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» MH17: ? »  DSB JIT »  DSB 13.10.15: MH17 Passenger information


DSB 13.10.15: MH17 Passenger information

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information86 from the airline and ground handling agent, such as the stubs that had
been torn from the boarding cards.87 The Royal Netherlands Marechaussee also
investigated, among other things, whether the border control systems contained relevant
passenger information and closely monitored news reports in public sources (social
media). With a legal request for assistance, the Royal Netherlands Marechaussee
obtained the flight reservation data from the Malaysian authorities. When collecting and
verifying the information, the Royal Netherlands Marechaussee also used Malaysia
Airlines registration forms that relatives had completed at Schiphol.88
The information from these various sources was combined into one list. All data were
entered into an analysis program to detect connections. Thereafter, the Royal Netherlands
Marechaussee searched its own information systems and that of the Municipal Personal
Records Database (GBA)89 for information to link relatives to victims.
The Royal Netherlands Marechaussee reported on the state of the investigation and on
the facts regarding the passengers on board, to the Operations Team in the region. The
Royal Netherlands Marechaussee also attempted to contact the Ministry of Foreign
Affairs via the public information number. However, it did not succeed, because the line
was overloaded with calls. After the Operations Team was disbanded on Friday 18 July,
because the Kennemerland Safety Region scaled down the crisis organisation, the Royal
Netherlands Marechaussee sought contact with the NCC that evening. Until that time,
the NCC had not been aware that the Royal Netherlands Marechaussee was compiling a
list containing passenger information. After this contact, the Royal Netherlands
Marechaussee handed over the list containing the information it collected to the NCC.
The next day, the NCC shared information received from the National Police with the
Royal Netherlands Marechaussee. The NCC also sent the list it compiled containing,
among other things, data from the Ministry of Foreign Affairs and data that the Royal
Netherlands Marechaussee had provided on the previous day.
During the days after the incident, the Royal Netherlands Marechaussee continued its
effort to fnalise the list. This was primarily for the purposes of identifying the victims.
After several days, the Royal Netherlands Marechaussee discovered, at the operational
level, that the LTFO was working on compiling ante mortem fles and was thus conducting
the same activities. At that moment, working agreements were made and the Royal
Netherlands Marechaussee stopped supplementing and verifying the victim information.
The Royal Netherlands Marechaussee then handed over the list they had compiled to the
LTFO.


86 The primary objective was to collect evidence in the interest of the investigation, while the secondary objective
was to confrm the identity of the passengers on board the aeroplane. This investigation report refers to
information instead of evidence.

87 Based on these stubs, a boarding list was compiled that was shared with the forensic investigation team.
88 Within the scope of the investigation (based on Article 126nd/126ud, frst paragraph, of the Code of Criminal
Procedure (Wetboek van Strafvordering), the Royal Netherlands Marechaussee also obtained the booking and
reservation information pertaining to flight MH17 from the airline. This information was not used in the frst phase
of compiling the list of passenger information.
89 Gemeentelijke Basisadministratie persoonsgegevens - GBA.

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LTFO
LTFO offcials collected passenger information for the purposes of the so-called ante
mortem investigation 90 The LTFO used the passenger list that circulated on the internet
on Friday as the starting point. This list contained names, genders and seat numbers.
LTFO offcials and the police searched in their own police systems for information about
the passengers. On Friday, the LTFO received a passenger list from the Ministry of
Foreign Affairs, which was followed by a list supplemented with passenger information
by the Ministry later that day. As of Saturday 19 July, the LTFO also received versions of
lists containing passenger information via the NCC and the Royal Netherlands
Marechaussee. This information was compared to the information that the LTFO had
collected itself. Subsequently, the LTFO compiled the ante mortem fles. Based on these
fles, pairs of family liaison offcers would later be sent to visit relatives in order to provide
them information and collect additional information.91
On Friday morning, a team of family liaison offcers met for the frst time in Leusden.
However, it turned out that there was still insuffcient information available for them to
start their work. On Saturday morning, the family liaison offcers met again. Each pair
received a number of ante mortem fles from the coordinator of the LTFO. At that moment,
not all of these fles appeared to be complete enough to inform and visit relatives. For
example, the names and addresses of relatives and the relationships between them still
needed to be fgured out.92 It was then not decided yet who should carry out this task.
Instead, the family liaison offcers did this themselves using the search systems.
Ministry of Foreign Affairs
The Ministry of Foreign Affairs used various sources to collect information about victims
and their link to relatives. The most important sources were the passenger lists of
Malaysia Airlines that were sent to the Ministry directly via Kuala Lumpur or via the NCC
and the information that relatives supplied by calling the information number of the
Ministry. In addition, the Ministry of Foreign Affairs on Saturday received data from
Eurocross93 and the ANVR.94 Given the moment the Ministry received these data, they
had little added value for the Ministry. At that moment, the Ministry had already handed
over its list to the police. The information was mainly used to compare the data with the
Ministrys list.95


