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Отчет DSB 13.10.15: MH17 Passenger information

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Code sharing
Code sharing (sharing a flight under different codes)28 is common in civil aviation. It
involves two or more airlines offering seats under their own codes and flight numbers
on a scheduled flight operated by one of these airlines. In other words, an airline can
sell a flight ticket under its own name for a flight that, in practice, is operated by
another airline. The airline with which the tickets are booked is obliged to inform
passengers about the airline that will actually be operating the flight. According to
ICAO rules, the airline that operates the flight is fully responsible for all the
passengers, so also for their safety and for the passenger list in the event of a serious
incident or accident.

According to the code share agreement between Malaysia Airlines and KLM, the airline
operating the flight handles the entire flight. In the case of MH17, this was Malaysia
Airlines. In accordance with this agreement, KLM played no role in handling the flight.
Flight MH17 on 17 July 2014
Flight MH17 on 17 July 2014 was overbooked by ffteen persons. Since several passengers
did not arrive on time, in the end it was only necessary to rebook eight people on a
different flight. When the aeroplane departed, 298 people (4 cockpit crew, 11 cabin crew
and 283 passengers) were on board the aeroplane. 269 of the passengers flew with a
ticket from Malaysia Airlines, 11 with a ticket from KLM, 2 with a ticket from Qantas, and 1
with a ticket from Garuda Indonesia. The passengers with a KLM ticket were travelling on
the basis of the code share agreement with Malaysia Airlines. The passengers who had
booked with Qantas or Garuda Indonesia were travelling by means of a combined flight,
flying part of the journey with these airlines and part of the journey with Malaysia Airlines.
For many passengers, Kuala Lumpur was not the fnal destination. They were to travel
further to, for example, Australia, Thailand or Indonesia.
The flight handling procedure was routine. Passengers could check in for the flight online.
All passengers departing from Schiphol did have to physically pass the check-in counter
manned by the ground handling agent 29 used by Malaysia Airlines. The only passengers
who had their passports scanned 30 prior to the flight where those on their way to
destinations for which registration was compulsory (the so-called API destinations; see
the blue box) and those for whom digital passport data were still lacking at Schiphol.
Some countries have made the registration and supply of additional data on incoming
passengers via Advance Passenger Information (API) mandatory for all airlines.31


28 The two-letter code of the airline concerned, such as MH for Malaysia Airlines and KL for KLM.
29 The ground handling operations at the airport (such as check-in, boarding, baggage handling, and the transport
of passengers and baggage to and from the aeroplane) can be provided by the airline itself or by a so-called
ground handling agent. A handling agent performs the ground handling operations as commissioned by the
airline (or several airlines). Each airline has different requirements for their handling services. Schiphol provides the
hardware necessary for the handling services and the airline provides the software at the airport.
30 The aviation sector refers to this scanning process as swiping.
31 These countries include Australia, Canada, China, India, Japan, Mexico, Russia, Spain (except for passengers from
Schengen countries), Turkey, the United Kingdom and the United States.

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Advance Passenger Information (API)
API is used to improve border control and to combat illegal immigration more
effectively. In this context, airlines must supply specifc information about passengers
to countries that request this information. The amount of API information that must
be supplied varies from one country to another. It basically consists of passport
information (date of birth, nationality and passport number) and sometimes includes
a passenger’s place of residence and domicile. The airline ensures that the required
information is supplied to the authorities via a network connection before a flight
arrives at its fnal destination.

The other passengers were able to board the aeroplane after presenting their passport
and boarding pass. This involved checking that the name in the passport corresponded
with the name on the boarding pass. A section of the boarding pass was torn off in the
process. The ground handling agent entered the data on the torn-off parts of the
boarding passes into the Departure Control System. This is the registration system that
Malaysia Airlines uses for flight handling and in which the required passenger information
is recorded.32
Passenger list
Just before departure, the ground handling agent at Schiphol compiled a passenger list
based on the information present in the Departure Control System. This list was handed
over to the in-flight supervisor 33 and was taken into the aeroplane. At that point, the
completed passenger list of the departing flight was accessible by all local stations of
Malaysia Airlines at Schiphol and other airports, such as the headquarters in Kuala
Lumpur.
The passenger list of flight MH17 on 17 July 2014 listed the passengers’ surname (written
out in full, without spaces between prefxes such as “van” and “de”), frst name and other
given names (at times not in full), gender (not for all passengers), the check-in number
and the seat number. See fgure 4. It also specifed whether the passenger was a child
with its own seat (indicated with a “C”) or a passenger with a child on his/her lap
(indicated with an “I”).


32 For this, see also Section 3.3.2 of this report under (c.) Availability of passenger information.
33 This person is in charge of a group of cabin crew and has a number of administrative tasks on board the aeroplane.

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https://c.radikal.ru/c09/1908/3f/94f6040bb1ac.png

Figure 4: Excerpt from the passenger list (anonymised) of flight MH17 on 17 July 2014. (Source: Malaysia
Airlines)

Свернутый текст

Surname Name Surname
(and any
initials)
Name
(and any
initials)
Check-in
number
Designation
child (‘child’
or ‘infant’)
Designation
child (‘child’
or ‘infant’)
Check-in
number
Seat Seat

After the crash of flight MH17 was reported, this was the frst passenger list that was
handed over to the authorities at Schiphol (see Chapter 4).
3.3 Analysis
3.3.1 Passenger information pertaining to flight MH17

Passenger list
The passenger list compiled by the ground handling agent based on the information
present in the Departure Control System turned out to correspond with the passengers
that were actually on board the aeroplane. This leads to the conclusion that the changes
that were made prior to departure - including changes due to rebooking several
passengers, for example - had been processed in the Departure Control System. The
names corresponded, with the exception of a few clerical errors, with the names of the
passengers who had actually boarded. The name and gender of the children who sat on
one of their parents’ lap were not listed. The information per passenger was limited, but
complied with the provisions of the Chicago Convention.

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nformation about nationalities
The passenger list did not provide any insight into the passengers’ nationalities. Malaysia
Airlines frst had to retrieve this information from the closed Departure Control System
and booking system at its headquarters. In the course of Thursday evening (22.30 CET;
20.30 UTC), Malaysia Airlines could provide the nationality of 236 passengers, but not do
so for 47 of them. The nationality and other passport information, such as the date of
birth and passport number, were only recorded in the airline’s system for passengers who
were travelling to an API country and for passengers who had booked with Malaysia
Airlines directly. Information about contact persons at home was available for travellers
who had booked directly with Malaysia Airlines insofar as the passengers had provided it.
With the aforementioned working method at Schiphol, Malaysia Airlines deviated from
the internal procedure that had been established for all Malaysia Airlines flights. As of
1 October 2008, Malaysia Airlines had made it compulsory to record the nationality of all
passengers in the Departure Control System34 for all flights, including those to countries
that do not require any API information. The reason for this was to expedite the
determination of the nationality of passengers in the event of irregularities with a flight.35
The Malaysia Airlines branch at Schiphol failed to implement this internal procedure for
the flights from Schiphol, including flight MH17. Between the time it was introduced in
2008 and the crash of flight MH17 on 17 July 2014 this was not picked up by any internal
audits or checks.
Following the crash, this internal procedure has been reintroduced by Malaysia Airlines
at Schiphol, which means that, from 19 July 2014, the nationalities of all passengers are
registered and recorded in the Departure Control System. As of 24 July 2014, Malaysia
Airlines has expanded its internal requirements for registering passenger information to
non-API countries even further. As of that date, in addition to the nationality, passport
information (passport number and date of birth) must be recorded at check-in, manually
or by scanning the passport. If this is not done at check-in, it must be done during
boarding. The aeroplane may only leave after it has been checked that the abovementioned passport data of all passengers are recorded.36 The data are recorded in the
Departure Control System.


34 Recorded in Malaysia Airlines’ Ground Operations Manual.
35 Malaysia Airlines’ Airport Service Notice of 18 November 2008.
36 Malaysia Airlines’ Airport Service Notice of 24 July 2014.

