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DSB 13.10.15: MH17 Passenger information

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The reports issued by the Dutch Safety Board are open to the public.
All reports are available on the Safety Boards website safetyboard.nl.

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MH17 Passenger
information

https://d.radikal.ru/d17/1908/90/de995434eb0a.png

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MH17 Passenger
information

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: ANP/J. Lampen

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Dutch 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 Dutch and English languages. If there is a difference in
interpretation between the Dutch and English versions, the Dutch text will prevail.

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CONTENTS
Abbreviations and terms ........................................................... ...............................6
Consideration.......................................................................................................... 9
Summary ...............................................................................................................12
1 Introduction ...........................................................................................................17
1.1 Background .......................................................................................................... 17
1.2 Objective and investigation question .................................................................. 18
1.3 Investigative approach ......................................................................................... 20
1.4 Scope of the investigation.................................................................................... 20
1.5 Frame of reference ............................................................................................... 21
1.6 Other investigations ............................................................................................. 23
1.7 Reading Guide ..................................................................................................... 23
2 Flight MH17 on 17 July 2014 .................................................................................... 24
2.1 Introduction.......................................................................................................... 24
2.2 Flight MH17 .......................................................................................................... 24
2.3 Releasing the passenger list................................................................................. 25
2.4 Informing the relatives.......................................................................................... 26
3 Passenger information before the crash .......................................................................29
3.1 Introduction.......................................................................................................... 29
3.2 Findings................................................................................................................ 29
3.3 Analysis................................................................................................................. 32
3.4 To summarise ...................................................................................................... 40
4 Passenger information
after the crash ............................................................................................................. 42
4.1 Introduction ......................................................................................................... 42
4.2 Relevant parties and processes............................................................................ 42
4.3 Planning ............................................................................................................... 47
4.4 Scaling-up and initial choices for the approach to the process ........................... 49
4.5 Registration of relatives........................................................................................ 52
4.6 Collection, distribution and verifcation of the passenger information................ 56
4.7 Informing relatives................................................................................................ 64
4.8 Relatives perceptions .......................................................................................... 67
5 Conclusions ..........................................................................................................70
6 Recommendations....................................................................................................75

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Appendix A. Investigation participants................................................ 77
Appendix B. Review ............................................................................ 79
Appendix C. Parties involved..................................................................... 80
C.1 Malaysia Airlines.................................................................................. 80
C.2 Amsterdam Airport Schiphol.............................................................. 80
C.3 Committee of Consultation ................................................................ 81
C.4 Municipality of Haarlemmermeer / Kennemerland Safety Region ........... 81
C.5 Operations Team ............................................................................... 81
C.6 National authorities ............................................................................ 82
C.7 Emergency Centres ........................................................................... 82
C.8 Travel organisations ............................................................................ 82
Appendix D. Frame of reference............................................................ 83
D.1 The Dutch Safety Boards frame of reference..................................... 83
D.2 International civil aviation legislation and regulations........................ 84
D.3 National regulations............................................................................ 88
D.4 Internal guidelines and plans of Malaysia Airlines .............................. 89
D.5 National crisis management legislation and regulations,
guidelines and agreements ................................................................ 90

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ABBREVIATIONS AND TERMS
ANVR                                 General Dutch Association of Travel Companies (Algemene
Nederlandse Vereniging van Reisondernemingen).
API                                    Advance Passenger Information: personal details pertaining to a
passenger that airlines must provide to the authorities of the
destination country at the latters request. API data include
passport details such as the surname, frst name, date of birth,
gender, nationality, passport number, country where the passport           
was issued and its expiry date.
CBP-S                                Schiphol Crisis Response Plan (Crisisbestrijdingsplan Schiphol): an
elaboration of the Regional Crisis Plan for municipalities and
emergency services of the Kennemerland Safety Region related to
Schiphol. Due to the connection between the crisis plan and the
CBP-S, there is a coherent system of planning with regard to the
preparation of the municipality and emergency services for the
response to (foreseeable) crises. The CBP-S is an outline plan for
multi-disciplinary cooperation.
CET                                 Central European Time: time in the time zone in Central Europe
that includes the Netherlands. During summer, CET is 2 hours
ahead of Universal Time Coordinated (UTC).
Committee of                   The Committee of Consultation (Commissie van Overleg) operates
Consultation                      as the action centre at Amsterdam Airport Schiphol during a crisis
                                      at the airport.
DCC                                Departmental Coordination Centre for Crisis Management (Departementaal coördinatiecentrum
                                       crisisbeheersing).
Departure                        Computer registration system used by the airline to process and
Control System                register data for flight handling (including data of the passengers
                                      that boarded the aeroplane).
GRIP                               Coordinated Regional Incident Response Procedure (Gecoördineerde regionale incidentbestrijdingsprocedure):
                                      procedure that defnes the coordination and cooperation between emergency services during an incident. The
                                       procedure distinguishes between
                                       several GRIP phases that depend on the scope of the incident.
Ground handling                A company that is commissioned by the airline to perform all ground
agent                              handling operations at the airport, such as check-in, boarding,
                                         baggage handling and transport to and from the aeroplane.
IATA                                 International Air Transport Association: international association of
                                       airlines.

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ICAO

International Civil Aviation Organization: United Nations organisation
that issues international standards for civil aviation.

ICCb

Interdepartmental Crisis Management Committee (Interdepartementale Commissie Crisisbeheersing): committee within the
national crisis structure in which, under the chairmanship of the
NCTV, interdepartmental crisis decision-making occurs at a senior
offcial level

KMar

Royal Netherlands Marechaussee (Koninklijke Marechaussee):
police organisation with a military status. One of the tasks of the
Royal Netherlands Marechaussee is the performance of police duty
at Amsterdam Airport Schiphol and at other airports designated by
the Minister of Security and Justice and the Minister of Defence, as
well as the security of civil aviation.

LTFO

National Forensic Investigation Team (Landelijk Team Forensische
Opsporing): national team comprising the National Police and
partners with expertise in the felds of forensic investigation and
victim identifcation.

MCCb

Ministerial Crisis Management Committee (Ministeriële Commissie
Crisisbeheersing): committee that can convene as part of the
national crisis structure in situations that require the coordination
of intersectoral crisis management and decision-making related to
the coherent approach of intersectoral crisis management at the
political-governmental level. The committee includes the Prime
Minister, the Minister of Security and Justice and the ministers of
the ministries involved in the crisis

NCC

National Crisis Centre (Nationaal CrisisCentrum): organisation that
forms the basis of the crisis organisation at the national level during
a crisis. The centre is part of the Ministry of Security and Justice
and operates under the authority of the NCTV. During a crisis (or
potential crisis), the crisis centre is the information hub for ministries
as well as for safety regions.