90 In this process, as much information as possible is collected about the missing persons. The information is
subsequently compared with the victims human remains. If there is a match, this is considered identifcation.
91 Relatives are interviewed so as to obtain as much detailed information as possible about the missing persons. If
necessary, DNA material may also be collected from family members in order to later compare this to the DNA of
the human remains.
92 If this is not done carefully, there is a risk of several liaison offcers visiting (different) family members of the same
victim or a risk of relatives being informed about different victims in their family at different times.
93 The emergency centre registered the information supplied by relatives who called the Eurocross emergency
number and submitted it to the Ministry of Foreign Affairs on Saturday 19 July.
94 The ANVR informed all of its members about the MH17 crash via a news email. The members were also asked to
communicate the number of passengers, that had booked a ticket for this flight with them, to the ANVR, so that a
single overview could be compiled of the travellers that had booked flight MH17 via ANVR travel agencies and
tour operators. On Friday 18 July, there was contact with the Ministry of Foreign Affairs. At the request of the
ministry, the ANVR asked the travel organisations to provide information about passengers who had booked with
them directly to the Ministry of Foreign Affairs. It is unknown how many travel organisations actually did so.
95 The Ministry of Foreign Affairs used its own Kompas crisis registration system to compile a victim information list.
That system contained a list of registered affected persons (victims) and a list of the details of relatives (the ones
who called). The SIS was not used. Use of this system would have been possible, as the National Operational
Coordination Centre (Landelijk Operationeel Coördinatiecentrum) notifed to the NCC.

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As of Friday morning, 18 July, two liaisons of the police were present at the Ministry.
These police employees sent the information they received from the Ministry to the
LTFO. This concerned, among other things, the most recent passenger list that the
Ministry of Foreign Affairs received from Malaysia Airlines on Friday afternoon. The
nationalities of four persons were missing from this list. The names, nationalities - and in
many cases - the genders and dates of birth of the other passengers were known. On
Friday afternoon, the Ministry of Foreign Affairs provided the list that it had compiled
containing information about victims and relatives (callers) to the liaison.
The Ministry did not process any information coming from the Malaysia Airlines
registration forms (completed by relatives) in its registration system. The Ministry was not
aware of the activities of the Royal Netherlands Marechaussee at Schiphol and had no
direct contact with the Kennemerland Safety Region as well.
NCC / NCTV
The NCC wanted to get the most complete picture of the crash as possible, primarily to
prepare for the decision-making by the ICCb and MCCb. The NCC also needed this
information in order to notify the mayors of municipalities of which residents had
perished. Therefore, the NCC contacted various parties, including Malaysia Airlines, the
Operations Team,96 the Ministry of Foreign Affairs and various embassies. On Friday
evening, the NCC consulted with the Royal Netherlands Marechaussee (see before), and
both parties shared information with each other.
On Saturday morning, the NCC frst had contact with the LTFO. Subsequently, information
was also exchanged with this party, and agreements were made about which list to use
to inform the mayors.
During this period, a conscious decision was made within the national crisis structure not
to include any direct representatives of Malaysia Airlines in the crisis consultations from
the moment that the Committee of Consultation at Schiphol was disbanded.97 As of that
moment, no direct exchange of relevant information between the national authorities
(within the national crisis structure) and Malaysia Airlines took place. During the evening
of 17 July, and several times in subsequent days, there was regular contact by phone
between, among others, the NCTV (in person) and the Regional Senior Vice President
Europe of Malaysia Airlines. These discussions did not result in Malaysia Airlines being
able to share its information about relatives with the national authorities or being directly
involved in the national crisis consultations on this matter.
4.6.2 Analysis
Malaysia Airlines complied with the national and international obligations to provide the
Dutch authorities with a passenger list containing the best possible information within
two hours after the crash of flight MH17 became known.


96 The Royal Netherlands Marechaussee also received the same list later on from the Committee of Consultation.
97 Following the scaling down of the Committee of Consultation, activities related to the disaster were conducted as
part of the normal operations at the airport.