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Sub-conclusions
The information on the passenger list of flight MH17 complied with the provisions of
the Chicago Convention. The names of the passengers on the list, with the exception
of a few clerical errors, corresponded with the names of the occupants of the plane.
Three small children without a seat had been recorded on the list, although without
their name or gender.
Information about the passengers’ nationalities was not included in the list, but was
available - in part - in Malaysia Airlines’ Departure Control System. But this only
applied to passengers who were travelling to an API destination and passengers
who had booked with Malaysia Airlines directly. For a part of the passengers, the
Departure Control System also contained passport information in addition to their
nationality. It would have helped if Malaysia Airlines had followed its own registration
procedure of 2008 at Schiphol, even though there was no international obligation to
do so. If this had been the case, the nationality of all passengers of flight MH17
would have been recorded and available in the Departure Control System.

3.3.2 Registration of passenger information prior to a flight
The fact that relevant information about the passengers after the crash was not available
at the push of a button can be explained by the manner in which the registration of
passenger information is organised in civil aviation. This section deals with:
a. the registration process - from booking to departure;
b. the type of information being recorded;
c. the consequences of both (a and b) for the availability of passenger information
following an aircraft accident.
This section describes the usual departure process as applicable in the aviation sector
for flights outside the Schengen Area.37
a. Passenger information from booking to departure
There are various steps involved in the process of obtaining passenger information from
booking a flight to compiling a passenger list when a flight departs. Figure 5 illustrates
how the passenger information passes through these steps.


37 The Schengen Area consists of 26 countries, including 22 EU Member States, Norway, Iceland, Switzerland and
Liechtenstein. These countries have signed the Schengen Convention to allow the free movement of persons
within the European Union.

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https://d.radikal.ru/d30/1908/29/6e7107ad908f.png

Booking a flight
Passengers can book their flight with various travel organisations such as tour operators38
or travel agencies, or directly with an airline. Tour operators and travel agencies each
have their own booking system, from which they partly export passenger information to
the relevant airline’s reservation system. This is done manually or - if there is a network
connection between the reservation systems - digitally. If a passenger books directly
online or with the airline itself, the information is automatically transferred to the booking


38 A tour operator is a company that compiles package holidays consisting of transport, accommodation and related
services. A travel agency acts as an intermediary between suppliers and customers of travel-related services such
as flight tickets, hotel accommodations and activities. In many cases, these services can be booked separately or
as a complete package

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system. This could be a central reservation system or a global distribution system.39
These systems combine the demand for and supply of flights. The systems are supplied
with flight data, such as availability of seats, prices and reservations, as well as with new
reservations with the corresponding passenger information.
As soon as a combination of a booking and a flight is made, the airline reservation system
creates a so-called passenger name record, linking the personal information to the flight
data. Based on this information, the airline can issue an e-ticket for the flight.
Check in
Approximately 48 hours before the flight’s departure, the passenger information is
transferred from the airline’s reservation system to the Departure Control System. This
only involves the information necessary for handling the flight. This information is
accessible to the airline and/or its ground handling agent at the beginning of the check-in
procedure.
Passengers can check in online or at the airport (at Schiphol this is done at the selfservice kiosk or at the check-in desk). When checking in at the desk, passenger
information in the Departure Control System is verifed by means of the passport. It
depends on the fnal destination and on the airline whether or not passport information
is recorded.

https://c.radikal.ru/c31/1908/df/9d84a2b476e6.png

Figure 6: Malaysia Airlines check­in desk at Schiphol Airport. (Source: ANP/E. Elzinga)


39 In the aviation sector, the term ‘central reservation system’ is used for the reservation system of one airline and
‘the term global distribution system’ for the collective reservation system of a large number of airlines.

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Border control
After checking in at Schiphol, the passenger passes through the Royal Netherlands
Marechaussee’s border control post. At this control post - if the passenger travels to a
country outside the Schengen Area - passports are checked and possibly the boarding
pass as well. The process involves a visual check; the information is not scanned and/or
structurally recorded. The Royal Netherlands Marechaussee’s border control post is
separate from the checks performed by the airline. The border control is done to combat
illegal immigration and to effectively fght organised crime.
Boarding
At Schiphol, passengers and their hand luggage are checked for security reasons. After
this security check, there is a fnal check based on the passport and boarding pass before
the passenger may board the aeroplane. The airline records in the Departure Control
System who actually board the aeroplane. The boarding information in the Departure
Control System forms the basis of the passenger list for the flight concerned.
It is fairly standard for flights such as those from Schiphol to Kuala Lumpur to be overbooked because experience has taught that there will be a number of no-shows due to
illness or delays, for example. Occasionally, passengers are even booked on a different
flight after boarding, so they have to disembark the aeroplane. To ensure that the
boarding information corresponds with the people that are actually in the aeroplane, all
changes must be processed in the Departure Control System before the flight takes off.
This also applies to transfers40 that occur at the last minute.
Flight departure
After the boarding procedure is completed, the airline or the ground handling agent
compiles a passenger list and a list of crew members, and ensures that this list
accompanies the aeroplane in paper form or on a USB flash drive. For the airline, the
passenger list in the aeroplane mainly has an operational function, such as to enable
good service provision during the flight. After completing the boarding procedure, the
passenger list is usually also immediately available electronically to the airline at the place
of destination and at its headquarters. If certain countries impose additional requirements
related to the provision of passenger information, this information is also sent to the
authorities of the destination country.

Sub-conclusion
Passenger information is recorded during booking, reserving and handling of the
flight, ending up in various registration systems used for this purpose. The airline’s
Departure Control System contains the most recent information about the
passengers that boarded the flight and is the basis for the passenger list on board
the aeroplane.


40 With a transfer, a passenger changes from one aeroplane to another aeroplane

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b. Type of passenger information
Personal data
Airline passengers must possess a valid travel document, such as a passport or other
proof of identity. Travellers are obliged to provide their passport information when
booking the flight and/or when checking in, if it is requested by the airline. Some travel
organisations and airlines ask all travellers for their passport information, nationality and/
or date of birth, regardless of whether there is an obligation to do so. Most airlines do
not do this, because of the additional time and costs associated with processing the
additional information.
Relatives’ details (contact persons at home)
Travel organisations largely determine themselves which personal data they request and
record in addition to the aforementioned compulsory information; no specifc related
requirements exist.
As a rule, travel organisations offer the possibility, as revealed by the investigation, to
provide details of contact persons at home so that they can be informed in case of an
emergency. European aviation regulations41 specify that airlines must offer travellers the
opportunity to provide contact details of a relative. Travellers are not obliged to provide
details of contact persons at home. If they do, the airline may only use this information in
the event of an accident or disaster; the information may not be passed on to third
parties or used for commercial purposes.
Reliability of information
Until a passenger checks in, the passenger information that is requested, recorded and
shared is not checked. This means that travellers - either consciously or not - can provide
incorrect information and can choose to omit non-compulsory information. A frst check
of part of the information is done during check-in and/or during boarding. In the meantime,
some details may have changed. A proof of identity may have expired, for example, which
means that a passenger is travelling with an identity document other than the one used to
book the flight. Lastly, contamination may occur because information is not transferred
properly from one system to the other or because errors are made during registration.