NCTV

National Coordinator for Security and Counterterrorism (Nationaal
Coördinator Terrorismebestrijding en Veiligheid): organisation (part
of the Ministry of Security and Justice) whose main purpose is to
prevent and limit social disruption by protecting vital interests.

Operations
Team

Multidisciplinary (regional) team that consists of representatives
from the fre department, the medical response service for
accidents and disasters, the police and the municipality. This team
is charged with operational management, coordinating with other
parties involved in the disaster or crisis, and advising the municipal
or regional policy team, if present.
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Passenger
information

The personal data of the passengers (in this case, of flight MH17)
and of their relatives.

Passenger
list

A list of the passengers on board an aeroplane drawn up by the
airline operating the flight. This refers to both the list in the
aeroplane and the list that the airline releases after an accident
(possibly in different versions).

Population
Management
Sub-plan

The Population Management Sub-plan (Deelplan Bevolkingszorg) is
a more detailed elaboration of the Kennemerland Regional Crisis
Plan. It describes the organisation, tasks and responsibilities of
municipalities and the measures that they take with regard to
disaster response and crisis management. Appendix C of the
sub-plan concerns population management at Schiphol.

Relative

Any person who feels or actually has a connection (especially a
family connection) with the victim. This includes at least the partner
(including a spouse, registered partner or cohabiting partner) and
frst-degree blood relatives (parents and children) as well as
second-degree blood relatives, i.e brothers and sisters and grandparents.

SGBO

Large-Scale and Special Operations Staff (Staf Grootschalig en
Bijzonder Optreden): action centre of, in this case, the Royal
Netherlands Marechaussee at Schiphol. The staff mainly focuses on
managing the operation in the feld

SIS

Victim information system (Slachtofferinformatiesystematiek): national
system to register victims and relatives information with the main
objective of informing relatives quickly and accurately about the fate
of their loved ones.

UTC

Coordinated Universal Time: universal time based on an atomic
clock and coordinated with the earths rotation. For cross-border
applications (such as aviation) times are often given universally in
UTC. In Central Europe (except for the British Isles and Portugal)
UTC+2 applies in summer. For Malaysia, UTC+8 applies in summer.

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CONSIDERATION
It is important for people who fear that a family member or friend has been involved in
an accident to obtain clarity about the fate of their loved ones as quickly as possible.
However, following the crash of flight MH17 on 17 July 2014, the relatives of Dutch victims
were subjected to uncertainty regarding the fate of their loved ones for an unnecessarily
long time. It took two to four days before they received confrmation from the Dutch
government that their loved ones were on the aeroplane. The Dutch Safety Board
investigated why this took so long.
The Dutch Safety Board appreciates the efforts of all parties that were involved in the
collection, verifcation and distribution of information pertaining to the passengers of
flight MH17 and in informing their loved ones. All those involved did their utmost - in the
areas in which they were involved - to ensure that this process ran as effciently as
possible. Nevertheless, the Board is of the opinion that it could have been handled
better, especially since there was a lack of control and coordination of all the efforts that
the individual parties undertook.
The investigation makes it clear that the passenger list that was available immediately
after the crash of flight MH17 was not suffcient to establish who was on the aeroplane.
To this end, Malaysia Airlines frst had to retrieve additional information about the
passengers, such as their nationality and date of birth, from the underlying registration
systems. Since the related information had not been entered for all the passengers, this
took some time to obtain. According to the Board, this situation could be improved
relatively effortlessly if the airlines were to record the nationalities of all passengers in the
systems that provide passenger information in the event of an aircraft accident.
The fact that it is not possible to establish who is on board an aeroplane at a simple
press of a button is well-known and generally accepted in the aviation sector. It was
therefore surprising to the Dutch Safety Board that the Dutch crisis organisation was
unable to respond in a speedy and adequate manner in this respect. After all, the
bottlenecks that emerged in the collection and verifcation of passenger information
were not new. The investigation that was conducted in relation to the crash of a Turkish
Airlines aeroplane close to Schiphol 1 also revealed that the passenger list that was
available immediately after the crash was neither complete nor reliable. The Board
expects the authorities involved to be aware of this and to be able to quickly verify the
passenger information, add to this information and link it to relatives. This turned out not
to be the case.


1 Dutch Safety Board, Emergency assistance after Turkish Airlines aircraft incident, Haarlemmermeer, 25 February
2009, July 2010.

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The fnding that parties learned little from the past was confrmed by the lack of
preparation for an aircraft accident abroad involving a large number of Dutch victims.
The scenario of such an accident is not unlikely, however. In recent decades, there have
been various aircraft accidents abroad with large numbers of Dutch victims. Examples
include the crash in Faro in 1992 and the crash in Tripoli in 2010. Nevertheless, the Dutch
authorities were not prepared, neither on the national nor on the regional level, for a
disaster such as the crash of flight MH17. The entire process of collecting, distributing
and verifying the information necessary to inform relatives about the fate of their loved
ones had not been thought through. As a result, it was not clear in advance who was in
charge of the overall process pertaining to this disaster. This lack of clarity led to
bottlenecks in the operations.
Several parties collected information about the passengers and their relatives, virtually
unaware of each others activities The parties carried out their work separately, based on
different responsibilities. The Ministry of Foreign Affairs had the consular task of retrieving
data on the victims and informing the relatives through the police. The Ministry set about
its task in the usual manner and limited itself to its usual - mainly internationallyfocused - network. The Ministry had very little idea of the activities being conducted by
parties outside that network, such as the Royal Netherlands Marechaussee, and did not
use the information those parties possessed.
Although various parties noticed that obtaining passenger information was a diffcult
process and that information was being collected by several parties, nobody assumed
responsibility for coordinating the activities. It is the Boards opinion that the National
Coordinator for Security and Counterterrorism (NCTV) should have taken the lead in this
matter. The national crisis structure in the Netherlands provides a crisis centre, the
National Crisis Centre (NCC, which is part of the NCTV). This interdepartmental
coordination centre should act as hub in crisis decision-making. Following the crash of
flight MH17, the NCC did not assume the coordinating role of retrieving information
about the victims and their relatives as quickly as possible.
It is not the frst time that the Dutch Safety Board concludes that the Dutch crisis
organisation has not functioned effectively.2 In its investigation it also observed
bottlenecks that had already been highlighted during the evaluation of the Dutch Safety
Regions Act (Wet veiligheidsregio´s).3 All in all, the Board arrives at the conclusion that
the crisis management structure in the Netherlands is now so complex that it impedes
effective cooperation between all parties involved. In the event of supraregional disasters
and crises, there is a lack of clarity about who actually exercises operational and
administrative control; especially the division of responsibilities between the safety
regions and the central governments crisis structure is a subject for discussion in this
respect.


