attended the meeting. During the meeting, the comments that the Dutch Safety Board
received from consulting the other states regarding the investigation into the causes of the
crash and the flight route of flight MH17 that needed explaining were discussed. An outline
of the recommendations was also presented. Furthermore, the reconstruction of a section
of the aeroplane was shown to those present. The reconstruction allowed those present to
examine the different damaged parts of the aeroplane in relation to one another and
thereby acquire more insight into the nature of the damage.
During the meeting, the Russian Federation presented its own ballistic investigation. It is
customary to inform the state that is conducting the international accident investigation
of such an investigation in advance. In these cases an invitation is sent to the state
conducting the investigation and possibly to the other participating states to propose
suggestions for the investigation and to be present at the investigation. The investigation
by the Russian Federation was not announced beforehand. It was not part of the
international investigation into the crash of flight MH17, since the Dutch Safety Board and
other participating states did not have the opportunity to form an opinion on the content.
The Russian Federation indicated that the aeroplane was downed by a missile that could
have been fred from either the ground or an aeroplane. This standpoint deviated from
what was jointly subscribed during the frst and second meetings (also by the Russian
Federation). The third meeting was closed with the joint conclusion (thus by the Russian
Federation as well) that the aeroplane was hit by high-energy objects of a missile that
detonated in front of and to the left of the cockpit. This joint conclusion is less far-reaching
than the conclusions in the investigation report on the crash of flight MH17.
Relationships with knowledge institutions and experts
During the investigation the Dutch Safety Board made use of knowledge and information
from third parties. The basic principle consistently adopted was that the Dutch Safety
Board be provided with suffcient information to enable the Board to form a picture of
the reliability of the expert assessment obtained. The Dutch Safety Board used the
expert assessment to arrive at its own and autonomous conclusions.
Guidance committee
To be able to form autonomous conclusions, the Dutch Safety Board obtains advice
about the weighting of the fndings drawn up by the investigation team. For this it

22

21

employs a Guidance committee. A separate Guidance committee was set up for each of
the four subjects of the investigation into the crash of flight MH17. For this organised
critique, the Dutch Safety Board attempted to incorporate all the required expertise in
the committees. The members of the guidance committees are mentioned in the
appendices of the investigation reports.
The members of the guidance committees have relevant expertise and are appointed in
a personal capacity. Each committee convenes several times in the course of an
investigation, and advises the Dutch Safety Board on the focus and the fndings of the
investigation, the comments from the parties concerned on the draft report, the
conclusions to be formulated, and the recommendations, insofar applicable. On occasion
guidance committees met jointly when this was helpful to the investigation.
Bringing the outside world inside
During the course of the investigation, the Dutch Safety Board consistently tried to keep
an open eye to facts, information, investigations, suspicions and theories presented by
outsiders pertaining to the crash of flight MH17. It did so with the conviction that the
quality of its conclusions would be improved if all kinds of perspectives were incorporated
in its formulation. The perspectives of parties other than the states and parties already
involved and their experts, can add great value to the process.
In order to identify what statements were circulating about the causes of the crash and
the flight route, the Dutch Safety Board asked Publistat (an organisation that monitors
media) to analyse the reports in international (social) media. This analysis served as the
basis for the hypotheses that the Dutch Safety Board included in the investigation (see
Section 3.3).
Regarding the results of investigations into the crash conducted by other parties, the
Dutch Safety Board examined the sources that formed the basis of these investigations,
for as much as possible. If the sources were accessible, the Dutch Safety Board assessed
whether it was useful to incorporate the fndings of the other parties in its investigation.

The investigation by RTL4 into fragments found at the crash site
One of the investigations conducted by other parties the Dutch Safety Board looked
into, concerns an investigation conducted on behalf of television station RTL4. At
the crash site one of its journalists found fragments that possibly originated from a
weapon and had them examined.
The fragments were handed over to the Dutch Safety Board on 20 March 2015. The
Dutch Safety Board had the NLR examine the fragments. The results were no
different from what the Dutch Safety Board already knew from the examination of
other fragments which the Dutch Safety Board knows for a fact came from the
wreckage or from the bodies of the victims.