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The operational process of collecting, distributing and verifying information about
passengers and relatives was uncoordinated and ineffcient on the part of the Dutch
authorities. Various authorities compiled their own lists for various objectives containing
information about victims and relatives. These authorities were virtually unaware of each
others activities.
The passenger lists that Malaysia Airlines submitted were not received at one central
place and distributed from there to all parties involved. Several authorities at and around
Schiphol within three hours from the moment the crash became known got hold of a
passenger list containing many of the passengers nationalities. At the national level, the
NCC and the Ministry of Foreign Affairs received a similar list with nationalities no sooner
than the night from Thursday to Friday.
The information exchange between private and public parties as well as between national
authorities and those at and around Schiphol was unstructured. There was no central
place where the available information was combined and verifed. As a result there was
never one current authoritative passenger list on the basis of which all parties could
extract information from. Consequently parties did duplicate work. The fact that the
national authorities did not allow active input from Malaysia Airlines created delays as
well as irritation.
The Ministry of Foreign Affairs was responsible, at the national level, for processing the
consular tasks that stemmed from the crash of flight MH17. For this reason, the Ministry
collected information about the victims and relatives so that relatives could be informed
about the fate of their loved ones. However, the Ministry lacked an overview of other
parties that were somehow involved in collecting, distributing and verifying information.
The Ministry worked with the parties that the Ministry was used to working with, among
others based on previous major incidents abroad. Some parties that collected or
possessed information for other reasons (such as the criminal investigation) and parties
that had access to systems with which information could be supplemented and verifed
were not involved in the Ministrys process. Due to this, the Ministry of Foreign Affairs
did not use all of the information that was available via other channels.
On the night of the crash, it became clear within the national crisis structure that it was
diffcult to acquire the passenger list. This would have been the best point in time for the
MCCb to decide on a coherent approach to the overall process regarding the passenger
information. In the days following the crash, it became clear to the NCC, which was
preparing the interdepartmental decision-making process (among other things), that
several parties (in the region, at Schiphol, and at the national level) were compiling lists.
The NCC could have brought this to the attention of the ICCb, so that this committee
would have been able to advice the MCCb on measures to better coordinate the parties
activities and to share information with each other. However, the issue was not discussed
by the committees. Due to this, the situation remained unchanged and the parties
continued their work without communicating with each other.

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Sub-conclusions
At 19.10 CET (17.10 UTC), Malaysia Airlines provided the frst passenger list to the
Royal Netherlands Marechaussee at Schiphol in the context of the Committee of
Consultation, thereby complying with national and international obligations in this
regard. However, the Dutch authorities subsequently lacked central coordination for
collecting, distributing and verifying information about victims and relatives. There
was no joint effort or teamwork between the central government and the
Kennemerland Safety Region and between ministries during this process. Moreover,
the cooperation between the central government and private parties was not
satisfactory. This was at the expense of the speed with which the authorities could
inform relatives about the fate of their loved ones.
Although it quickly became clear to the ICCb and MCCb that obtaining passenger
information was diffcult, no measures were taken to ensure a coherent approach to
the process of collecting, distributing and verifying passenger information.

4.7 Informing relatives
4.7.1 Findings

In the days after the crash of flight MH17, numerous (public and private) parties issued
information to the relatives at different times. As indicated earlier, relatives who wanted
to know more about the fate of their loved ones contacted various parties. The following
briefly describes what information was provided by those parties at that time, shortly
after the crash:
During the night of 17-18 July 2014, Malaysia Airlines allowed the relatives who were
present in the Steigenberger hotel to view the passenger list that was available at that
time. This list specifed the frst and last names and seat numbers of the passengers
and, in some cases, their nationality as well. The relatives that had already left the
hotel at that time and those that had called Malaysia Airlines information number
were phoned early in the morning of 18 July 2014 to inform them that their loved
ones were on the passenger list.
The Ministry of Foreign Affairs gave people who telephoned the Ministrys information
number details about the subsequent process, for example, about the role of the
family liaison offcers.
In a number of cases, the travel organisations told relatives who contacted them
whether or not a specifc person had booked flight MH17 with them. When doing so,
they emphasised that they did not know whether the person in question had actually
boarded the aeroplane. In addition, a number of travel organisations also actively
approached people whom their customers had designated as the contact person at
home to contact in case of an emergency.
Eurocross, the emergency centre on duty at the time, did not provide information to
relatives who telephoned, but referred them instead to the Ministry of Foreign Affairs.