2 Dutch Safety Board, Emergency assistance after Turkish Airlines aircraft incident, Haarlemmermeer, 25 February
2009, July 2010. Dutch Safety Board, Fire at Chemie-Pack in Moerdijk, 5 January 2011, February 2012.
3 Hoekstra Committee, Evaluatiecommissie Wet veiligheidsregios en het stelsel van rampenbestrijding en crisisbeheersing (Evaluation Committee for the Dutch Safety Regions Act and the system for disaster prevention and
crisis management), September 2013.

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The Dutch Safety Board is aware that, in the wake of a disaster, initially the situation will
always be chaotic. However, it surprised the Board that the Dutch crisis organisation was
unable to respond adequately to this type of situation yet again, especially as this is
exactly the sort of thing that one might expect a crisis organisation to be able to do. In
recent years, efforts have been made to eradicate the bottlenecks that were identifed in
the crisis organisations operations by drafting an increasing number of manuals and
procedures. It is the Boards opinion that this can actually impede the effective
management of crises, not least because the introduction of new tools and terms can in
practical terms lead to a greater lack of clarity and increase confusion about the steering
of crisis management processes. The investigation into passenger information revealed,
for example, that there are different views regarding in which cases the recently
introduced incident response phase GRIP Rijk can be declared effective.
The Board therefore sees no beneft in developing additional manuals, procedures and
other tools to ensure that operations run smoothly. The time has come to critically review
the existing crisis organisation and identify where it can be clarifed and simplifed, so
that it becomes perfectly clear to all involved who is in charge and who is doing what in a
given situation.

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SUMMARY
All 298 passengers of Malaysia Airlines flight MH17 lost their lives when the aeroplane,
which had departed from Amsterdam Schiphol Airport, crashed in the eastern part of
Ukraine. Many of the victims were Dutch. The crash had a huge impact on Dutch society,
while elsewhere sorrow and disbelief about the crash were great as well. This was the
start of a diffcult and uncertain time for the victims families. After hearing the news
about flight MH17 many of them rushed off to Schiphol to get information. Relatives also
contacted organisations that had opened up an information number. This, however, did
not bring an end to their uncertainty. In practice, it took two to four days before the
Dutch authorities confrmed to the relatives of the Dutch victims that their loved ones
were on the flight. The Dutch Safety Board has investigated why it took two to four days
and whether it would be possible to speed up this process in the future. The Dutch
Safety Board is of the opinion that the authorities should be able to inform relatives
within 48 hours, leaving aside exceptional personal circumstances, whether their loved
ones were on the flight.
Based on its investigation, the Board has reached the following conclusion:

The relatives of the Dutch victims of the crash of flight MH17 had to wait for an
unduly long time before they were given clarity regarding the presence of their
loved ones on the aeroplane, because:
the passenger information that was available immediately after the crash offered
an insuffcient foundation to be able to confrm to relatives that their loved ones
were on the aeroplane;
the Dutch crisis organisation was insuffciently prepared for such a situation, and
there was a lack of control and coordination in the execution.
As the Ministry of Security and Justice (in particular the National Coordinator for
Security and Counterterrorism - NCTV) did not take charge of the organisation and
the Ministry of Foreign Affairs cooperated insuffciently with other interested parties,
the information that the various parties gathered regarding the victims and their
relatives was not combined. As a result, it took a long time before the correct
information was available and relatives could be informed.

The investigation has shown that the passenger information that was available after the
crash of flight MH17 was not suffcient to confrm to the relatives that their loved ones
were on the flight. Malaysia Airlines has done what could be expected of an airline based
on the aviation regulations. The airline issued a list of the passengers names, which
afterwards turned out to be almost entirely correct, and handed this list to the Dutch
authorities as soon as possible. Additional information about the passengers, such as

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their nationalities and dates of birth, had to be extracted from secondary registration
systems; as a result, it took some time before the data were available. For 75% of the
passengers, this was possible on the evening of the crash; for the rest of the passengers,
up to two days were required to collect additional information. Not being able to establish
who was on board the flight at the push of a button is not an exceptional situation. This is
a known and generally accepted fact in the aviation sector. The Board therefore expects
that authorities that have a role to play in the process of informing the relatives of the
victims are familiar with this. They should be aware of the fact that they still need to
perform numerous actions after receiving the passenger list from the airline. They need to
verify the passenger information on the list, add to this information and link it to relatives.
However, the investigation into the passenger information pertaining to flight MH17
makes it clear that the authorities were inadequately prepared. Neither the national, nor
the regional crisis management plans included a detailed scenario for an aircraft accident
abroad with a large number of Dutch victims. There was no indication of a coordinating
plan with a clear allocation of roles and responsibilities. Nor was there any coordinating
institute in place, as was previously recommended by the International Civil Aviation
Organization (ICAO).
In cases where there is a lack of preparation, it is all the more important that parties
respond immediately and appropriately to the crisis situation and agree on who does
what and who is in charge. This was not the case. As a result, different parties proceeded
separately, based on different responsibilities, to collect information about victims and
relatives and to draw up lists: Malaysia Airlines, the Royal Netherlands Marechaussee, the
National Forensic Investigation Team (LTFO), the Ministry of Foreign Affairs and the
National Crisis Centre (NCC). It was not always known or clear among these parties who
was doing what, and why. Information was not shared, or only shared on an ad-hoc basis.
The parties didn´t make use of the existing victim information system (SIS), which makes
it possible to collect the available information in one place. The Board is of the opinion
that had such a system been used, the cooperation and information sharing among the
parties and thus the effciency of the overall process would have benefted.
The Board has found that the approach of the Ministry of Foreign Affairs and that of the
NCTV determined the course of the process. The Ministry of Foreign Affairs had the consular
task of retrieving data on the victims and informing the relatives through the police. The
Ministry, however, limited itself to its own procedures and frameworks and to its usual
network, as a result of which it failed to use information already available outside that
network. This approach was not conducive to general cooperation. The Board is of the
opinion that the Ministry, because of its priority task with regard to this crash, should have
taken note of the activities of other parties and should have put these activities to good use.
The NCTV did not assume the role of controlling the overall process, while the situation
that occurred clearly called for this. The national crisis structure in the Netherlands
provides a crisis centre, the NCC, which is part of the NCTV, that should be able to
connect the parties concerned during a crisis in order to ensure that activities are
coordinated. At one point, the NCC was in touch with all parties and was aware that
several of them were compiling lists. Nevertheless, this did not lead to the NCC taking
over the coordination and bringing the relevant parties in contact with each other.