41 Article 20, paragraph 3, EU Regulation 996/2010.

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Sub-conclusions
There is no uniformity in the information that is recorded per passenger. Airlines are
not obliged to register passport information of every passenger on board the
aeroplane Only for passengers that travel to an API country airlines must comply
with the information requirements imposed by the country in question.
Passenger data are not verifed until check-in. Subsequently, a limited amount of the
information is verifed. As there is hardly any verifcation of the information, the
reliability of passenger information cannot be guaranteed.

c. Availability of passenger information
Filtering information
During the process from booking to departure, the registered passenger information is
transferred from one registration system to another and ends up in the Departure Control
System. The Departure Control System is the most up-to-date source of information
about the passengers on board the aeroplane. This information is immediately available
to the airline and can be retrieved from the system more or less at the push of a button.
Not all passenger information ends up in the Departure Control System. For the purpose
of effciency and commercial interests,42 only the information needed for handling the
flight is transferred. The consequence of this fltering is that various data remain in the
various systems. Especially during the booking phase, a lot of practical information is
recorded that in the case of an accident is useful to establish who were on the flight and
who their relatives are. This information may concern address and contact details of
passengers, for instance, or details of contact persons at home that can be contacted in
case of an emergency.
Information in the Departure Control System
The Departure Control System supports flight handling at the airport and only contains
the data needed to do so. These are functional details about the passengers (name,
business/economy class, meal preferences, children without their own seat et cetera.) as
well as API data (such as nationality, passport number and date of birth). Although API
data are used mainly for security purposes (improved border control and combating
illegal immigration), it offers leads for verifying passengers’ identity details.
As long as countries demand different information and airlines restrict themselves mostly to
recording obligatory information, personal data in the Departure Control System will vary
per passenger. If passengers travel within the Schengen Area, there is no legal obligation to
verify proof of identity for a flight and therefore also no obligation to record the relevant
information. In this case, whether the information is registered or not depends on the airline.


42 Personal data have commercial value, for example for making tailored offers to the person concerned.

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The fact that airlines can record more information than is strictly necessary is
demonstrated by the initiatives of Malaysia Airlines to record passport details (nationality,
passport number and date of birth) for all passengers. Clarity with regard to the
nationalities involved is one of the frst points on the agenda following an accident. The
authorities must be informed if any of their nationals are involved in the accident.
Furthermore, identity-related information, such as a passport number or date of birth, is
valuable for compiling a victim profle. Rapid availability of contact details of persons at
home assists the process of locating relatives.
Accessibility
In order to retrieve the information that is not recorded in the Departure Control System,
but in other systems (such as those of travel agencies), several actions will be needed.
Airlines have no access to the booking systems of travel organisations. Moreover, there is
no guarantee that the information required is available in the relevant systems,
because - as mentioned in the previous section - there are no obligations with regard to
the booking information that has to be recorded. The information entered in the system
depends on the travel organisation/airline (with respect to what it requests) and the
passenger (with respect to what information he/she provides when booking). Conversely,
travel organisations do not have access to the airline’s Departure Control System. This
also applies to the code share airline that is not involved in handling the flight (in this
case, KLM). Code share partners and travel organisations can only consult the booking
information. Therefore they do not know if the persons that booked the flight through
their services actually boarded the aeroplane. This information is only known to the
airline that operates the flight and/or its handling agent.

Sub-conclusions
Only the information needed for handling the flight ends up in the airline’s Departure
Control System. As a result, other information, which could be important following
an aircraft accident, is ‘left behind’ in various registration systems. Not all of these
systems are accessible to the airline, which means that the information recorded in
these systems is not available at the push of a button. As long as countries demand
different information and airlines restrict themselves to record no more than
obligatory information, the personal data available will vary per passenger.

3.4 To summarise
Malaysia Airlines compiled a passenger list that complied with the guidelines that apply
to the aviation sector. This passenger list contained information about the passengers’
names and gender. More information was needed to determine with certainty who was
actually on board the aeroplane.43 This information could not be retrieved from the
systems immediately because of the organisation of passenger information on the one


43 Information about the nationality, date of birth and passport number.

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hand, and the lack of an obligation to record this information for all passengers on the
other. Not all of the recorded information ended up in the Departure Control System, the
computer system used for handling the flight. Some of the information was left behind in
the booking and reservation systems of other parties and consequently was not
immediately available to Malaysia Airlines. Malaysia Airlines was however capable of
supplying the records of the nationality of all persons on board within two days.
In conclusion, it can be stated that the expectation that passenger information will be
available at the push of a button following an aircraft accident does not ft in with reality.
A passenger list can always be provided, but the information on such a list provides an
insuffcient basis for contacting relatives and giving them an immediate, defnite answer
as to whether or not their loved ones were on the flight. As a result, the authorities
involved will always need to gather and verify further information before they are able to
notify relatives.

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4 PASSENGER INFORMATION
AFTER THE CRASH

4.1 Introduction
It is extremely important for relatives and other persons close to victims to receive a
defnite answer about the fate of their loved ones as quickly as possible following an
aircraft accident. Fast and reliable information provision related to the question of who
were on board the aircraft and their condition is therefore crucial. The passenger list
provided by the airline shortly after an aircraft accident forms the starting point; it is a list
with the passenger information available at that time, as described in the previous
chapter. The quality and composition of the passenger list varies from one airline to the
other, as well as per flight (regional, intercontinental). It is clear that the passenger list
does not contain the information that the authorities need in order to confrm to the
relatives of victims that their loved ones were on the flight. To do so, the available
information about victims and their relatives must frst be gathered, linked and verifed.44
This chapter begins with an overview of the relevant parties and processes in Section 4.2.
The following sections describe how the information process unfolded in practice after
the crash of flight MH17. It examines the planning in the preparatory phase (Section 4.3)
as well as the implementation in the acute phase: scaling up (Section 4.4), registering
relatives (Section 4.5), collecting, distributing and verifying passenger information
(Section 4.6) and informing the relatives (Section 4.7). Section 4.8 describes the relatives’
perceptions.
4.2 Relevant parties and processes
When an aircraft accident occurs, several parties may be assigned a role in collecting,
distributing and verifying passenger information, depending on the situation. The same
parties are not involved and/or do not play a primary role in all cases. When an aeroplane
crashes in the Netherlands, the safety region involved plays a prominent role in the
process of registering victims and relatives and in informing the latter. When Dutch
nationals are involved in an aircraft accident abroad, it is up to the Ministry of Foreign
Affairs to get an overview of the victims and to make sure that their relatives are
informed.45 If an aircraft crashes on route to or from a Dutch airport, the public and
private organisations in and around the airport, for various reasons, also have a
responsibility related to collecting, distributing and verifying information regarding
victims and relatives and informing the latter.


44 The information is only fully validated and reliable after identifcation of the victim.
45 As a rule, in the Netherlands the task of informing relatives is carried out by the police.

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In the case of the crash of flight MH17, namely the crash of a Malaysian aeroplane abroad,
which departed from Schiphol with many Dutch nationals among the victims, the parties
cited below played the following role in the information process.
Airport parties at Schiphol
First and foremost, the airport parties at Schiphol include the airline involved, in this case
Malaysia Airlines. The airline is obliged to hand over a passenger list to the authorities
within two hours. The planning46 is organised in such a way that during a crisis at the
airport involving a flight on route to or from Schiphol, the passenger list is requested by
the Committee of Consultation,47 which is the action centre at Amsterdam Airport
Schiphol during a crisis at the airport. The Committee of Consultation subsequently
provides the list to the mayor of the Municipality of Haarlemmermeer.48 An offcial from
the airline can be invited to participate in the committee.
Local and regional parties
If an accident occurs involving an aircraft on route to or from Schiphol, the mayor of the
Municipality of Haarlemmermeer plays a role if there is a breach or imminent breach of
public order and safety in the municipality resulting from that accident. This may involve
activities to deal with the influx of relatives and other people interested to the airport,
such as organising reception for relatives.49 During the acute phase, the mayor of the
municipality or chair of the safety region bears responsibility for gaining an overview of
the victims and for informing their relatives if the accident has taken place in his/her
municipality or safety region. If the aircraft was on route from or to Schiphol, the mayor
of the Municipality of Haarlemmermeer plays a supporting role in informing relatives that
gather at Schiphol.50 The Operations Team51 in the region is charged with the operational
management of the incident and coordination with other relevant parties.
Royal Netherlands Marechaussee
The Royal Netherlands Marechaussee is responsible for executing police duties at airports.
In light of this role, the Royal Netherlands Marechaussee - under the authority of the Public
Prosecutor - has the independent task of collecting information in the context of a criminal
investigation. To this end, it is necessary to obtain and complete the passenger list.
The Royal Netherlands Marechaussee is also represented in the crisis organisation at
Schiphol. Due to its police duties at Schiphol, the Royal Netherlands Marechaussee is
involved in various activities following an aircraft accident, such as registering relatives
that arrive at the airport or securing the location where relatives are gathering. To compile
the list of victims and relatives, the region can call on the Royal Netherlands Marechaussee
for assistance, as this organisation has access to sources (information systems) and
possesses skills suitable for investigative work. Therefore, the Royal Netherlands
Marechaussee can use its knowledge and expertise to beneft the crisis organisation.