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Relatives were asked to provide the same details numerous times by various parties. In
addition to the unnecessary emotional stress caused to the relatives, this state of affairs
also led to confusion during the frst few days about which organisation possessed the
correct information and hence was the right point of contact for the relatives.
On Saturday 19 July, Malaysia Airlines published the passenger list with the passengers
nationalities at 13.30CET (11.30 UTC). At that time, the Dutch authorities had not yet
offcially informed the relatives of Dutch victims of the fact that their loved ones were on
board the aeroplane. Furthermore, Malaysia Airlines had also not yet contacted all of the
relatives at that point in time.98
The Ministry of Foreign Affairs and/or the central government, strove initially to ensure
that the list of victims and their relatives would be complete before handing over the list
to the police so that the relatives could be informed. The same approach was adopted
by the LTFO, that also strove to ensure completeness of the fles (names, addresses and
family connections) before informing the relatives.
Ultimately, this principle was abandoned and the authorities started informing relatives
despite the fact that the information was not complete for all passengers. Furthermore,
the central government decided not to make any announcements via the information
number of the Ministry of Foreign Affairs with regard to the names that were on the
passenger list.
Family liaison offcers
From Saturday afternoon onward, family liaison offcers from the National Police sought
contact with the frst relatives whose details were known to the police99 and informed
them offcially - on behalf of the central government - about the fate of their loved ones.
In most cases, the family liaison offcers made a personal visit to the homes of the
relatives. From Sunday on, a number of relatives were informed by telephone frst. It was
decided to contact them by telephone as otherwise it would not have been possible to
inform all of the relatives prior to the relatives meeting on Monday 21 July in Nieuwegein.
In spite of this, it was not possible to completely rule out the eventuality that the meeting
would be attended by relatives who had not been informed by the authorities in any way
at all.
Finally, it is important to note in this context that the media started to distribute
information about possible victims within hours of the reports of the crash of flight MH17.
This information came from a variety of sources, including social media.100 During the
night from Thursday to Friday, a passenger list already circulated on the internet, even
though Malaysia Airlines had not yet published it. In addition, during the frst few days
after the crash, the media distributed information about the subsequent procedure, for


98 At that time, Malaysia Airlines had informed all relatives who had contacted the airline. After the passenger list was
made public, other relatives also contacted the airline, after which they too could be informed and be offered
support.
99 Not all of the relatives of victims were approached by the family liaison offcers. The police contacted the relatives
of victims who were known to them.
100 For example, via images of the crash site, via the Facebook pages of passengers and their friends, and via
journalists.

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example about assigning family liaison offcers to the relatives, even though the relatives
themselves had not been informed on this. Shortly after the frst reports of the crash
appeared a number of travel organisations also announced via the media how many
Dutch nationals had booked tickets with them for this flight.
4.7.2 Analysis
It is important for relatives that they are informed as quickly as possible about the fate of
their loved ones. Naturally, when doing so, ensuring that the information they receive is
complete and accurate is of crucial importance. In this process, speed and due diligence
may sometimes be at odds with each other. It is therefore up to the parties involved to
assess whether they possess suffcient information to adequately inform relatives. Social
media complicate matters, as these media enable information to be distributed with
increasing speed.
After the crash of flight MH17, the media distributed information about possible victims
within a few hours. Relatives who had travelled to Schiphol or telephoned organisations
to obtain information did not receive any defnite answers at that time. The situation
became clearer when Malaysia Airlines started to contact relatives to inform them that
their loved ones were indeed on board the aeroplane, and when Malaysia Airlines
published the passenger list. However, most relatives considered the moment the family
liaison offcers contacted them to be the moment they were formally notifed of the fact
that their loved ones were on board the aeroplane. This occurred two to four days after
the crash.
The authorities involved in informing the relatives had to decide when they would share
certain information with the relatives and when they would offcially release certain
information to the public. Malaysia Airlines also faced a decision of this nature with regard
to the time of publication of the passenger list. A European regulation101 defnes that the
names of persons on board may not be made public before the competent authorities
have informed the family members of the persons concerned. However, Malaysia Airlines
published the passenger list while the relatives of the Dutch victims had not yet received
offcial confrmation from the authorities.102 In the opinion of the Board, the publication
of the list at that moment was an understandable decision, since a signifcant amount of
(unconfrmed) information about possible victims was already circulating on the internet
at that time.
Relatives who sought information via the information number of the Ministry of Foreign
Affairs did not receive an answer to the question whether their loved ones were on the
passenger list. Furthermore, the central government intended to draw up a complete
and verifed list of victims of the crash before informing the relatives. Even though this
list was not complete and verifed on Saturday, the decision to start informing the
relatives was nevertheless taken. With this decision, the authorities involved acted in
accordance with what could be expected of them at that time. In the opinion of the
Board, relatives are entitled to information about the fate of their loved ones as soon as


101 Article 20, paragraph 4, EU Regulation 996/2010.
102 Malaysia Airlines hoped that making the list public would result in family members, who where yet unknown,
contacting the airline. This was indeed what happened.