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The lack of coordination and control had an effect on the term within which relatives
were informed about the fate of their loved ones. Both Malaysia Airlines and the Dutch
authorities notifed relatives about whether their loved ones were on the passenger list,
but they did not coordinate the exact moment at which they supplied this information.
As a result, Malaysia Airlines made the passenger list of flight MH17 public before the
family liaison offcers of the Dutch National Police delivered the offcial message to the
families on behalf of the central government. The central government wanted to wait
until a complete, verifed list of victims and relatives was available. This led to a delay.
Many relatives were therefore subject to uncertainty longer than was strictly necessary.
Through different channels they were confronted with news that had not yet been
provided by the authorities. Especially where the use of social media is involved, it is
important to carefully weigh up the time required for the sake of completeness and the
speed at which information spreads through these channels. If the authorities do not wait
until the information about all the victims is complete, but start to inform the relatives as
soon as is established that their loved ones were on the aeroplane, the Board is of the
opinion that it is possible to notify relatives within 48 hours (leaving aside exceptional
personal circumstances).
As soon as the family liaison offcers became the personal contact point for relatives, the
information provision process improved. Relatives perceived the deployment of the
family liaison offcers as very positive, as they offered the assistance and information that
were so badly needed.
Recommendations
The Boards investigation has brought several points to light with regard to improving
and accelerating the process of informing relatives. To this end, the Board fnds the
following matters to be important:
keeping records on nationality;
improving the process of collecting, distributing and verifying passenger information
and improving the provision of information to victims relatives, and
simplifying the Dutch crisis organisation.
Keeping records on nationality
In the Boards opinion, in future the nationalities of the passengers should be available
on the passenger list that is drawn up by the airline. This relatively simple procedure
would make it easier to register victims of aircraft accidents and to trace and inform their
relatives. The Board considers it excessive to require all airlines to, for example, register
the passport numbers of passengers and the details of contact persons at home, as the
benefts - given the small chance of an accident - do not outweigh the extra effort that
this would require. In the opinion of the Board, a passenger list that includes the
nationalities of all passengers and a smoothly functioning crisis organisation, would
provide suffcient guidance after an aircraft accident to retrieve information about victims
and their families more quickly. The Board therefore recommends the following:

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To the Minister of Infrastructure and the Environment:
1. Take initiatives at international level to incorporate the registration of the
nationality of airline passengers in international regulations. In the meantime,
encourage airlines to record the nationality of each passenger travelling to or
from a Dutch airport before departure, in the systems that provide passenger
information in case of an accident.

Improving the process of collecting, distributing and verifying passenger
information and improving the provision of information to relatives.

In the opinion of the Board, the NCTV should have managed the overall process in order
to improve its effciency. The Board feels that a clear management role is required to
ensure that the activities of individual parties are coordinated, and that information is
shared as well as collected and managed in one place. Nonetheless, other parties
involved, such as the Ministry of Foreign Affairs, have a specifc task within that process
and need to contribute, in the context of that task, to the coordination of the process.
Taking that into consideration, the Board makes the following recommendation:

To the Minister of Security and Justice:
2. Establish that in case of accidents (including aircraft accidents) abroad involving
a large number of Dutch victims, the NCTV controls the overall process of
collecting and verifying passenger information. Make sure that it is clear to other
relevant public and private organisations that the NCTV is in charge, including
what this means for the process and for everyones duties, responsibilities and
authorities within that process.

Simplifying the Dutch crisis organisation
One of the aims of the progress letter on the National Security Strategy that was
established in the Council of Ministers on 1 May 2015 is to improve crisis management.
The progress letter states that the need exists for a maximally flexible crisis organisation,
that can act quickly and decisively on both the administrative and the operational level in
all situations. It also states that clear responsibilities and authorities, and having as few
layers as possible, will help speed things up. To this end, the aim is to simplify the crisis
organisation and increase its flexibility. In line with this development, the Dutch Safety
Board is of the opinion that the Dutch crisis organisation, which in the view of the Board
is too complex, should be reviewed to see what it is needed to make it function more
effectively in major crisis situations. People can and should learn intensively from other
crises and assessments thereof. To this end, the Board recommends:

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To the Minister of Security and Justice:
3. Include the lessons learned from this investigation and previous investigations
into the functioning of the Dutch crisis organisation in the announced
improvement, simplifcation and flexibilisation of crisis management. Make sure
that unambiguous control and overruling power form part thereof.

T.H.J. Joustra M. Visser
Chairman, Dutch Safety Board General Secretary

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1 INTRODUCTION
1.1 Background
On Thursday 17 July 2014 at 12.31 CET 4 (10.31 UTC) Malaysia Airlines 5 flight MH17
departed from Amsterdam to Kuala Lumpur. There were 283 passengers and 15 crew
members on board the Boeing 777-200. At approximately 15.20 CET (13.20 UTC), Russian
air traffc control noted that it had lost contact with the aeroplane. It was soon discovered
that the aeroplane had crashed near the Russian border, in the eastern part of Ukraine.
All 298 occupants lost their lives.
Days of uncertainty lay ahead for relatives and friends of the occupants of the aeroplane.
It was important for them to obtain clarifcation about the fate of their loved ones as
quickly as possible. However, not all the information necessary to inform relatives of the
Dutch passengers of flight MH17 regarding the fate of their loved ones was available
right away. The general expectation was that - with todays technology - it should be
possible to retrieve all the information that passengers provide before they board the
aeroplane from the computer systems at a single push of a button. This was not the case.
It took several days before the relatives of the Dutch victims received formal confrmation
from the Dutch authorities. Between Saturday 19 July and Monday 21 July, the Dutch
authorities informed one or more of the relatives of all Dutch victims that their loved ones
had been on the flight.
The observation that passenger information was not immediately available led the Dutch
Safety Board to conduct an investigation into the steps necessary to formally confrm the
presence of passengers on board flight MH17 to their relatives. In deciding whether to
launch an investigation into this matter, the Dutch Safety Board included previous
experience pertaining to the availability of passenger information after the crash of a
Turkish Airlines aeroplane in 2009. The passenger list that was made available to the
authorities shortly after this crash was incomplete. The passenger list included the frst
eight letters of the surnames and - in so far as available - the frst names of the
passengers. The passenger list did not include the date of birth, place of birth or
nationality of the passengers. Moreover, the number of passengers listed on the
passenger list was not correct. Several occupants lost their lives or were wounded in the
crash. Due to the incomplete victim registration the names of the victims, their temporary


4 All times mentioned in this report are given in Central European Time (CET) followed by the Coordinated Universal
Time (UCT) in brackets.
5 Where this report refers to flight MH17, the flight on 17 July 2014 is meant.