46 See the Schiphol Crisis Response Plan and the Population Management Sub-plan of the Kennemerland Regional
Crisis Plan.
47 See Appendix C for an explanation.
48 See Appendix C for an explanation.
49 See Appendix D for an explanation.
50 The latter also applies to accidents that occur outside the Kennemerland Safety Region.
51 See Appendix C for an explanation.

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National Police / National Forensic Investigation Team (LTFO) / Family liaison offcers
The responsibilities of the National Police include enforcing public order and detecting
criminal offences. Additionally, the police provides assistance in emergency situations
such as disasters. The police tasks performed by the Royal Netherlands Marechaussee
within the scope of the Schiphol Crisis Response Plan, are handled outside that scope (in
the Netherlands) by the National Police. The National Police also uses its knowledge and
expertise to beneft the crisis organisation.
The LTFO is a national team of specialists in the feld of forensic investigations and victim
identifcation at large and complex crime scenes.52 The team is deployed in the event of
disasters in the Netherlands, such as the Bijlmer disaster and the freworks disaster in
Enschede. The team can also be deployed abroad, as has been the case for the crash of
flight MH17 in Ukraine. The LTFO is only deployed abroad by order of the Minister of
Security and Justice at the request of the Minister of the Interior and Kingdom Relations.
The family liaison offcers of the National Police are called in for assistance in the event of
major disasters. They inform relatives about the fate of their loved ones. From the time
they inform family members, they act as the relatives’ contact with the authorities.
Victims’ and relatives’ data are necessary for identifying victims. To this end, the LTFO
creates so-called ante mortem fles. Family liaison offcers are also charged with collecting
additional information for these fles. The LTFO coordinates the deployment of the family
liaison offcers.
Ministry of Foreign Affairs
Each ministry takes measures to deal with disasters and crises in their own policy areas.
To do so, each ministry has a departmental coordination centre (DCC). When Dutch
nationals are possibly affected by a disaster, accident or crisis abroad, the Ministry of
Foreign Affairs is the ministry responsible for handling the resulting consular activities. In
addition to international coordination, for example with embassies, a priority task of the
Ministry of Foreign Affairs is to establish the details of victims and missing persons and
inform relatives accordingly. The Ministry of Foreign Affairs has its own crisis telephone
team, which in the event of major disasters can be deployed to provide and record
information. This means that, in the event of a civil aviation accident involving Dutch
victims abroad, the subsequent actions aimed at registering details of the victims and
their relatives fall under the formal responsibility of the Ministry of Foreign Affairs.
The Ministry of Security and Justice and the National Coordinator for Security and
Counterterrorism (NCTV)
The Minister of Security and Justice is the coordinating minister with regard to crisis
management. He is responsible for the organisation, the operations, coherence and
integral approach to the crisis management policy and related system. The NCTV fulfls
this task 53 in the so-called ‘cold’ phase (in preparation for a crisis) as well as the ‘warm’


52 The LTFO is a team of police and other partners, such as Defence, university hospitals and forensic dentists. The
LTFO has two main tasks: 1. forensic investigation, focused on the possible perpetrator (or perpetrators) and
establishing the circumstances surrounding the incident, and 2. recovery and identifcation of the victims.
53 NCTV, National Manual on Decision-making in Crisis Situations (Nationaal Handboek Crisisbesluitvorming), April
2013, and nctv.nl.

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phase (during a national crisis or serious threats).54 Coordination in the absence of a crisis
involves protecting the interests and increasing the resilience of society. To this end, the
NCTV, among other things, performs activities that focus on promoting the identifcation
and analysis of threats and risks related to national security. The NCTV fulfls a role in
chains and networks that alternates between facilitating, guiding or steering, with the
purpose of enhancing the effectiveness of the actors involved.
During a crisis, the NCTV, in association with the relevant ministries and safety regions,
assumes the role of crisis manager and coordinates the crisis communication.55
The national crisis structure56 can be activated when several ministries are involved in
dealing with the crisis. This structure can consist of three crisis teams: the Advisory Team,
the Interdepartmental Crisis Management Committee (ICCb), with the NCTV as its chair,
and the Ministerial Crisis Management Committee (MCCb), with the Minister of Security
and Justice or the Prime Minister as its chair. In the case of flight MH17, only the ICCb
and the MCCb were activated. The ICCb is activated by one or more of the permanent
members or at the request of a ministry’s Secretary-General, Director-General or
Inspector-General. The ICCb’s tasks include exchanging information and identifying
information gaps, gaining an overview of the situation and making an assessment of it
and taking measures related to preparation, response and follow-up. The ICCb also
advises the MCCb per situation regarding the convening of the committee, the
preparation, response and follow-up of intersectoral crises and decision-making on the
measures’ coherence. Decision-making at the political-governmental level is the
responsibility of the MCCb.57 This committee will not assume any powers from a minister.
The ministers concerned will exercise their authority in accordance with the commission’s
decisions. The chair of the ICCb (the NCTV) as well as an offcial representative at the
level of the Director-General or Secretary-General from the ministry most closely involved
participate in the MCCb as permanent advisors.
The MCCb can declare GRIP Rijk effective (see blue box). The chair of the MCCb informs
the competent authority via the National Crisis Centre about declaring GRIP Rijk effective
and about the related consequences.


54 Organisation regulation of the Ministry of Security and Justice 2011.
55 NCTV, Annual Plan 2014, January 2014.
56 See Appendix D for an explanation.
57 The MCCb decides on a coherent approach to the whole range of measures and facilities provided by central
government working together with other organisations in preparation for, during and as a follow-up to intersectoral
crises in which national security is at risk.

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Scaling-up and GRIP system
In the event of a major incident, support workers from the different support services
(fre department, police, medical care and population management) have to quickly
adapt in the context of their daily activities and together provide the (multidisciplinary)
incident response. Fast decision-making and intensive cooperation are important in
this respect. It requires the crisis management to be coordinated. This is why a
coordinated regional incident response procedure (GRIP) has been established and
a corresponding system has been developed. In the GRIP system, various scaling-up
levels are distinguished. In each phase, the crisis organisation is expanded and
organisational units and offcials are assigned specifc tasks, competences and
responsibilities.
Until recently, the Netherlands used GRIP 1 to 4. These GRIP phases relate to the
organisation of the disaster response and crisis management by the safety region’s
support services. Following several accidents at the beginning of 2013, two
additional phases were added to the GRIP system that apply to supraregional
incidents: GRIP 5 for supraregional incidents and GRIP Rijk for national incidents.
GRIP Rijk involves the central government applying its legally assigned powers to
certain aspects of the crisis strategy. GRIP Rijk is not a scaling-up level and can be
declared effective at any GRIP phase, such as GRIP 2. This application of legal
powers may intervene with the powers of, for example, local authorities. Therefore,
it is important that the central government informs the other competent authorities
accordingly. The MCCb can declare GRIP Rijk effective if a crisis involves several
ministries and the vital interests of the State or society are threatened in such a way
that there is (potential) social disruption. The MCCb convening does not necessarily
mean that GRIP Rijk is declared effective.