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this information is available. This means that consideration must be given to whether the
relatives of individual victims can start to be informed even if the information is not yet
complete for all passengers. The Board is of the opinion that, given the speed at which
information is able to circulate through modern media, a review of the basic principles is
appropriate, without compromising the authorities reliability. Relatives declared to the
Dutch Safety Board that it was emotionally stressful being confronted with information
via the media which had not yet been provided to them via the offcial channels.
Finally, the Board fnds that the coordination between Malaysia Airlines and the Ministry
of Foreign Affairs about the time of providing information to the relatives was far from
optimal. In the crisis meeting of the Ministry of Foreign Affairs (DCC), it was agreed that
the fnal passenger list would be published when all of the relatives had been informed.
However, the Ministry of Foreign Affairs and Malaysia Airlines didnt make agreements
regarding how and when they would inform the relatives about the victims of the crash of
flight MH17. This topic was discussed in the ICCb on Friday morning, and it was decided
that the Ministry of Foreign Affairs would contact Malaysia Airlines in this respect. The
Ministry did not pursue this action.

Sub-conclusions
Malaysia Airlines decision to publish the passenger list, even though the authorities
had not yet provided confrmation to the relatives is - in view of the context in which
this occurred - understandable. The authorities initially waited until the information
was complete for all the victims before informing their relatives. As a result, two to
four days passed before one or more relatives of each Dutch victim received offcial
confrmation that their loved ones were on board the aeroplane.
The authorities could have informed the relatives of individual victims that their
loved ones were on board the aeroplane, subject to the necessary reservations,
sooner, if the basic principle of waiting until the information was complete for all the
victims was abandoned earlier.

4.8 Relatives perceptions
4.8.1 Findings

Immediately after the crash, many relatives were almost completely certain that their
loved ones were on board the aeroplane. They had a pressing need for offcial
confrmation from the Dutch authorities as to whether or not their loved ones were on
board. They felt that there was a lack of direct contact with the authorities during the frst
few days.
It was not clear to the relatives which organisation they should (best) approach with their
questions. Malaysia Airlines in the Netherlands or in Kuala Lumpur, the travel organisation,
Schiphol, the Ministry of Foreign Affairs, or some other party? They approached various

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organisations in an attempt to quickly obtain clarifcation of the situation; in addition to
those mentioned above, they also contacted the municipality, the police and Victim
Support The Netherlands (Slachtofferhulp Nederland).
Most of the organisations that relatives contacted were unable to help them in the frst
hours following the crash. Also, major discrepancies arose at the times when relatives did
obtain information. In the Steigenberger hotel, Malaysia Airlines allowed the relatives
present there to view the passenger list at approximately midnight. Many of the relatives
had already left the hotel earlier that evening without receiving that kind of information.
Relatives whose details were known to Malaysia Airlines in Kuala Lumpur (through the
Malaysia Airlines information number) or at Schiphol (via the registration forms),103
received a telephone call from Malaysia Airlines in the early hours of the morning of
Friday 18 July to let them know whether or not their loved ones were on the passenger
list. Others either did not receive such a telephone call, or only much later.

https://c.radikal.ru/c11/1908/92/5e072e189df6.png

Figure 9: Flowers at Schiphol, laid there in memory of the victims. (Source: ANP/R. de Waal)
Relatives who called the information number of the Ministry of Foreign Affairs that
Thursday evening were put on hold for a signifcant amount of time before discovering
that the Ministry had no information for them about whether their loved ones were
included on the passenger list. Relatives left their details with various organisations; it
was not clear to them whether these details were shared between those organisations. In
addition, a number of relatives indicated that they did not receive a return call even
though they expected one.
The relatives experienced this situation as a lack of coordination with regard to information
provision. They continually had to chase after information in a situation where the offcial
channels were diffcult to reach. This changed from the moment there was contact with
the family liaison offcers, who served as a permanent contact with the authorities for the
relatives and provided them with information regarding the process as well as information
about their loved ones. The relatives were able to put all of their questions to the family
liaison offcers. The relatives declared that they greatly appreciated the family liaison
offcers efforts.