23

22

Various persons and organisations approached the Dutch Safety Board on their own
initiative with information that could possibly be relevant to the investigation. The Dutch
Safety Board assessed this information for relevance and reliability, and, if relevant and
reliable, incorporated it in the investigation.
1.4.2 Professionalism
The Dutch Safety Boards objective in conducting its investigations is to provide a defnite
answer about what happened and how this happened, and to draw authoritative
conclusions and lessons from its fndings. From that objective, it is important that the
Dutch Safety Boards investigations are conducted in such a way that the fndings and
conclusions are valid and reliable. This implies that the Dutch Safety Board guarantees
that the investigation is conducted by persons who have relevant and up-to-date
expertise in both content and methods.
The next part of this section describes how the Dutch Safety Board guaranteed the
professional execution of the investigation into the crash of flight MH17. In this context it
should be noted once more that dependence on expertise forms a risk to the Dutch
Safety Boards autonomous conclusions. The previous paragraph described how the
Dutch Safety Board approached this issue.
Composition of the investigation teams
The Dutch Safety Board strives to have all the necessary knowledge and skills among its
own personnel and tries to realise this through recruitment, selection and training. The
investigation teams for each project are multidisciplinary and consist of investigators that
possess the knowledge and skills required for the investigation at hand. For the
investigation into flight MH17 the Dutch Safety Board called upon investigators having
expertise on the subject of aviation, defence, health, crisis management, administrative
processes and risk management.
The investigation into flight MH17 was an exceptionally large and complex project for the
Dutch Safety Board. The project took up a great deal of the available resources:
approximately three-quarters of the 72 staff members were at some point assigned to
the investigation or to activities in support of it.
Involving external investigators and support
The Dutch Safety Board is an organisation with a broad scope of activity.11 Thus bringing
in specifc external expertise is unavoidable, especially for extensive investigations such
as that into the crash of flight MH17. The most relevant selection criteria when involving
external staff are relevant expertise, proven quality and impartiality of the external
employee. The Dutch Safety Board prefers to use its own network in the sector related to
an investigation, contacts in sister organisations and independent knowledge institutions
such as universities when recruiting external investigators.
To prevent any conflicts of interest with an external investigator, the Dutch Safety Board
tries not to recruit any persons that work for organisations that are or could become
directly involved in the accident or incident. Each external employee is subject to strict


11 The Dutch Safety Board permanently employs circa 46 investigators (full-time equivalents).

24

23

confdentiality with regard to all that he or she will have access to during the course of the
investigation. He or she must also declare to be of irreproachable behaviour and he or
she must provide a certifcate of good conduct (verklaring omtrent gedrag) or undergo a
security screening.
Third party investigations
Regularly, the Dutch Safety Board outsources parts of an investigation to third parties,
such as when the Dutch Safety Board does not have the right resources or knowledge to
conduct that particular part of the investigation. Such investigation assignments are
conducted under the responsibility of the Dutch Safety Board by renowned research
agencies and bodies that guarantee quality. The results of sub-investigations outsourced
by the Dutch Safety Board are treated as recommendations. The Dutch Safety Board
assesses the results in terms of their reliability, in some cases by asking a different
organisation to assess the results of an outsourced investigation. The outcomes of the
outsourced sub-investigations form part of the Dutch Safety Boards investigation. The
Dutch Safety Board will only make their results public in the fnal investigation report or
its appendices. When the reports of the outsourced sub-investigations are integrally
included in the appendices, they are so in their original state and have not been edited
by the Dutch Safety Board.
Parts of the investigation into the crash of flight MH17 were outsourced. This applied to
the following sub-investigations:

Sub-investigation

Conducted by

Forensic investigation and material analysis of the fragments recovered

NFI; NLR; Element Materials
Technology

Investigation of the fracture lines in relation to the failure analysis

NLR; TU Delft

Weapon simulations

NLR*, TNO

Blast damage simulations

TNO

Possible trajectories of the missile

NLR*

List of publicly available information related to the threats and reduced
safety of the airspace above the eastern part of Ukraine

HCSS

Role of the Dutch intelligence services AIVD and MIVD in the decisionmaking related to the safety of flight routes

CTIVD*

* The reports of these sub-investigations are included in the appendices of the investigation report regarding
the crash of flight MH17.