The National Crisis Centre (NCC)
In the event of a crisis, the NCC plays an important role. The NCC is part of the Ministry
of Security and Justice and falls under the authority of the NCTV. The NCC acts as the
interdepartmental coordination centre and hub for administrative information provision
and crisis communication. The NCC is the support staff and facilitates interdepartmental
crisis decision-making (and the relevant preparation for it) at the civil-service as well as
the political-governmental level in the event of a crisis.58 With regard to the preparation
for interdepartmental decision-making, several key areas of concern can be distinguished,
including:
• Information: The assembling (monitoring, collecting and initial assessment) of factual
information including subject-related information. What is actually happening?
• Measures: What does the factual information mean and what measures are or need to
be taken and by whom? This involves a combination of administrative and operational
measures.59


58 In the ICCb and MCCb.
59 NCTV, National Manual on Decision­making in Crisis Situations (Nationaal Handboek Crisisbesluitvorming), April 2013

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The NCC is also responsible for informing mayors of municipalities of which residents
have perished, in this case as a result of the crash of flight MH17.
Private parties
In addition to the different authorities and the airport parties, other parties may also be
involved in the process of collecting, distributing and verifying passenger information
and informing relatives. Firstly, this concerns the coordinating emergency centre. The
Netherlands has four major emergency centres. Every year, one of them assumes the
coordinating role in the event of major calamities and disasters abroad.60 Eurocross was
the emergency centre on duty when the MH17 crash occurred.
Travel organisations also play a role, such as in this case travel organisations with whom
passengers had booked a ticket for flight MH17 and the General Dutch Association of
Travel Companies (ANVR).
4.3 Planning
4.3.1 Findings

The investigated legislation, regulations and plans based thereon, as well as the various
interviews conducted by the Dutch Safety Board, give the impression that the authorities
have failed to develop a scenario for aircraft accidents abroad involving a large number
of Dutch nationals. There is no overarching plan for collecting, distributing and verifying
information about victims and relatives and for informing the latter.
With regard to the plans, procedures and manuals that were drawn up, such as the draft
National Emergency Plan for civil aviation accidents (concept Nationaal Noodplan voor
burgerluchtvaartongevallen) by the Ministry of Infrastructure and the Environment,61 the
Embassy procedure for incidents at Schiphol (Ambassade procedure in geval van een
incident op Schiphol) (2010) and the Guide for Crisis Management at Airports
(Handreiking crisisbeheersing op luchthavens) by the Dutch Institute for Physical Safety
(2011), the Dutch Safety Board established that they:
• do not include any scenario for an aircraft accident involving a large number of Dutch
victims abroad, and/or
• are still partly in the draft phase (and therefore not in force), and/or
• do not focus on the process of collecting, distributing and verifying information about
victims and relatives with the aim of informing the latter about the fate of their loved
ones.
The draft protocol for releasing names of victims abroad (conceptprotocol Vrijgeven
namen slachtoffers in buitenland) drawn up by the NCC (2012) does apply to a disaster or
major incident abroad involving Dutch residents. This document was compiled in
preparation for the NCC’s task of informing mayors as quickly as possible as to which of


60 In the event that eight or more Dutch nationals are involved.
61 See Appendix D for an explanation.

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their residents are involved. The draft protocol provides an overview of tasks and
responsibilities of the various parties that play a role in such a case, but it does not focus
on an aircraft accident. Several relevant parties that can play a role in and around the
airport are not specifed in the document, such as the safety region, the Committee of
Consultation and the Royal Netherlands Marechaussee.
The national risk assessment and regional risk profles of the safety regions with major
airports62 do not include a scenario for an aircraft accident abroad involving a large
number of Dutch nationals either. The Dutch Safety Regions Act makes it compulsory for
airports to have a disaster response plan in place. In the Kennemerland Safety Region,
this plan is part of the Schiphol Crisis Response Plan. The Kennemerland Safety Region
has included a scenario for aircraft accidents outside Kennemerland in this plan.63
According tot the plan this scenario can be used for aircraft accidents outside the
Netherlands,64 however, its elaboration focuses exclusively on Dutch safety regions as
source areas.65 The plans of these (and other) safety regions cited above do not appear
to make any connection between the activities in the region and those of national
authorities with regard to obtaining and sharing passenger information and the process
of registering and informing relatives.
4.3.2 Analysis
The Dutch authorities were not prepared on either a national or regional level for a
scenario involving an aircraft accident abroad involving a large number of Dutch victims.
More specifcally, it appears that 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 in advance for this scenario. This is remarkable because,
to a large extent, the same steps must be followed for every accident involving a
passenger aeroplane before relatives can be informed about the fate of their loved ones.
The possibilities and limitations of airline systems that contain passenger information do
not vary per scenario. Moreover, it is striking because accidents involving a large number
of Dutch victims have happened before, as with the crash of an aeroplane in Tripoli.
Although the relatives of the Dutch victims of the accident were informed relatively
quickly,66 the crash in Tripoli led to the NCC developing the draft protocol for releasing
names of victims abroad. However, to date, this protocol has still not been adopted.
Moreover, the protocol in its current form would not have led to the coordination of the
overall process, given that it does not provide a comprehensive approach in this respect.


62 Kennemerland (Schiphol), Rotterdam-Rijnmond (Rotterdam-The Hague Airport), Brabant Zuid-Oost (Eindhoven),
Drenthe (Eelde) and Zuid-Limburg (Maastricht).
63 If such a scenario does unfold, it could have an impact on the airport, or processes at the airport, in the region in
which the airport is located. This is for example due to the presence of people dropping off or collecting others,
the need to provide information, psychological after-care et cetera. The disaster response plans of several other
airports include a similar scenario.
64 The plan states that the scenario, which was included following incidents such as the aeroplane crash in Tripoli and
the ash cloud in Iceland, is to be used in the event of an aircraft accident abroad (outside of the Netherlands)
involving an aircraft that is heading for or that departed from Schiphol. In its elaboration, the scenario includes a
sentence meaning that the ‘safety region source area’ may also be read as ‘foreign power’.
65 The Kennemerland Safety Region recognised this and indicated that it will integrate the lessons learned from the
crash of flight MH17 in the crisis organisation. Among other things, this concerns further specifying the preparations
for aircraft incidents abroad.
66 Relatives could be informed more quickly because, apart from nine people, all the Dutch victims had booked their
trip with two travel organisations.

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Each party with a responsibility that affects this process prepared, individually or in
coordination with other parties, for its own task. There was no overarching preparation
with a clear distribution of tasks and responsibilities. As a result it was not clear how
parties would relate to each other, who would coordinate the process and who bore
ultimate responsibility for compiling a verifed list of victims and relatives.

Sub-conclusion
In planning no scenario was considered for an accident abroad involving an
aeroplane departing from or heading to the Netherlands with a large number of
Dutch nationals on board. There was no overarching preparation with a clear
distribution of tasks and responsibilities, which meant that it was unclear which party
bore ultimate responsibility for compiling a verifed list of victims and relatives.

4.4 Scaling-up and initial choices for the approach to the process
4.4.1 Findings

Various organisations in and around Schiphol and at the national level began scaling up
their own crisis organisation once the frst media reports appeared and it was confrmed
that a Malaysia Airlines aeroplane originating from Schiphol had crashed:
• The Airport Manager of Amsterdam Airport Schiphol decided to convene the internal
crisis team; the Committee of Consultation. One of the frst action points of this
committee was to obtain the passenger list. Members of the Committee of
Consultation soon realised - given the experience with this flight on other days - that
it involved a flight that most probably had many Dutch nationals on board.
• The Royal Netherlands Marechaussee at Schiphol scaled up its own crisis organisation
and convened its Large-scale and Special Operations Staff (SGBO).67 At the frst
meeting of the SGBO, the Royal Netherlands Marechaussee was given some tasks.
An important task was to collect information for criminal investigation and for
determining the facts. Part of this task was to complete the passenger list (gather and
verify information).68 The SGBO decided to verbally report the progress of the
activities to the Operations Team of the Kennemerland Safety Region.69
• The Kennemerland Safety Region scaled up to GRIP 2 in accordance with the Schiphol
Crisis Response Plan 70 (see blue box in Section 4.2). The Operations Team included
liaisons from Amsterdam Airport Schiphol and the Royal Netherlands Marechaussee.
The representative of Amsterdam Airport Schiphol was in contact with the chair of


67 Action centre of, in this case, the Royal Netherlands Marechaussee at Schiphol.
68 For the investigation process and the subsequent identifcation process it was important, for example, to obtain
an overview of the persons that had actually been on board, identifable information regarding the passengers
and crew, and addresses of the identifed persons with a domicile or residence in the Netherlands.
69 Feedback did not concern the contents of the passenger list, because this was considered to be a component of
the investigative task of the Royal Netherlands Marechaussee, which falls under the responsibility of the Chief
Public Prosecutor.
70 Scenario of an aircraft accident outside the Kennemerland region.