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18

location and the nature of their injuries were not clear for some time.6 As a result relatives
were informed about the fate of their loved ones at a late stage.7
1.2 Objective and investigation question
The authorities are responsible for personally informing relatives regarding a death
resulting from an accident or a crime, or a person missing. In the Netherlands this task is
carried out by the police. To be able to provide a formal confrmation, it must be
established with certainty who the victim is and who his or her relatives are. In case of a
crash involving an international flight, the process begins by determining who boarded
the flight and their respective nationalities. The airlines passenger list is the main starting
point for this process. Information about the nationality of the victims makes it possible
to determine which countries have suffered victims.8 The authorities in these countries,
such as the Netherlands, are then responsible for the process of informing the relatives
of victims from their respective countries. The authorities should therefore receive the
information about the nationalities of the victims as soon as possible. If the information
on the passenger list is insuffcient and/or unreliable, authorities will have to gather
additional information about the passengers and verify the information in order to draw
up a fnal list of victims. Relatives should then be linked to the list of victims and their
relationship to the victims verifed.
In the investigation into passenger information pertaining to flight MH17, the following
question is key:

Why did it take two to four days before relatives of Dutch victims of the crash of
flight MH17 received confrmation from the authorities that their loved ones were on
board the flight? Are there measures which could accelerate this process in future?
The investigation question is divided into the following sub-questions:
What passenger information did the airline have available? How can it be
explained that the required information concerning the passengers of flight
MH17 could not be generated immediately by the systems?
What steps were taken between the crash of flight MH17 on 17 July 2014 and the
authorities informing relatives of Dutch passengers? How can it be explained
that this took two to four days?


6 The crash of a Turkish Airlines aeroplane at Schiphol airport resulted in various improvements to the victim
information process, including the development of the victim information system (SIS).
7 Dutch Safety Board, Emergency assistance after Turkish Airlines aircraft incident, Haarlemmermeer, 25 February
2009, July 2010.
8 Complicating factors may include passengers having dual nationality or passengers not living in the country that
issued their passport.

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19

The investigation question refers to formal confrmation by the authorities. Relatives
require certainty and, with this in mind, attach great value to an offcial confrmation by
the authorities, even if it is obvious from other channels that their loved ones were on
board the aeroplane. Relatives expect to receive reliable information and fnal
confrmation from an authority.
Figure 1 shows the process from the moment of the crash of flight MH17 to the moment
when relatives received formal confrmation from the authorities.9 The process consists of
two parts: the part that took place prior to the crash, from booking flight MH17 to
compiling the passenger list for departure (this part answers the frst investigation subquestion and is described in Chapter 3), and a part that took place after the crash, from
providing the passenger list to formally informing the relatives of the passengers (this
part answers the second investigation sub-question and is described in Chapter 4).

https://b.radikal.ru/b06/1908/e9/9d5bad80fb24.png

Figure 1: Diagram illustrating the process from the moment when a flight is booked to the moment when
the Dutch authorities formally inform relatives about the presence of their loved ones on board the
aircraft.

The sole objective of this investigation by the Dutch Safety Board is to draw lessons to
ensure that relatives are informed as soon as possible in future.


9 Victim information provided by emergency services and hospitals is an important source of information pertaining
to the fate of the passengers. Since there were only fatalities and no wounded passengers after the crash of flight
MH17, the information provided by emergency services and hospitals has not been taken into consideration for
this fgure.

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20

Prior to a flight, airlines compile a list of passengers that boarded the aeroplane. In
the event of an aircraft accident or a disaster, this list is the frst source of information
about the passengers. This report uses the term passenger list to refer to the list of
passengers that is compiled by the airline; this refers to the list on board the
aeroplane as well as the list released by the airline following an accident (of which
several different versions may exist).
The details of the passengers and their relatives are referred to in this report as
passenger information.
Regulations do not clearly defne the term relative. In this report, the term relative is
used to refer to any person who has or feels a connection (including a family
connection) with the victim. This includes at least the partner (including the spouse,
registered partner, cohabiting partner) and frst-degree blood relatives (parents and
children) as well as second-degree blood relatives (brothers and sisters and
grandparents).

1.3 Investigative approach
In order to answer the investigation questions documentation was requested from
various relevant parties and interviews were conducted. The Dutch Safety Board used
the information gathered to identify how data provided by passengers prior to the flight
are registered in the systems, which parties have carried out which steps to collect and
verify the information about the passengers of flight MH17 and to inform the relatives,
and when. No fewer than ffty interviews were conducted, both with employees of the
parties involved in the process, as indicated in fgure 1, as well as with relatives of the
Dutch victims. Investigators from the Dutch Safety Board also made working visits to
airlines to obtain practical insight into the registration of passenger data prior to a flight.
1.4 Scope of the investigation
The investigation focuses on the period from the moment when information about
passengers of flight MH17 was registered (that is from the moment when flight MH17 was
booked) up to the moment when the relatives of Dutch victims received confrmation
from the authorities that their loved ones were on board the aeroplane.
The process of identifying the victims is not included in the scope of this investigation.
With regard to collecting passenger information after the crash and informing relatives,
the investigation focuses on the steps taken by Malaysia Airlines and Dutch public and
private parties. The Dutch Safety Board has not investigated how information was
provided to the relatives of the victims in the other countries involved