103 For example via a registration form completed at Schiphol or via a telephone call to Malaysia Airlines.

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4.8.2 Analysis
The relatives experienced the lack of coordinated information provision during the frst
few days after the crash of flight MH17 as emotionally stressful. Even though various
information numbers were opened, none of the possible sources was able to provide the
information the relatives needed. There was no clear communication with relatives about
the purpose of the information numbers, as demonstrated by the press conference held
by Malaysia Airlines on the evening of Thursday 17 July, when it was stated that the
emergency number of the Ministry of Foreign Affairs was to be used for information
services. As a result, it was not clear that this number (provided by the Ministry of Foreign
Affairs) was only intended to collect information about possible victims and their relatives
(in the context of the registration process) and not to provide information about the
names of (potential) victims to relatives.
Because relatives could not easily get in touch with Malaysia Airlines and the Ministry of
Foreign Affairs, due to the fact that the telephone lines were overloaded and became
blocked, they also contacted other organisations. These were equally incapable of
answering their questions. Many relatives did, however, leave their details with those
organisations. It was not clear whether the different organisations would share those
details with each other. It was unclear to the relatives which organisation was in possession
of the correct information and was the point of contact.
The questions of relatives remained mainly unanswered until contact was established
with the family liaison offcers who were deployed by the National Police in order to
inform the relatives. As a result of the efforts of the family liaison offcers, the relatives
received information about the victims and the process that would follow. This resulted
in the communication with the authorities that the relatives had desperately needed
during the preceding few days.

Sub-conclusion
After the crash of flight MH17, various parties (public and private) provided solicited
and unsolicited information to the relatives at different times and in different ways. The
relatives perceived the uncoordinated provision of information as emotionally stressful.
During the frst few days after the crash, it was not clear to them whom they should
(best) contact for information about their loved ones. The way in which the relatives
experienced the provision of information by the Dutch authorities is generally perceived
as positive from the moment they were contacted by the family liaison offcers.

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5 CONCLUSIONS
On 17 July 2014, the Netherlands was shaken by the crash of flight MH17. The need for
information about the victims was huge: who were on the aeroplane, which Dutch
nationals were among the victims? In addition to Malaysia Airlines, it was up to the
authorities to provide this information. The Board notes that the employees of the
organisations concerned did their utmost to collect and verify information about the
passengers and their relatives. Despite this commitment, the authorities did not succeed
in informing the relatives of every Dutch victim within 48 hours - the term which should
be aimed for according to the Board - to provide clarity regarding the presence of their
loved ones on board the aeroplane. In answer to the question why the relatives had to
wait so long for a confrmation from the authorities, the Board has arrived at the following
main conclusion.

Main 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 board 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 board 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.
Because the Ministry of Security and Justice (in particular the National Coordinator
for Security and Counterterrorism) did not take charge of the organisation and the
Ministry of Foreign Affairs cooperated insuffciently with other parties involved, the
information that the various parties gathered on 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.

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The main conclusion is divided into the following conclusions.

Conclusion 1
A complete and reliable passenger list is generally not available at the push of a
button. This was also the case with flight MH17. To determine with certainty who the
Dutch victims were, additional information had to be collected and verifed.

The airline has the duty to supply a list containing the best possible passenger information
to the appropriate authorities within two hours. What is meant by best possible is not
set down in any regulations. After the crash of flight MH17, Malaysia Airlines provided the
Dutch authorities with information as soon as the opportunity arose. This was during the
frst meeting of the Committee of Consultation at Schiphol, where Malaysia Airlines
handed over the passenger list of flight MH17 as it was also present on board the
aeroplane. On this list were the names, genders and seat numbers of the passengers.
The information contained in the passenger list was insuffcient to determine which
passengers were from the Netherlands. The information required for this purpose, such
as information about nationalities, could not immediately be retrieved from the computer
systems. Starting from about fve hours after the crash, this was possible and Malaysia
Airlines could issue this information for most passengers. The complete passenger list
was available on Saturday 19 July. This took time because Malaysia Airlines did not record
the nationality of all passengers (despite the fact that an internal procedure required this)
and other passport information. This is not required under international regulations. Such
a registration obligation only applies when a passenger travels to a country with an API
obligation.104
In addition, only the information required for handling the flight ends up in the computer
system that the airline uses for compiling the passenger list. This is standard practice in
the aviation sector. Part of the data that passengers provide prior to a flight, such as
contact details of relatives, remain in the different booking and reservation systems of
travel organisations and airlines. As a result, these data are not immediately available at
the time of an aircraft accident.
In practice, it is not possible to meet the societys expectation that it will be clear who
are on board the aeroplane at the push of a button. The frst passenger list to be
delivered will generally not be complete nor reliable enough to provide relatives with a
defnitive answer about whether or not their loved ones were on the flight.


104 Certain countries have made the registration and supply of additional data on incoming passengers via Advance
Passenger Information mandatory for airlines. See Section 3.2 in this report for an explanation.

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Conclusion 2
Central government and the safety region concerned were inadequately prepared for
the process of confrming to relatives of the victims of flight MH17 whether or not their
loved ones were on board the aeroplane. Despite earlier aircraft accidents, no
appropriate scenario had been developed. Several parties were busy collecting,
distributing and verifying information, separately and based on different responsibilities.
Since there was no central place where this information could be collected, much time
was needed to establish a single list of victims and relatives. There was a lack of
coordination and control. The NCTV should have taken the lead here.