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the Committee of Consultation. From 21.45 CET (19.45 UTC) onward, the meetings of
the Operations Team were also attended by a liaison of the NCC. Obtaining the
passenger list and setting up a national information number were important topics at
the meetings of the Operations Team.71
• Initially the NCC did not feel that the Netherlands was facing a national crisis. The
NCC’s original impression was based on the fact that the crash of flight MH17 had not
taken place in the Netherlands and that media reports during the initial period
following the crash suggested that only a few Dutch nationals were on board. The
NCC did not yet believe there was a need to scale up. The NCC did monitor reports
in the media (including social media), interpreted this information and informed
various people and parties (including the NCTV in person and the Minister of Security
and Justice) about the news. As it gradually became apparent that it concerned a
flight originating from Schiphol with many Dutch passengers on board, the need for
the NCC’s signifcant involvement became clear and it began scaling up to the
national crisis structure around 18.00 CET (16.00 UTC). At 19.00 CET (17.00 UTC)
feedback from the crisis meeting with the Ministry of Foreign Affairs revealed that the
national crisis structure would be activated and that the ICCb would convene. At that
moment, the NCC’s priority was to obtain a clear picture of the number of Dutch
nationals on board and it tried to obtain relevant information from the various
organisations involved.
• After reading the media reports, the Ministry of Foreign Affairs immediately activated
its own crisis organisation. It called up members of the crisis telephone team, followed
soon by the frst crisis meeting at the Ministry. At that meeting, it was considered very
important to achieve clarity concerning the passenger list. At the frst crisis meeting
of the Ministry of Foreign Affairs, it was decided to convene the Interdepartmental
Commission for Crisis Management (ICCb). The Ministerial Commission for Crisis
Management (MCCb) was slated to meet later that evening.
• On Thursday evening, the National Forensic Investigation Team (LTFO) also scaled
up. A number of senior offcials met at Schiphol to make initial preparations regarding
victim identifcation and repatriation from Ukraine. On Friday evening, 18 July, a
delegation of the LTFO left for Ukraine. Other offcials of the LTFO in the Netherlands
continued to focus on preparing a list of missing persons and on identifying the
victims.
Several offcials of the national authorities made different statements in interviews. The
Dutch Safety Board concludes from these interviews that there was a difference of
opinion both between and within the ministries regarding who was in charge of the crisis
organisation with respect to the information process. Some offcials of the Ministry of
Foreign Affairs believed that the Ministry was in charge of the process of registering and
verifying information about victims and their relatives. The higher offcial level was of the
opinion that the Ministry of Security and Justice was in charge. Different opinions on the
matter also existed within the Ministry of Security and Justice itself. For example, the


71 Shortly after the disaster was reported, several offcials from the Municipality of Haarlemmermeer (subsequently
followed by the Operations Team) committed to opening a national information number. Opinions on why that
number was not opened at that time range from the belief that too few Dutch victims were involved, to the fact
that they had to wait for adequate staff to man the emergency telephone team before the number could be
opened.

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NCC was only fulflling a facilitating role with regard to the safety region and there was
no steering by the central government. The NCTV (in person) was of the opinion that he
was in charge.
In the course of the evening of 17 July, the Kennemerland Safety Region also began to
wonder who was managing and coordinating the overall process. After there was a
consultation at the strategic level between the safety region and the NCC, the safety
region at the end of the evening came to realise that the management and coordination
resided at the national level. The Kennemerland Safety Region no longer saw any
administrative challenges and dilemmas for its own organisation. After consultation
between the leader of the Operations Team and the mayor of the Municipality of
Haarlemmermeer, it was therefore decided that scaling up the regional organisation (to
GRIP 3) was not necessary. Preparations were made to eventually scale down.72 The
MCCb did not declare GRIP Rijk effective or give any indication to the parties involved.
4.4.2 Analysis
When handling the crash of flight MH17, there was at the very least a lack of clarity about
who was in charge of the crisis organisation: was GRIP Rijk declared effective and was the
central government in charge or not? At the safety region as well as at various ministries,
offcials made statements that were not in line with each other in this regard. There were
various opinions about the role of the central government and/or the Ministry of Security
and Justice. As already stated in the 2013 report entitled Eenheid in Verscheidenheid
(Unity in Diversity), it must be clear who is actually in charge. There was confusion in this
regard among all parties participating in the crisis organisation.
The differences in opinions residing at the national level as well as at the regional level
could be related to unfamiliarity with the national crisis structure. The meeting of the
ICCb (chaired by the National Coordinator for Security and Counterterrorism) and
specifcally the MCCb (chaired by the Minister of Security and Justice or the Prime
Minister) could have given the impression that GRIP Rijk had been declared effective
and/or that the Ministry of Security and Justice was in charge. Yet, even when GRIP Rijk
has not been declared effective, it is possible for the MCCb to convene in a situation that
requires coordination of an intersectoral crisis and requires decision-making on the
related coherent approach. This situation occurred in the case of the crash of flight MH17.
Although there was an intersectoral crisis with implications for national security, in this
specifc case there were no legally assigned powers to be applied to the region.
Consequently, GRIP Rijk could not have been declared effective. Moreover, GRIP Rijk in
this situation would not have resulted in another division of responsibilities between the
ministries with regard to the process of collecting, distributing and verifying passenger
information and informing relatives. Ministers remain responsible for their own tasks,


72 The Kennemerland Safety Region had asked the NCC whether the region could offer the NCC any support. This is
partly why GRIP 2 remained in force until Friday morning. The central government no longer made any appeals to
the safety region. The Kennemerland Safety Region formally scaled down at 11.00 CET (9.00 UTC) on Friday
18 July. Potential actions would be taken through the regular structures (in a mono-disciplinary fashion). At that
moment, the Royal Netherlands Marechaussee was still compiling the passenger list. Consequently, the Royal
Netherlands Marechaussee decided to report the progress of the passenger list to the NCC. Contact between
these parties was achieved early Friday evening

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independent of GRIP Rijk. What’s more, even if GRIP Rijk had been declared effective,
there would not have been a scenario nor an elaborated plan for dealing with an
aeroplane accident abroad involving many Dutch nationals.
Separate from the option to declare GRIP Rijk effective, there are other possibilities for
the parties involved clarifying the division of tasks between them. National authorities,
the region and Malaysia Airlines could, for example, have made working agreements on
sharing relevant information.

Sub-conclusion
In the initial days after the crash, there was much confusion about who was in charge
of the crisis organisation. Various parties that had a role in - or an interest in the
outcome of - the process of collecting, distributing, and verifying passenger
information differed in opinion about who was in charge of this aspect of the crisis
organisation.

4.5 Registration of relatives
4.5.1 Findings

Registration at Schiphol
Following news of the crash of flight MH17, worried relatives who feared for the fate of their
loved ones gathered at Schiphol in the hope of getting answers as to whether their relatives
were on board the crashed aeroplane. The frst group of people arrived at Schiphol at
about 19.00 CET (17.00 UTC). They were received at the panorama restaurant Dakota’s. As
the number of relatives arriving at Schiphol grew during the course of the evening, the
reception was moved to the nearby Steigenberger Hotel. Malaysia Airlines took the lead in
receiving the relatives.73 The airport authorities, the Royal Netherlands Marechaussee and
several other parties 74 offered support. Among other things, registration forms were
handed out to be completed by the relatives. These forms were then collected by Malaysia
Airlines with primary assistance mainly from the Royal Netherlands Marechaussee. Malaysia
Airlines provided the Royal Netherlands Marechaussee with copies of the collected forms.
No attempts were made by any authority to take over the responsibility for registering
relatives from Malaysia Airlines.
That same Thursday evening, however, a few employees from the Municipality of
Haarlemmermeer responsible for tasks related to public safety, including the offcer on
duty for population management, arrived at Schiphol. These employees of the Municipality


73 The municipality bears ultimate responsibility for (coordinating) acute reception and looking after people. This
also applies to Schiphol airport. The airlines are expected to perform a number of tasks (including compiling
inventories and offering support/assistance) and providing people to perform these tasks. The airport plays a
facilitating role, such as organising transport to a temporary reception centre.
74 KLM Care Team, Airport Medical Services, the Airport Chaplaincy, Community Health Services - Psychosocial
Support (GGD­Psychosociale Hulpverlening).