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The overall performance of the Dutch crisis organisation after the crash of flight MH17
was only examined insofar as this was relevant to the process of informing the relatives of
Dutch victims. A wider investigation into this matter is being conducted by the Dutch
Research and Documentation Centre (Wetenschappelijk Onderzoek en Documentatiecentrum).
1.5 Frame of reference
The Dutch Safety Board assesses the fndings of this investigation into passenger
information pertaining to flight MH17 against a frame of reference. This frame of reference
comprises regulations and guidelines on the one hand, and the Dutch Safety Boards
own frame of reference on the other. The latter pertains to the assessment by the Dutch
Safety Board of what can be expected from the parties involved in addition to legislative
provisions.
Regulations and guidelines
Under the Chicago Convention,10 an airline must carry a list of passenger names in the
aeroplane when transporting passengers.11 Annex 9 (Facilitation) of the Chicago Convention
provides a format for the passenger list.12 This format includes only the passengers
surnames and initials.
Airlines departing from the European Union are obliged under European regulations to
provide the authorities of any involved country with a validated list containing the best
possible information about all passengers on board the aeroplane within two hours of an
aircraft accident being reported.13 There is no further clarifcation of validated or best
possible. Under the guidelines of the International Civil Aviation Organization (ICAO),
the airline is also the frst designated party to inform the relatives of victims and to
provide passenger information to other authorities that have a role in helping victims and
relatives. Furthermore, the airline should also set up a free information telephone number
for relatives.
In its manual 14 ICAO establishes that the need for providing assistance to relatives may
arise in countries with nationals among the victims of an aircraft accident. Since many
institutions and authorities are involved in providing assistance to relatives, ICAO
recommends Member States to appoint a coordinating organisation. This coordinating
organisation (or coordinator) must be involved in developing the plans and, after an
accident, is vitally important to enable institutions to work together and to be able to
provide proper assistance to victims and relatives. The coordinating institute can also act
as a contact for relatives and authorities.


10 Convention on International Civil Aviation, ICAO Doc 7300, usually referred to as the Chicago Convention.
11 Article 29 (f) of the Chicago Convention.
12 Annex 9 (Facilitation) Appendix 2 of the Chicago Convention.
13 Article 20, EU Regulation 996/2010.
14 ICAO Doc 9973, Manual on Assistance to Aircraft Accident Victims and their Families.

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The Boards basic principles
Partly based on the above, the Dutch Safety Board expects airlines to register, as
accurately as possible, which passengers and crew members are on a flight, thus ensuring
that an accurate list of all occupants of the aeroplane will be available as quickly as
possible in the event of an aircraft accident. The Board is of the opinion that the
information provided by an airline following an aircraft accident should provide starting
points to inform relatives about the presence of their loved ones on the aeroplane
quickly. This means that, in addition to their names and initials, the information should
also include at least the nationality of those on board.15 The more complete the list, the
quicker there will be clarity regarding the victims and their relatives.
The Board considers it important that it is not just the airline that informs relatives, but that
relatives also receive a formal confrmation from the authorities about whether or not their
loved ones were actually on board the aeroplane.16 The Dutch authorities are in charge of
informing relatives of Dutch passengers in this regard. The Board expects the Dutch
authorities to be prepared for a scenario in which an aeroplane with many Dutch nationals
on board is involved in a crash abroad and that, in its preparations, consideration has gone
into how all the parties involved should work together in such a situation in order to inform
relatives quickly. In fact, such a scenario is not unthinkable. A large-scale accident occurred
in Tripoli in 2010, for example. Seventy Dutch nationals lost their lives in that crash.
The Board expects the following from parties comprising in the Dutch crisis organisation:
Parties are familiar with the crisis system of which they are part and are aware of their
own and others roles, responsibilities and competences. Also, they have an understanding of the parties that play a role in the process of collecting, distributing and
verifying information about victims and relatives and informing the latter after an
aircraft accident. It should be clear which party is in charge of this process and which
other parties have a role to play.
Parties are able to respond appropriately to crisis situations and do everything
necessary to inform relatives as quickly as possible. To this end, they work together as
effectively as possible and share the available information in order to compile a
complete and verifed passenger list as quickly as possible.
The Board also refers to the Eenheid in verscheidenheid 17 (Unity in Diversity) report on
cooperation between authorities in crisis management. This report states that, in the event
of (supraregional) disasters and crises, there must be no discussion about who is in charge,
who informs whom, who communicates with the public and what the public is told. It
involves joint action by all authorities involved leading to coherent crisis management.
Cooperation between different safety regions, between the central government and the
safety regions, and between ministries is essential to truly act as a single authority.


15 Whether the obligation to register a passengers nationality applies depends on the destination of the passenger.
16 The authorities must issue a formal statement of death to a victims relatives after a victim has been identifed.
Prior to this, the Board believes that it is important that relatives are informed by the authorities whether their
loved ones were actually on board the aircraft as soon as possible.
17 Unity in diversity, Elaboration of the Recommendation by the Administrative Working Group for Supraregional
Cooperation (Eenheid in verscheidenheid, Uitwerking Advies Bestuurlijke Werkgroep Bovenregionale Samenwerking), February 2013 (compiled following, inter alia, the fre at Chemie-Pack in 2011 and the crash of the Turkish
Airlines aeroplane in 2009).

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The Board considers it important that relatives of victims of an aircraft accident or disaster
are informed formally about whether or not their loved ones were actually on board the
aircraft as quickly as possible and no later than after 48 hours (leaving aside exceptional
personal circumstances). The period should be as short as possible so as not to subject
relatives to uncertainty any longer than necessary. On the other hand, authorities must
go through a number of steps in order to provide this certainty. If the names and
nationalities of all the passengers are known within two hours after the accident, the
authorities of the countries involved can focus on the list of victims from their country.
They need to verify and supplement the list and link the victims to relatives. This requires
research and is time-consuming. Registration systems and digital sources, such as the
basic municipal administration, make it possible for the Dutch authorities to link data.
Additionally, some relatives will get in touch of their own accord. Therefore, the Board is
of the opinion that it is feasible that relatives of victims receive formal confrmation from
the Dutch authorities regarding the presence of their loved ones on board the aircraft
within 48 hours (leaving aside exceptional personal circumstances).18
1.6 Other investigations
In addition to this investigation, the Dutch Safety Board investigated the causes of the
crash, the flight route taken by flight MH17 on 17 July 2014 and the decision-making
process related to flight routes over conflict zones in general. All the investigations were
published simultaneously and can be consulted on the Dutch Safety Boards website.
1.7 Reading Guide
Chapter 2 describes the main facts concerning reports about the victims of the crash and
the provision of information to their relatives. Chapter 3 describes the compilation of the
passenger list of flight MH17 and the impact this process had on the availability of
passenger information after the crash. Chapter 4 describes the activities that were
undertaken after the crash to inform the relatives of Dutch victims about the fate of their
loved ones. This chapter outlines the activities of Malaysia Airlines as well as the activities
of public and other private parties in the Netherlands. Chapter 5 presents the conclusions
of the investigation. These conclusions lead to recommendations, which are included in
Chapter 6.