The authorities fulflling a role in the process of informing the relatives about the victims
should have been aware, in view of previous aircraft accidents,105 of the fact that
passenger information after an aircraft accident is neither complete nor reliable. This also
applies to the bottlenecks in managing processes within the crisis organisation. Because
insuffcient lessons were drawn from other accidents, the identifed bottlenecks again
arose during the aftermath of the crash of flight MH17. A detailed scenario of an accident
abroad with an aeroplane with many Dutch people on board was lacking in both the
national and regional plans. There was no indication of a coordinating plan with a clear
allocation of roles and responsibilities. Nor was there any coordinating organisation in
place, as was previously recommended by the International Civil Aviation Organization
(ICAO).
In the initial days after the crash, there was much confusion about who was in charge of
the overall process of collecting information about the passengers and their relatives as
soon as possible. 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.
Due to the lack of clarity, a situation emerged in which different private and public parties
drew up lists containing information about victims and relatives separately. Among the
parties, it was not always known or clear who was doing what and why they were doing
this. In addition to Malaysia Airlines, various authorities - the Royal Netherlands
Marechaussee, the LTFO, the Ministry of Foreign Affairs and the NCC - prepared lists for
different purposes. No proper agreements were reached about sharing information, as a
result of which the information exchange took place in an ad hoc and unstructured way.
The parties only dealt with the parties with whom they were accustomed to be working.
The Board noted that the attitude of the Ministry of Foreign Affairs played an important
role here. The Ministry, as is usual when Dutch citizens are affected abroad, had the
consular task of retrieving data on the victims and to inform the relatives in this regard
through the police. The Ministry proceeded mainly according to its own procedures and
frameworks and limited itself to its usual network. As a result, the Ministry did not make
use of all the information that was already available from parties outside this network,


105 Particularly the crash of a Turkish Airlines aeroplane close to Schiphol Airport in 2009 and the crash of an Afriqiyah
Airways aeroplane near Tripoli in 2010.

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such as Malaysia Airlines and the Royal Netherlands Marechaussee. This attitude was not
conducive to general cooperation. The Board is of the opinion that the Ministry, because
of its priority task in this disaster, should have taken note of the activities of other parties
and should have put these to good use.
Parties did not make any use of the existing victim information system (SIS) by which the
available information could be gathered in one place. This system was developed in
response to, among other things, the problems pertaining to victim registration after the
crash of the Turkish Airlines aeroplane in 2009. The use of the SIS could have facilitated
the cooperation and information sharing among the parties and thus improve the
effciency of the overall process.
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 NCTV
should have taken the lead here. The national crisis structure in the Netherlands provides
for a crisis centre, namely the NCC (part of the NCTV), which must be able to get a total
overview of the parties involved during a crisis, including what they are doing and what
information they have. It is the NCCs duty to connect these parties in order to make
working arrangements. At one point, the NCC was in touch with all authorities and with
the airline and was aware that work was being carried out on lists in multiple places.
Nevertheless, this did not result in the NCC taking over the coordination and bringing
the relevant parties in contact with each other.

Conclusion 3
The lack of coordination and control of the overall process affected the term in which
relatives got a defnitive answer from the Dutch authorities. In addition, the
authorities initially wanted to wait until there was a full, verifed list of Dutch victims
and relatives before they gave relatives the offcial confrmation that their loved ones
were on board the aeroplane. This led to a further delay. The relatives were left in
uncertainty for too long with regard to the presence of their loved ones on board
the aeroplane.

Both Malaysia Airlines and the Dutch authorities notifed relatives that their loved ones
were on flight MH17, but they did not coordinate the time when they passed on this
information. Malaysia Airlines contacted relatives from the day after the crash and
published the full passenger list on 19 July. At that stage, the Dutch authorities had not
yet informed the victims relatives. The decision of Malaysia Airlines to publish the list of
passengers while the Dutch authorities were not yet ready is understandable given the
context in which this happened.
Appointed by the Ministry of Foreign Affairs, family liaison offcers of the National Police
provided the formal confrmation from the authorities to the relatives. It took two to four
days after the crash before the message was passed on to the relatives by the family
liaison offcers. The authorities initially wanted to wait until a complete and verifed list of

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victims was available. A large number of relatives were therefore left in uncertainty about
the fate of their loved ones longer than necessary. The Board is of the opinion that the
decision to wait for a complete and verifed list does not ft into the modern era in which
messages spread rapidly via social media. Although it is inevitable that relatives are
confronted with news of which they have yet to get formal confrmation, it is still in the
interest of the relatives to inform them quickly - if necessary with a reservation - as to
whether their loved ones were on board the aeroplane.
The Board is of the opinion that relatives should be informed where possible within
48 hours, leaving aside exceptional personal circumstances. With strong management of
the activities that are needed, a central desk where the information is brought together,
and the decision not to wait for the information of all the victims to be complete this
should be possible

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6 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:
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:

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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:

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.