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of Haarlemmermeer identifed the needs of the relatives there. Because Malaysia Airlines
had assumed responsibility for the registration of relatives, with assistance from the Royal
Netherlands Marechaussee, the municipality’s employees did not roll out the process
Informing Relatives.75
Malaysia Airlines failed to share the information gathered about the relatives with the
national authorities (namely the NCC and the Ministry of Foreign Affairs). On Friday
morning, an offcial from the Municipality of Haarlemmermeer 76 attempted, via the NCC,
to establish contact between the airline and the Ministry of Foreign Affairs to share the
information that Malaysia Airlines had collected through its emergency number with the
Ministry. This contact was established at the end of Friday morning, but did not result in
Malaysia Airlines transferring the collected information to the Ministry of Foreign Affairs.
Except for passenger lists, the NCC and the Ministry were not interested in information
about relatives, such as that provided on the registration forms. Malaysia Airlines did
share this information with its headquarters in Kuala Lumpur. The airline wanted to
contact the authorities in order to, among other things, obtain clarity about the nationality
of some victims. Malaysia Airlines was not invited to participate in the national crisis
decision-making consultations. Although Malaysia Airlines undertook several attempts to
contribute to these consultations, the relevant national authorities within the national
crisis structure barred Malaysia Airlines from said consultations.77
Registration elsewhere
In addition to the relatives who went to Schiphol, there were also relatives who called for
information by telephone. The parties whom they tried to contact, however, were not
able to confrm whether their loved ones were on the flight. During this contact with the
relatives, however, several parties were able to register relatives’ information. These
parties were:
• Eurocross: The Eurocross emergency centre opened an emergency number at about
18.15 CET (16.15 UTC). Eurocross in its registration system registered the personal
details (name, phone number, email address and relationship to victims) of the people
who called that emergency number.78 On Saturday, Eurocross provided all the
information it had registered to the Ministry of Foreign Affairs and to the police. The
information collected by Eurocross was not shared directly with Malaysia Airlines.
• Malaysia Airlines: Malaysia Airlines opened an international information number for
relatives of the crash victims at about 20.15 CET (18.15 UTC). Relatives calling this


75 In response to the draft version of the investigation report the Municipality of Haarlemmermeer and the
Kennemerland Safety Region stated in a joint response that the process Informing Relatives (just as the process
Public Management), should have been initiated in accordance with the Population Management Sub-plan.
76 The liaison from the Municipality of Haarlemmermeer who had a seat on the Committee of Consultation at
Schiphol.
77 Since the cause of the crash was not yet clear, the national parties barred Malaysia Airlines from the national crisis
consultations. The airline was involved in (the preparations for) the frst relatives meeting, which was held on
Monday 21 July, and was in a later stage part of the National Core Team for Crisis Communication (Nationaal
Kernteam Crisiscommunicatie).
78 At about 21.00 CET (19.00 UTC), the Ministry of Foreign Affairs announced that it would serve as the point of
contact, thereby offcially ending Eurocross’s role in the incident, although it continued to coordinate all insurancerelated questions for the emergency response services. After the Ministry of Foreign Affairs had opened an
emergency number, Eurocross referred all callers to the Ministry of Foreign Affairs. Eurocross also referred travel
organisations to the Ministry. Eurocross did not forward any information from the travel organisations to the
Ministry

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number were connected to the Malaysia Airlines headquarters in Kuala Lumpur,
where they were able to communicate with staff in English. On Friday, Malaysia
Airlines, with assistance from KLM, set up a telephone exchange in the Netherlands
in order to facilitate communication in Dutch. Malaysia Airlines registered the
information of the relatives who called the information number.
• Ministry of Foreign Affairs: The Ministry of Foreign Affairs opened an emergency
number for relatives at about 21.20 CET (19.20 UTC). This number was to be used for
the purpose of collecting information about potential Dutch victims and their relatives
and to inform the latter as effectively as possible about options for additional
assistance. The number was not intended as a means to inform the relatives about
who was or was not on the passenger list of flight MH17. Malaysia Airlines presented
this number at 22.30 CET (20.30 UTC) at a press conference at Schiphol and requested
relatives to call that number. Following this announcement, calls flooded in and
overloaded the information number.79 To register relatives’ information (and
information about the victims), the Ministry used its own crisis registration system,
Kompas. For the registration process the Ministry did not utilise Malaysia Airlines’
registration forms that were completed at the airport by the relatives. The Ministry of
Foreign Affairs also failed to use and integrate the information about relatives
gathered by Malaysia Airlines in Kuala Lumpur, into the Kompas system.
Use of victim information system (SIS)
Investigations into past accidents, such as the 2012 train collision in Amsterdam and the
Turkish Airlines crash in 2009, revealed victim registration as one of the bottlenecks. In
2010, the Minister of Security and Justice asked the Security Council to solve the
bottlenecks cited in the investigation reports with respect to the issues pertaining to
victim registration.80 This resulted in the development of a national victim information
system (see blue box).
Shortly after the crash of flight MH17 was reported, the NCC obtained information about
the possibility of activating the SIS, which would be usable in this situation. The NCC was
to bring this possibility to the attention of the crisis meeting at the Ministry of Foreign
Affairs. The reports from this crisis meeting, however, do not allude to any discussions
about the use of the SIS. Instead, the Ministry opted to use a system it was familiar with.


79 Consequently, many people at home and abroad called the number, also, for example, to book a flight. The
Ministry of Foreign Affairs did not attempt to clarify the purpose of the telephone number by means of external
communication and in that way help people navigate to the right contact point.
80 A joint investigation conducted by the Inspectorate of Security and Justice and the Health Care Inspectorate into
the train collision that occurred at Amsterdam Central Station on 21 April 2012 led the Inspectorates to conclude
that the victim registration system was not managed properly.

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Victim information system (SIS)
The SIS has been operational since 1 January 2014 and is managed by the Institute
for Physical Safety. The system is designed to create a uniform victim registry in the
event of a crisis in the Netherlands in order to notify relatives in a timely fashion after
a major incident has occurred. The system focuses mainly on notifying the relatives
of seriously injured or deceased persons (non-self-reliant victims). During an incident,
the safety region can activate the SIS. Under the Safety Regions Decree (Besluit
veiligheidsregio’s), municipalities (population management team) are responsible for
the process of informing elatives. The development of the SIS has however created a
shift in the implementation of the process, in which the SIS has taken over several
municipal tasks, such as collecting registered information about the victims,
communicating with relatives, matching and linking relatives to victims, and providing
this information to the relatives concerned.
Relatives can contact the national front offce of the SIS (website and call centre)
when they are searching for a (potential) victim. The information from the emergency
medical services,81 hospitals (via the emergency medical services), police, mortuaries
and the front offce of the SIS is gathered in the national back offce of the SIS, so
that the victims can be linked to the relatives. In the case of a fatality, the police will
notify the relatives and provide guidance (regarding the conduct of police
investigation, if applicable).

4.5.2 Analysis
The above shows that various parties (Malaysia Airlines, the Royal Netherlands
Marechaussee, the Ministry of Foreign Affairs, Eurocross) registered information about
the relatives of the Dutch passengers of flight MH17. But it was not clear who was in
charge of this registration process. As a result, information on the relatives was registered
at different places and the information was not fully exchanged between the parties
involved. As a consequence, no single party had a full list of the relatives who had
reported, leading to the lack of a central list on the basis of which all parties could extract
information from.
The SIS focuses on major incidents in the Netherlands. Following the reports of the crash
of flight MH17 it appeared that the system could also be used in this case. No one made
use of this existing possibility. Had the system been used, then a central front offce at
the Royal Dutch Touring Club (ANWB) and a back offce at the LTFO, linking information
about relatives to victims in one place, would have been operational. The Board is of the
opinion that the use of the SIS could have helped promote cooperation between the
parties involved and thus the effciency of the process.