Internal and external assessment of the fndings
During the investigations, the Dutch Safety Board obtained advice from various experts
and institutions, such as Victim Support the Netherlands (Slachtofferhulp Nederland) and
grief counselling experts. In addition, Dutch Safety Board staff members not involved in
the investigation team read and assessed one or more investigation reports in terms of
different quality aspects such as comprehensibility, substantiation and consistency.
Meetings held with experts during the investigations allowed them to critically assess the

25

24

analysis of the investigation results and comment on the reports. The feedback from
these internal and external assessments were included in the continued investigations
and incorporated in the reports.
Using statements made by experts and parties involved
An important part of the investigation material received by the Dutch Safety Board, in
addition to documents and technical sources, consists of verbal or written statements by
experts and persons that are involved in an accident or incident in some way. As the way
in which the statements are taken is a decisive factor for their reliability, the Dutch Safety
Board devotes special attention to its interviewing techniques. All the investigators
employed by the Dutch Safety Board receive regular training in this area. A key
component of the training course focuses on the interviewer avoiding affecting the
interviewee (intentionally or accidentally). Moreover, usually two investigators are present
and generally an audio recording is made of the interviews. The Dutch Safety Board
works with reports on the interviews, signed by those interviewed.
Even when a statement has been taken in accordance with the highest standards
imaginable, it still constitutes source material with a relatively low degree of reliability.
Therefore, the Dutch Safety Board adopts the basic principle that a statement alone is
not suffcient for substantiating a fnding. A statement must be corroborated by as many
other types of source material as possible.
1.4.3 Transparency
The Dutch Safety Board attaches great value to conducting its investigation in a way that
is comprehensible to others, so that in turn they can form their own opinion on the
investigations validity and reliability. Moreover, it is important that the Dutch Safety
Board informs the different stakeholders (relatives, other parties involved, the general
public) about the investigation and its fndings in such a way and at such times that they
are not unnecessarily obstructed from coming to terms with their grief or drawing lessons
from the event.
The extent to which the Dutch Safety Board can practise transparency is limited due to
the legal obligation to protect its sources. Other than the information in the fnal report,
the Dutch Safety Board does not release any underlying source information related to
the investigation, except in exceptional cases.12 The purpose of this source protection is
to enable those involved in an accident or incident to give the Dutch Safety Board full
disclosure without fearing any disciplinary measures or (criminal) prosecution. This means
that the Dutch Safety Board is in an optimal position for discovering the true causes of an
incident and for drawing lessons from it.
The following part of this section describes how the Dutch Safety Board, taking into
account the limitation mentioned above, achieved transparency in the investigation into
the crash of flight MH17.


12 Kingdom Act Dutch Safety Board, Article 59, 5th paragraph jo Article 69.

26

25

Preliminary report
According to Annex 13 to the Chicago Convention when there is an accident involving an
aircraft with a maximum mass of over 2,250 kg, a preliminary report is sent to the states
involved and to ICAO. Given the scope of the disaster and its impact on Dutch society
and on other nations that suffered victims, the Dutch Safety Board chose to publish this
report after a consultation period. In publishing the preliminary report, the Dutch Safety
Board aimed to provide the relatives of the victims, while the investigation was still in
progress, with factual information about the crash and the fndings up until that time.
Dutch relatives received the preliminary report an hour before it was published on
9 September 2014 under embargo via the family liaison offcers13 deployed by the
National Police. This allowed the relatives to become acquainted with the reports content
before it was released by the media.
Consultation and review
Both Annex 13 to the Chicago Convention and the Kingdom Act Dutch Safety Board
include provisions concerning to which parties and in what manner the draft report must
be presented for consultation, as well as the way in which the resulting comments are to
be processed. The objective of these provisions is to ensure that the fnal report does
not contain any factual inaccuracies and to be informed of interested parties views on
the fndings and conclusions that the Dutch Safety Board has drawn on the basis of the
facts investigated.
Discussed below are comments arising from the Annex 13 consultation with regard to the
results of the investigation into the causes of the crash and the flight route of flight MH17.
The rationale for this is that the Dutch Safety Board considers it important to explain in a
general sense which comments on these subjects were not incorporated. The exact
comments on all investigated aspects by all parties that were not incorporated in the
investigation reports are available in the tables of comments published on the website of
the Dutch Safety Board.
On 2 June 2015, the Dutch Safety Board presented the results of the investigation into the
causes of the crash and the flight route to the accredited representatives of Australia,
Malaysia, Ukraine, the Russian Federation, the United Kingdom and the United States for
consultation. The results were also presented for consultation to the European Aviation
Safety Agency (EASA) and EUROCONTROL. Parties were requested to provide signifcant
and substantiated comments. The Dutch Safety Board received comments from all states,
varying from textual comments and proposals to clarify texts to indications of factual
inaccuracies. The Dutch Safety Board examined all comments and determined whether or
not they should be incorporated in the report. The main issues that were not incorporated
in the report are summarised below.