18 Because, from a legal perspective, identifcation must take place before it can be confrmed with certainty that the
person concerned indeed died during the crash, this is a probability that borders on certainty.

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2 FLIGHT MH17 ON 17 JULY 2014
2.1 Introduction
This chapter reconstructs the main events in the days following the crash concerning
reports about the victims and the provision of information to their relatives. The
reconstruction is mainly limited to the facts that society in general and relatives in
particular were privy to. The events taking place ´behind the scenes´ are described and
analysed in Chapters 3 and 4.
2.2 Flight MH17
The afternoon of Thursday, 17 July 2014: Malaysia Airlines flight MH17 was ready for
take-off from Amsterdam Airport Schiphol to Kuala Lumpur International Airport in
Malaysia.

https://b.radikal.ru/b16/1908/43/37bbc1d8c025.png

Figure 2: Malaysia Airlines Boeing 777200 at Schiphol, ready for departure. (Source: ANP/V. Kuypers)
It was a scheduled flight; on board the aeroplane were passengers with various
destinations. For a number of them, Kuala Lumpur was not their fnal destination; they
were to travel on to Thailand, Indonesia or Australia, for example. The flight was
overbooked, which meant that a few passengers were asked to take a later flight. In the
end it was necessary to book eight people on a different flight. With a delay of 13 minutes
as a result of the overbooking and the late arrival of some connecting passengers, the
aeroplane departed at 12.13 CET (10.13 UTC) from gate G3 to the runway for take-off.

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The aeroplane took off at 12.31 CET (10.31 UTC).19 When the aeroplane approached the
border between Ukraine and Russia, it disappeared from the radar at 15.20 CET
(13.20 UTC). This was reported to the Malaysia Airlines headquarters in Kuala Lumpur by
Russian air traffc control shortly after 15.30 CET (13.30 UTC). In the following half an hour
these reports were verifed and confrmed. Around 16.00 CET (14.00 UTC) Malaysia
Airlines headquarters in Kuala Lumpur informed the Malaysia Airlines branch at Schiphol
on the missing of flight MH17.
In the Dutch media the frst news reports appeared shortly after 17.00 CET (15.00 UTC). It
was reported that an aeroplane had crashed close to the border between Ukraine and
Russia. This was probably flight MH17. At approximately 17.30 CET (15.30 UTC) Malaysia
Airlines confrmed in a press release that air traffc control had lost contact with flight
MH17 around two hours earlier.20 According to the initial media reports, there were
295 people on board: 280 passengers and 15 crew members, all of whom had probably
lost their lives.
As more information emerged, the scale of the event became increasingly clear. In the
Netherlands, awareness was growing that many Dutch nationals were among the victims.
Crisis management was initiated and parties began obtaining clarifcation about who was
on the flight so that relatives could be informed accordingly.
2.3 Releasing the passenger list
During the course of Thursday evening (22.30 CET; 20.30 UTC) Malaysia Airlines Regional
Senior Vice President Europe held a press conference along with the CEO of Amsterdam
Airport Schiphol and the Malaysian ambassador in the Netherlands. Malaysia Airlines
announced that there had been 283 passengers and 15 crew members on board the
plane - three people more than the airline had previously announced in a press release.
These were three young children who did not have their own seats and were sitting on
their parents laps. Also, an initial impression of the nationalities of the occupants
emerged. Malaysia Airlines announced that there had been at least 154 Dutch nationals
on board the aeroplane.21 The nationality of 47 passengers had not yet been established
with certainty at that time. The 15 crew members were all Malaysian nationals.
On Friday, the airline provided several updates throughout the day 22 with regard to the
number of victims per country. At the end of the day, the nationality of 294 of the
298 passengers had been established. At that moment, 189 victims were known to have
the Dutch nationality.


19 Dutch Safety Board, Preliminary report: Crash involving Malaysia Airlines Boeing 777200 flight MH17,
September 2014.
20 Malaysia Airlines, Media Statement & Information on Flight MH17. Media Statement 1: MH17 incident,
malaysiaairlines.com/mh17.
21 It was also announced that the other passengers originated from the following countries: 27 from Australia, 23
from Malaysia, 11 from Indonesia, 6 from the United Kingdom, 4 from Germany, 4 from Belgium, 3 from the
Philippines and 1 from Canada. The nationalities of 47 passengers were not yet clear. The three children without
their own seats were not included in the list.
22 Malaysia Airlines, Media Statement & Information on Flight MH17. Media Statement 2 and Media Statement 4,
malaysiaairlines.com/mh17.

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On Saturday 19 July, at 13.30 CET (11.30 UTC) Malaysia Airlines published a fnal
passenger list including all passengers nationalities.23 The Malaysia Airlines list stated
the victim count per country, as displayed in the following table.

Country/nationality

Number of victims

The Netherlands

193

Malaysia

43 (including 15 crew members)

Australia

27

Indonesia

12

United Kingdom

10

Germany

4

Belgium

4

Philippines

3

Canada

1

New Zealand

1

Some passengers turned out to have dual nationality. These dual nationalities concerned
nationalities from Malaysia, the Netherlands, Australia, Belgium, Germany, Indonesia,
Israel, Italy, Philippines, New Zealand, Vietnam, the United Kingdom and the United
States. As a result of the dual nationalities, different lists circulated in the media.24
2.4 Informing the relatives
Relatives reception at Schiphol
Once the frst news reports appeared, relatives gathered at Schiphol; the frst of them
arrived there around 19.00 CET (17.00 UTC). After having heard the news, they needed
information. The crucial question was whether their loved ones were on board when the
aeroplane crashed. The relatives that arrived at Schiphol were received in panorama
restaurant Dakotas. Malaysia Airlines handed out forms by means of which the relatives
could register.
Due to the large influx of relatives, among other reasons, Amsterdam Airport Schiphol
decided, together with Malaysia Airlines, to move this operation to the nearby Steigenberger hotel.25 The Malaysia Airlines Family Support Centre was established in this hotel.