81 Emergency medical services organisation in the region (Geneeskundige hulpverleningsorganisatie in de regio -
GHOR).

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Sub-conclusions
Information about relatives who got in touch because they were concerned about
the fate of their loved ones, requesting information on who was on flight MH17, was
registered in different places by various parties. This registered information was not
consolidated into a single list of possible relatives of the passengers on board flight
MH17.
The SIS was not used. The use of this system could have facilitated cooperation
between the parties and thus the effciency of the process.

4.6 Collection, distribution and verifcation of the passenger information
Firstly, it was Malaysia Airlines’ responsibility to provide authorities with the best possible
information about all passengers who were on board the aeroplane. This information was
very important to the crisis organisations in the ten countries that were mourning victims.
It provided them with an important starting point for obtaining an overview of the victims
and their relatives. Several private and public parties were involved in this process in the
Netherlands.
This section broadly outlines:
a. the distribution of the initial Malaysia Airlines passenger list and subsequent updates
to and between the various parties, and
b. the efforts made by the four authorities who compiled lists of information about the
victims and their relatives.
4.6.1 Findings
a. Distribution of the passenger list
Malaysia Airlines’ headquarters in Kuala Lumpur informed the Malaysia Airlines branch at
Schiphol of the missing of flight MH17 around 16.00 CET (14.00 UTC). Immediately
thereafter, Malaysia Airlines’ emergency response plan was implemented both in Kuala
Lumpur (headquarters) as well as at Schiphol. The headquarters set up an Emergency
Operations Center (EOC), which as of that moment was responsible for handling the
missing of flight MH17. One of the EOC’s frst tasks was to safeguard the passenger
information by sealing it. At 17.15 CET (15.15 UTC) the manager responsible for this asked
the administrator of the system containing the passenger information to block the
passenger information for flight MH17 in the system. As of that moment, the passenger
information was sealed, and a very limited number of persons had access to the list.
At Schiphol, Malaysia Airlines’ support centre played an important role as soon as the
crash became known in handling the airline’s crisis tasks. The Regional Senior Vice
President was in charge of the branch. The goal was to coordinate with headquarters in

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Kuala Lumpur on the one hand and to provide information about the passengers and
maintain contact with the Dutch authorities and the media on the other hand.
Malaysia Airlines was able to provide an initial passenger list within two hours. Malaysia
Airlines’ station manager at Schiphol handed over this initial list in the Committee of
Consultation to the Royal Netherlands Marechaussee at Schiphol when this opportunity
arose. This happened at 19.10 CET (17.10 UTC), when the Committee of Consultation frst
convened. The passenger list was not shared with everyone in the Committee of
Consultation. The passenger list contained information about the passengers’ names,
genders and seat numbers. See also Figure 4 in Chapter 3 in this regard. All passengers
on board the aeroplane were included on the passenger list. The name and gender of
the three young children who had not been assigned their own seat were however not
specifed.
Shortly after, the airline was able to supplement the passenger list with information about
nationality, passport number and date of birth for approximately 75% of the passengers.
An excerpt of the passenger list containing supplementary information is displayed in
Figure 7

https://d.radikal.ru/d39/1908/42/ae41cae89daa.png

Figure 7: Excerpt of the passenger list in which the passport information (nationality, date of birth, passport
number and passport expiry date) was included, in addition to the name and gender, for 75% of the
passengers. (Source: Malaysia Airlines)

Свернутый текст

urname
Day and month of birth
Number of travel
document (passport)
Name
Gender
Year of birth
Expiry date of
travel document
Age
Nationality

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Initially, the Malaysian government was responsible for when this information would be
released. With time, Malaysia Airlines was able to determine the nationality of an
increasing number of passengers. Accordingly various updates of the passenger list were
released, circulating between the different parties:
• On Thursday evening at 20.20 CET (18.20 UTC), the parties at Schiphol, namely the
Committee of Consultation and the Royal Netherlands Marechaussee, already
possessed information about the nationalities of a large number of the passengers
(the nationality of 47 passengers at that time was still unknown). The national
authorities, like the NCC and the Ministry of Foreign Affairs, did not have this
information. At that moment, the NCC only got hold of the frst passenger list, which
included the name, gender, and seat number. The Ministry of Foreign Affairs had not
yet received any list. There was some displeasure within the ICCb and MCCb about
the fact that information about the passengers’ nationalities was not available. This
created a tense atmosphere between the National Coordinator for Counterterrorism
and Security (in person) and the Regional Senior Vice President of Malaysia Airlines.
Both maintained regular contact, but this did not result in practical cooperation in
order to jointly resolve the problems.
• The Ministry of Foreign Affairs initially had no contact with the parties in and around
Schiphol, but rather tried to contact Malaysia Airlines directly and via the Dutch
Ambassador in Kuala Lumpur. During the night from Thursday to Friday, Malaysia
Airlines’ headquarters in Kuala Lumpur provided a list of names and some of the
nationalities (the nationality of 41 passengers was not listed) to the Dutch Ambassador
in Kuala Lumpur. The Ambassador then sent this list to the Dutch Ministry of Foreign
Affairs. On Friday, 18 July at 13.20 CET (11.20 UTC), Malaysia Airlines sent an updated
passenger list containing names, nationalities (the nationality of four passengers was
still unknown at that time) and quite some additional information about the passengers
to the Ministry of Foreign Affairs.82
• The NCC tried to obtain passenger information from the airline and from the
Operations Team.83 After midnight (01.18 CET, 23.18 UTC) the NCC obtained a list
containing nationalities for the frst time from the liaison of the Municipality of
Haarlemmermeer.84 The nationality of 60 passengers was missing on this list. The
NCC forwarded this information to the Ministry of Foreign Affairs the next morning.
The NCC received no subsequent update of the passenger list after this.
The Committee of Consultation and the Operations Team noted on Thursday evening at
19.30 CET (17.30 UTC) and 22.30 CET (20.30 UTC) that coordination of the passenger list
was a cause for concern. This cause for concern was shared with the mayor of the
Municipality of Haarlemmermeer.
On Saturday 19 July, at 13.30 CET (11.30 UTC) Malaysia Airlines published a passenger
list containing all the passengers’ names and nationalities.


82 It was not possible during the investigation to examine all of the communications of all parties involved. However,
the information that was available for the Dutch Safety Board provides a clear picture of the parties who were in
contact with each other, whether they shared information and when this took place.
83 From 21.00 CET (19.00 UTC), a NCC liaison was present during meetings of the Operations Team.
84 The list originated from the public order and security offcial, who had participated in the Committee of
Consultation as a representative of the municipality on Thursday 17 July 2014.

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b. Compilation of lists of victims and/or relatives

https://b.radikal.ru/b35/1908/7a/1b27621a4ec0.png

Figure 8: Parties that gathered or communicated information about victims and / or survivors.
Lists of the victims and/or their relatives were compiled and supplemented by different
parties: by Malaysia Airlines, the Royal Netherlands Marechaussee at Schiphol, the LTFO,
the Ministry of Foreign Affairs and the NCC. Even travel organisations through whom
passengers had booked flight MH17, the General Dutch Association of Travel Companies
(ANVR) and the Eurocross emergency centre collected information about victims and
relatives.
Royal Netherlands Marechaussee
Shortly after the crash of flight MH17 had become known, the Royal Netherlands
Marechaussee assigned itself the task of completing the passenger information
(collecting and verifying information) in the interest of the criminal investigation.
In the context of investigating who was on flight MH17, the Royal Netherlands
Marechaussee picked up the frst passenger list (which was a printout from the Departure
Control System containing names, genders and seat numbers) from the Malaysia Airlines
branch at Schiphol.85 The Royal Netherlands Marechaussee then collected additional


85 The Royal Netherlands Marechaussee also received the same list later on from the Committee of Consultation.


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