13 In the Netherlands, family liaison offcers were used to provide the relatives of the victims with information on
behalf of the authorities. They function as a personal contact point between the authorities and the relatives.

27

26

The Russian Federation submitted a substantial number of comments during the
consultation. Many of those comments contributed to the quality of the report and were
incorporated in it. Some of the comments were not incorporated.
For example, the Russian Federation has stated that it is not possible to ascertain the type
of warhead that detonated and the type of missile that carried it. In its comments, the
Russian Federation referred to outcomes of various tests and calculations that were made
available during the last progress meeting. These concerned among other things the
location of the detonation, the way in which the fragments spread after detonation and the
direction from which these fragments perforated the aeroplane. More information can be
found in Appendix L.
The Russian Federation also commented on the presence of weapon systems in the eastern
part of Ukraine with respect to the fghting parties. However, the investigation only
examined weapon systems that were known to be common in use in the region. The
question of what weapon systems were in the possession of which parties was not part of
the investigation into the causes of the crash.
Lastly, the Russian Federation did not consider the references to the unrest in Crimea at
the beginning of 2014 a possible sign of deteriorating safety in the Ukrainian airspace.
However, these references were made in the report to understand why airlines were
prohibited from flying over Crimea. The impossibility of flying over Crimea was relevant to
the decision-making with respect to flight routes above the eastern part of Ukraine.
The comment from Ukraine requesting the removal of the conclusions pertaining to airspace
management was not accepted. The essence of Ukraines comment was that the risk to civil
aviation at cruising altitude posed by the armed conflict in the eastern part of the country
was adequately assessed. However, the facts that were gathered contradict this.
Communication policy
The needs, expectations and perceptions in the outside world have influenced the
choices the Dutch Safety Board made concerning the type and scope of its reporting.
During the investigation, the Dutch Safety Board publicised information about the
investigation process more than had been customary. The Dutch Safety Board also
published a number of relevant documents on its website to provide clarity about some
of the agreements that were made. This concerns the agreements between the Dutch
Safety Board and other parties with regard to taking charge of the investigation into the
crash of flight MH17 and with regard to the recovery of the wreckage.
On several occasions members of the House of Representatives of the Dutch Parliament
asked the involved members of cabinet questions about the investigation. Since the
members of cabinet do not have access to the Dutch Safety Boards work and have no
insight into its progress, the Dutch Safety Board supplied them with information to
enable them to answer these questions. This information was limited to the investigation
process and was not related to the investigations approach or fndings.

28

27

The press and news reports published by the Dutch Safety Board were not shared with
other parties in advance, leaving aside some exceptions. In certain cases, the Dutch
Safety Board believed it was necessary to supply parties with the information that it was
going to publish prior to the moment of publication. In particular, in cases where
information was directly related to a (joint) mission carried out by (or with) another party,
the content of the news report was shared in advance with the party concerned. Visiting
the crash site to recover wreckage pieces, for example, was carried out in a joint operation
with the Ministry of Defence. For this reason the Dutch Safety Board shared the related
news reports with this Ministry in advance.
Informing the relatives
The Dutch Safety Board wanted to keep the relatives of the victims informed of the
progress of the investigation as effectively as possible. Never before did the Dutch Safety
Board have to deal with such a large group of relatives originating from so many different
countries during an investigation. The Dutch central government organised information
meetings for the relatives and the Dutch Safety Board attended these meetings to
provide information about the process of the investigation and to answer the questions
of relatives.
During the investigation, the Dutch Safety Board maintained contact with the MH17
Aviation Disaster Foundation (Stichting Vliegramp MH17), Victim Support the Netherlands
(Slachtofferhulp Nederland) and the family liaison offcers and sought their advice prior
to having meetings, publicising reports or other kinds of communications. The relatives
of the victims received information via a special forum before it was shared with the
media. Where possible, questions asked to the Dutch Safety Board by relatives via a
dedicated forum, family liaison offcers or via Victim Support the Netherlands were
answered immediately.
The relatives were offered the opportunity of being present when the wreckage pieces
arrived at the Gilze-Rijen Air Base. About 40 relatives were present at that time. Some
time later, the relatives were also invited to view the wreckage themselves (2 - 6 March
2015). This opportunity was used by 533 relatives of 151 of the victims. They were allowed
to leave flowers in the hangar with the wreckage pieces. Among them were a number of
relatives of victims from other countries. The Dutch Safety Board produced a video
recording of the wreckage pieces to provide relatives who were not able to visit GilzeRijen with an impression. Other interested parties, such as the media and those involved
in the investigation into the crash of flight MH17, were also invited to view the wreckage
pieces.14


14 In total about 65 journalists made use of the opportunity. Among these, media reporters and correspondents
from different countries and various (international) press agencies.