23 Malaysia Airlines, Media Statement & Information on Flight MH17, Media Statement 7, malaysiaairlines.com/
mh17. Well before its publication, namely during the night from 17 to 18 July, an initial passenger list (including
names and seat numbers) appeared on a Philippine website. It is unknown who placed the list on this site. On
Friday 18 July, the list also appeared on the GeenStijl website.
24 The Dutch media reported that there were 196 Dutch victims. The Dutch authorities also assumed there were 196
Dutch victims. The difference between this number and the 193 Dutch victims as stated in the table on this page is
a result of the fact that the nationalities on the Malaysia Airlines list were based on the passports that the
passengers used to check in.
25 Other reasons for moving the reception to the hotel were the protection of the relatives, the uncertain duration
and the impact on the airport processes.

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Here too, Malaysia Airlines handed out registration forms to the relatives. The information
provided to the relatives there was limited in the frst instance to a verbal statement from
a Malaysia Airlines employee (in English, partly translated into Dutch). This statement did
not provide any further information about the victims. After midnight, Malaysia Airlines
employees allowed the relatives present at the hotel to view the passenger list, which
contained names and some of the passengers nationalities. Relatives who had already
left the hotel at that time, where phoned by Malaysia Airlines in the early morning.
Information numbers
Malaysia Airlines opened an international information number for relatives of victims on
the day of the crash, around 20.15 CET (18.15 UTC). This number was communicated
through the media within the hour. Relatives could use the number to contact Malaysia
Airlines headquarters in Kuala Lumpur. The calls were answered in English. As of Friday,
Malaysia Airlines, with KLMs support, also set up a switchboard in the Netherlands, so
that communication from that moment on was also possible in Dutch. On Thursday
17 July, at 21.20 CET (19.20 UTC), the Ministry of Foreign Affairs in the Netherlands
opened an emergency number for relatives.26 Malaysia Airlines presented this number
during that evenings press conference, with the request that relatives use that particular
number. The information numbers of Malaysia Airlines and the Ministry of Foreign Affairs
were frequently called, causing the telephone lines to become blocked, so that callers
had to wait for a long time before they could speak to someone. As a result of the urgent
need for clarifcation, relatives also called other organisations. Many of their questions
remained unanswered until, from Saturday 19 July, there was contact with the family
liaison offcers, who had been deployed by the National Police to inform relatives.
Confrmation to relatives
Early in the morning of Friday 18 July, Malaysia Airlines employees began calling
(possible) relatives from Kuala Lumpur and from Schiphol to inform them as to whether or
not their loved ones were on the passenger list. At that moment Malaysia Airlines only
called people whose contact details they possessed, such as the people who had left
their contact details on the registration form or via Malaysia Airlines information number.
The formal confrmation to the relatives by the Dutch authorities started on Saturday
afternoon, 19 July. Family liaison offcers of the National Police informed the relatives
offcially in person. The family liaison offcers acted as a link between the authorities and
the relatives. The formal confrmation to relatives continued on Sunday 20 July and
Monday 21 July. Since it was not possible to visit the relatives of all the Dutch victims
prior to the relatives meeting organised by the government on the afternoon of Monday
21 July, a number of them received the formal confrmation by telephone. Some relatives
were offcially informed about their loved ones being on board the aeroplane for the frst
time during the relatives meeting.
After the frst acquaintance with the family liaison offcer, the latter continued to act as
the personal contact for the relatives concerned.


26 The Ministry of Foreign Affairs initially used its standard phone number to inform people about the crash. However,
as the phone calls increased markedly, the Ministry opened a different information number later the same evening

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The most important events discussed in this chapter are displayed chronologically in Figure 3.

Thursday
17-7-2014

12:31 MET (10:31 UTC) Malaysia Airlines aeroplane departs from Schiphol.
15:20 MET (13:20 UTC) Flight MH17 disappears from the radar.
17:00 MET (15:00 UTC) First reports of the crash in Dutch media.
17:30 MET (15:30 UTC) Press release by Malaysia Airlines: confirmation that flight MH17 is missing.
19:00 MET (17:00 UTC) Relatives arrive at Schiphol.
20:15 MET (18:15 UTC) Malaysia Airlines opens international information number.
21:20 MET (19:20 UTC) Ministry of Foreign Affairs opens emergency number.
22.30 MET (20.30 UTC) Press conference at Schiphol:
- 283 passengers and 15 crew members;
- first impression of nationalities involved.

Friday
18-7-2014

After midnight             Relatives at Schiphol get access to Malaysia Airlines passenger list.
Early morning                   Malaysia Airlines starts calling relatives from Kuala Lumpur.

Saturday
19-7-2014

13.30 MET (11.30 UTC)       Malaysia Airlines publishes passenger list including nationalities.
Afternoon                                Family liaison officers start informing the relatives of Dutch victims.

Monday
21-7-2014

Afternoon             First meeting for relatives of Dutch victims organised by Dutch government.

Figure 3: Timeline of events that are relevant to the process of formally informing relatives that their loved
ones were on board the aeroplane.

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3 PASSENGER INFORMATION
BEFORE THE CRASH

3.1 Introduction
As mentioned in the previous chapter, Malaysia Airlines published a passenger list
containing the names and nationalities of the persons on board the aeroplane no sooner
than Saturday 19 July. This led to the question why this information was not available
immediately following the crash. Airline passengers are usually asked to present
identifcation, such as a passport, at several moments before boarding the aeroplane.27
One would therefore expect the information provided by passengers prior to the flight
to be known to the airline and to be easily accessible from its systems.
This chapter examines the process of recording passenger information prior to flight
MH17 in relation to the availability of this information following the crash on 17 July 2014.
Section 3.2 describes which passenger information pertaining to flight MH17 was
available and which was not available. Section 3.3 deals with the registration and
processing of passenger information in civil aviation and its impact on the availability of
passenger information in the case of an aircraft accident. The chapter concludes with a
summary.
3.2 Findings
General
Flight MH17 was a daily flight, operated by Malaysia Airlines, from Amsterdam Airport
Schiphol to Kuala Lumpur International Airport. Flight MH17 was a popular flight due to
the transfer options and the favourable departure time from Schiphol. This flight had a
good connection to flights coming in from the United States and arrived in Kuala Lumpur
in the morning. KLM also runs a daily flight between Amsterdam and Kuala Lumpur. A
code share agreement between Malaysia Airlines and KLM applies to both flights.


27 This depends on, among other things, the airline and the destination.


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