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Отчет DSB 13.10.15: MH17 About the investigation

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APPENDIX J
REQUEST WITH REGARD TO THE REMOVAL OF THE REMAINING PIECES
OF WRECKAGE

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APPENDIX K
ANALYSIS TECHNIQUES USED
STEP
Sequentially Timed Events Plotting (STEP 33) is a multi-linear technique in which events
are grouped in a matrix according to a fxed format. The horizontal axis gives the time
line, the vertical axis gives the actors involved in the event. This manner of structuring
offers the investigation team the opportunity to identify causal and temporal relationships
between events in the circumstances of an incident. These relationships can be subjected
to closer examination in further analysis steps.
Tripod Beta
Tripod Beta34 was developed in order to be able to explain and control the origin of
human error. This technique assumes four general principles:
1. Accidents occur when barriers fail or are lacking
2. Barriers fail due to human error
3. Human error is determined by the context in which the barrier should have been
maintained
4. The context in which human error occurs is determined by actions or lack thereof at
management level in the organisation
The Tripod technique offers a rigid terminological framework and a syntax that makes it
possible to identify barriers, human error, context factors and the underlying causes at
management level systematically.
STAMP
Systems-theoretic Accident Model and Processes (STAMP 35) is a non-linear analysis
technique that views the occurrence of hazards as a systems theory control problem. The
assumption of STAMP is that safety is an emergent characteristic of complex sociotechnical systems, in which both the individual components and their underlying
interactions need to satisfy certain conditions. STAMP offers a terminology and syntax
that allow for systematic examination of potentially inadequate control.


33 See also: Hendrick, K., & Benner Jr, L. (1987). Investigating Accidents with STEP. Marcel Decker. Inc. New York, U.S.
34 See also: Doran, J.A., & Van Der Graaf, G.C. (1996, January). Tripod-BETA: Incident investigation and analysis. In
SPE Health, Safety and Environment in Oil and Gas Exploration and Production Conference. Society of Petroleum
Engineers.
35 See also: Levenson, N.G. (2011). Engineering a safer world. Systems Thinking Applied to Safety, The MIT Press,
Cambridge, MA, U.S.

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APPENDIX L
RESPONSE TO THE COMMENTS OF THE RUSSIAN FEDERATION
During the last joint meeting, the Russian Federation endorsed the notion that flight
MH17 was hit by pre-formed fragments coming from a warhead that detonated to the
left of the cockpit. The Russian Federation questioned the fndings on the basis of which
the Dutch Safety Board concluded that the crash of flight MH17 was caused by the
detonation of a 9N314M warhead. The Russian Federation’s comments with regard to
each fnding of the Dutch Safety Board are listed in the table below, together with a
response by the Dutch Safety Board

Finding
Dutch Safety Board

The Russian Federation’s comment

The Dutch Safety Board’s response

been considerably more extensive.
For this reason, the Russian
Federation posited that a smaller
warhead must have caused the
damage pattern observed

particular with regard to the boundaries
of the impact pattern.

2. The Russian Federation also applied
the stringing method to establish a
detonation location in an other way.
In this, the Russian Federation also
took into account the impact damage
on the inside of the fuselage. For this
purpose, use was made of photographs showing holes in various
frames and stringers (the inside of the
fuselage). Strings were run from the
holes in the frames and stringers
through the holes in the fuselage in
order to arrive at a detonation
location. The detonation location
established in this manner lies ouside
the volume of space in which the
detonation must have taken place as
established by the Dutch Safety
Board. Besides that, the location
deviates from the detonation location
established by the Russian Federation
mentioned under point 1.

As indicated above, the stringing
method that was used is not a sound
method for determining an exact detonation point on the basis of impact
damage. Moreover, the damage on the
inside of the fuselage cannot be
included in such an analysis, as the
fragments of a warhead that penetrate
an object do not continue in the same
direction; instead, they deviate from
their course and ricochet. Therefore,
the trajectory that would be described
by a warhead fragment inside an aeroplane’s fuselage cannot be deduced
and cannot be used to determine a
warheads detonation location. Only the
impact pattern caused by penetrations,
perforations and ricochets visible on
the outside can be used to determine
the general origin of the fragments.

3. The Russian Federation stated that
the operation of the so-called
‘proximity fuse’ - a sensor inside the
missile - is of such a nature that a
9N314M warhead carried by a 9M38-
series missile would not have detonated in the volume indicated by the
Dutch Safety Board. According to the
Russian Federation, the detonation
location for the combination of the
type of missile and warhead
concerned would be about 3 to 5
metres further to the rear

The data pertaining to the sensor
involved were received - through the
Russian Federation - from the manufacturer of this type of missile. The data
was used in new calculations and on the
basis of these calculations, the Dutch
Safety Board concluded that it was
technically possible that a 9N314M
warhead carried by a 9M38 series
missile detonated in the volume of
space as indicated by the Dutch Safety
Board.

The bow-tie shaped
fragments

The Russian Federation provides three
general reasons why the discovery of the
pre-formed (cubic and bow-tie shaped)
fragments would be insuffcient evidence
to demonstrate that the aeroplane was
hit by a 9N314M warhead that detonated
to the upper left-hand side of the
cockpit, in close proximity to it

The Dutch Safety Board’s conclusion
that the crash of flight MH17 was caused
by the detonation of a 9N314M warhead
is not just based on the discovery of
these pre-formed fragments. The Dutch
Safety Board has used all of the fndings
cited in the left-hand column of this
table to substantiate this conclusion.