29

28

2 PRELIMINARY REPORT
2.1 Introduction

On 9 September 2014, the Dutch Safety Board published its preliminary report (Rapport
van eerste bevindingen) regarding the causes of the crash. In this report, the Dutch
Safety Board reported the frst results of the investigation, which was still in full swing at
that time. For the preliminary report use was made of the investigation material that was
available at that time, including the data from the flight data recorder, the cockpit voice
recorder, data regarding the crew, the flight plan, the state of the maintenance of the
aeroplane, flight-relevant meteorological information, Notices to Airmen (NOTAMs) and
data from the relevant air traffc control services. The Dutch Safety Board also had access
to photographs and satellite images of the area (Google Earth), on which pieces of
wreckage of the crashed aeroplane were visible.
It is important to note that the fndings in the preliminary report were established on the
basis of the investigation material that was available up until then. Caution was called for
when drawing conclusions at that time. After the preliminary report was published,
additional investigation material became available, such as a part of the wreckage, the
human remains of the occupants and other physical evidence, which enabled the Dutch
Safety Board to draw authoritative conclusions about the causes of the crash. The Dutch
Safety Board wanted to be very careful at all times not to draw conclusions before the
investigation was fully completed.
2.2 Provisions of Annex 13
According to Annex 13 a preliminary report should be submitted to the relevant states
and ICAO within thirty days after an accident involving an aeroplane with a maximum
mass of over 2,250 kg. The preliminary report may also include safety warnings. The
content depends partially on the progress of the investigation and the need to report
certain results. The Dutch Safety Board chose to publicise the preliminary report.
2.3 Publication of the preliminary report
Given the exceptional circumstances in which the investigation into the causes of crash of
flight MH17 occurred, the time needed to draw up the preliminary report exceeded the
thirty days specifed by Annex 13 for this. Because of this, the report was published about
three weeks later, on 9 September 2014. At the time of publication of the preliminary
report, the investigation into the causes of the crash was still in full swing. The fndings
were therefore based solely on the sources that the Dutch Safety Board had at its disposal
at that time. These data were compared and analysed. Based on these analyses, frst
insights in the crash could be given.

30

29

The Dutch Safety Board considered it important to report fndings on which the
representatives of the states participating in the investigation had been able to give their
view. The draft of the preliminary report was therefore submitted to them for comment.15
At the request of the Dutch Safety Board, all representatives sent their responses to the
draft report within the consultation period of 48 hours. The Dutch Safety Board assessed
the reactions and amended the report where the Dutch Safety Board deemed it was
necessary.
At the request of the Russian Federation, the preliminary report was discussed in the
Security Council of the United Nations on Friday, 19 September 2014. The other state
members considered the investigation to be transparent up to that date and insisted on
the completion of the follow-up of the investigation.
After the preliminary report was published, more investigation material became available
(including wreckage pieces of the aeroplane that could be recovered from the wreckage
area as from November 2014) and the investigation was continued with the additional
investigation material. Also, the investigation material that was already available prior to
the publication of the preliminary report was analysed further.
2.4 Erratum
Because of a difference between the Dutch and English version of the reports, on 10
September 2014, one day after the publication of the report, an amendment was made
to the Dutch version. On page 14, the following sentence was deleted: De NOTAM met
luchtruimbeperking was uitgevaardigd in reactie op het neerschieten van een Antonov
24 vliegtuig op 14 juli dat op een hoogte van FL210 vloog. [The NOTAM with airspace
restrictions was issued in reaction to the shooting down of an Antonov 24 aeroplane
flying at an altitude of FL210 on 14 July.] The sentence was deleted because, in this
phase of the investigation, it could not be established with complete certainty that this
information was accurate. In translating the original English report into Dutch, the relevant
sentence was accidentally not removed. Also, Figure 2 in the report did not always
mention the correct type of aeroplane. But this had no affect on the tentative conclusions
in the preliminary report.


15 Annex 13 does not require that a preliminary report be coordinated with the other parties that participate in the
investigation.


» MH17: ? »  DSB JIT »  DSB 13.10.15: MH17 About the investigation