1. The Russian Federation stated that,
assuming that a 9N314M warhead
detonated close to the aeroplane, the
number of bow-tie shaped and cubic
fragments found is too small. In
addition, the Russian Federation
stated that the ratio of the different
shapes of the particles found is not
commensurate with the ratio between
these shapes in a 9N314M warhead.

The detonation of the warhead took
place at an altitude of ten kilometres,
and only a fraction of the pre-formed
fragments present in the warhead will
have hit the aeroplane. Moreover,
fragments do not necessarily get stuck
in the aeroplane after impact and will
have come loose and will have been
lost during the break-up of the
aeroplane, the fall of the pieces of
wreckage, during the search for victims
at the crash site, or during the recovery
and transport of the wreckage. In
addition, the fragments’ shape and
weight may have changed as a result of
the impact, making it more diffcult to
recognise the fragments’ original
shape. This means that the chance of
fnding recognisable pre-shaped fragments is very small.
Two bow-tie shaped and two cubic
fragments were recovered from the
bodies of crew members and from the
wreckage. The Dutch Safety Board’s
investigation has demonstrated that
these particular fragments originated
from a warhead that detonated in close
proximity to the aeroplane. The bow-tie
shaped fragments are typical of a
9N314M warhead. Such bow-tie shaped
fragments are not unique to this type of
warhead, but - insofar as the Dutch
Safety Board has been able to establish
- other warheads containing such
fragments are not common in use in the
region. The discovery of two of such
fragments in the remains of the flight
crew members and the wreckage is a
signifcant substantiation for a warhead
of that type being the cause of the
break-up of flight MH17.

2. The Russian Federation stated that,
based on a test performed by AlmazAntey, the weight of the pre-formed
fragments found does not match with
the fragments originating from a
9N314M warhead. The fragments are
supposedly too light

The Dutch Safety Board was not invited
to be present during the test, but the
results of the test were presented
during the last Annex 13 meeting. The
test was performed in a stationary
situation on the ground, which is
completely different from the detonation of a warhead at an altitude of
about ten kilometres. The air density at
an altitude of ten kilometres and the
speeds of the missile and the aeroplane
have a substantial influence
on the spread of the fragments at the
moment of detonation and, stemming
from that, the impact, the impact
pattern and the fnal shape and weight
of the fragments.
As indicated before, the fragments’
shape and weight can change as a
result of the impact, among other
things by deformation and the abrasion
of material. The extent to which this
happens strongly depends on the
location where the detonation took
place and on the material that the
fragments impact. Therefore, the
results of the tests are irreconcilable
with the weight of the fragments
actually found.

3. The Russian Federation stated that
the discovery of such pre-formed
fragments is insuffcient evidence for
concluding that these originated
from a specifc type of surface-to-air
missile. According to the Russian
Federation, such pre-formed fragments are present in other weapon
systems as well, including air-to-air
missiles

The damage pattern observed does not
match the damage pattern expected
from an air-to-air missile. Insofar as the
Dutch Safety Board has been able to
establish, air-to-air missiles carrying a
warhead containing bow-tie shaped
fragments are not common in use in the
region. In addition, no other aircraft
that could have launched an air-to-air
missile was observed on the radar data
as provided by the Russian Federation.

Injuries of the three
crew members in the
cockpit

None

At a late stage the Dutch Safety Board
could share with the Annex 13 parties
that the injuries to the three crew
members in the cockpit could be
related to pre-formed fragments from
the warhead. No comments with regard
to this matter were received from the
Russian Federation

The in-flight
break-up of the
aeroplane

None

By not commenting, the Russian
Federation endorses the analysis which
states that the in-flight break-up of the
aeroplane was caused by a warhead
containing pre-formed fragments
exploding to the left of the cockpit

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Finding
Dutch Safety Board

The Russian Federation’s comment

The Dutch Safety Board’s response

Discovered traces of
an explosive device
and the pain

None

At a late stage the Dutch Safety Board
could share with the Annex 13 parties
that objects had been found whose
form and appearance match parts of a
specifc missile.
The Netherlands Forensic Institute
analysed these parts and two fragments
that were found in the aeroplane. This
entailed the analysis of traces of an
explosive device and of paint. The
results of these analyses were only
made available to the Dutch Safety
Board after the last Annex 13 meeting.
As a result, they were not known to the
Russian Federation and no comments
with regard to this matter were received
from the Russian Federation.

The calculated
missile trajectory

The Russian Federation stated that the
possible trajectories that the missile
could have followed to the detonation
location volume were calculated
incorrectly. It was alleged that the
calculations had been based on faulty
conditions. The Russian Federation
especially stated that the detonation
location was calculated incorrectly. On
the basis of its own calculations, the
Russian Federation stated that the
missile trajectory would have originated from a limited area to the south
of the village of Zaroshchenskoye.

The Russian Federation based its
calculations on an incorrect detonation
point and orientation of the weapon,
resulting in an incorrect missile
trajectory.

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Visiting Address
Anna van Saksenlaan 50
2593 HT The Hague
T +31(0)70 333 70 00
F +31(0)70 333 70 77
Postal Address
PO Box 95404
2509 CK The Hague
safetyboard.nl


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