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APPENDIx A
INVESTIGATION PARTICIPANTS
A.1 Guidance committee
The Dutch Safety Board established an Guidance committee for this investigation. This
committee consisted of external members possessing expertise relevant to the
investigation and extraordinary councillors, under the chairmanship of one of the Board
members of the Dutch Safety Board. The external members had a seat in the Guidance
committee in a private capacity. During the investigation, the Guidance committee met
four times to exchange thoughts with the chairman of the committee and the project
team regarding the structure and results of the investigation. The committee performed
an advisory role in the investigation. Final responsibility for the report and the
recommendations lies with the Dutch Safety Board.

E.R. Muller
(chairman)

Vice-chairman, Dutch Safety Board

B.J.A.M. Welten

Associate member of the Board, former commissioner of the Groningen
regional police and of the Amsterdam-Amstelland regional police

J.A.J.M. Kneepkens

Director Rulemaking European Aviation Safety Agency, former Director
General Aviation CAA

H. Mayer

Former director, Civil Aviation Security NCTb

U. van de Pol

Member of the Personal Data Committee of the Municipality of Amsterdam,
former vice-chairman of the Dutch Data Protection Committee

D. van Putten

Lieutenant General (retired) of the Royal Netherlands Marechaussee

R. Sicking

Former manager at Heathrow Airport and Brussels Airport

A.P.J.M. Rutten

Associatie member of the Board, former Chief Operational Offcer of the
Schiphol Group

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A.2 Project team
The project team of the investigation Passenger information was made up of the following
individuals:

M. Visser

Program manager

R.J.H. Damstra

Project manager

S. Pijnse van der Aa

Investigator

D.A. Oomen

Investigator

A. van der Zande

Investigator

A. Jagan

Investigator (involved until 1 March 2015)

C.B. Godron

Investigator (involved until 1 March 2015)

A. van der Kolk

Advisor research and development

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APPENDIx B
REVIEW
In accordance with the Kingdom Act Dutch Safety Board (Rijkswet Onderzoeksraad voor
veiligheid), a draft version of this report was submitted to the parties involved. These
parties were asked to check the report for factual errors and ambiguities. The draft
version of this report was submitted to:
Malaysia Airlines;
Amsterdam Airport Schiphol (Schiphol Group);
Municipality of Haarlemmermeer;
Kennemerland Safety Region;
Ministry of Foreign Affairs;
Ministry of Security and Justice;
Ministry of Defence;
National Police.
The responses after inspection were processed in the following manner:
Corrections of factual inaccuracies, additions at the detail level and editorial
commentary have been taken over by the Board (where relevant). The corresponding
parts of the text have been amended in the fnal report. These comments are not
listed separately.
If the Dutch Safety Board has not taken over certain comments, the Board has
explained its decision not to do so. These comments and the explanation are included
in a table that, along with the publication of the investigation report, has been
published on the website of the Dutch Safety Board (safetyboard.nl).

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APPENDIx C
PARTIES INVOLVED
This appendix contains an overview of the most important parties that had a role in
providing, collecting and sharing passenger information pertaining to flight MH17 or
otherwise played a relevant role.
C.1 Malaysia Airlines
Malaysia Airlines is Malaysias national airline. Its head quarters is in Kuala Lumpur.
Malaysia Airlines is a member of the oneworld Alliance of airlines. Malaysia Airlines has
entered into code share agreements with many airlines belonging to that alliance as well
as other airlines, including KLM.106
Malaysia Airlines has its own branch at Schiphol. Thirty-one people are employed there.
The operational management of the daily flights from Schiphol is done from this location,
under the responsibility of the head quarters in Kuala Lumpur. A Station Manager is
responsible for this. A ground handling agent - which is another company - carries out all
ground operations at the airport for and on behalf of Malaysia Airlines. Malaysia Airlines
performs daily flights from Amsterdam Schiphol to Kuala Lumpur and vice versa. After
the crash of MH17, both the headquarters in Kuala Lumpur and the branch at Schiphol
were involved in collecting and providing information in the context of the crisis activities.
As an involved airline, Malaysia Airlines is a participant in the Committee of Consultation
(see below). In accordance with EU Regulation No. 996/2010107 and the Population
Management Sub-plan, Malaysia Airlines is obligated to make the passenger list
available to the mayor as quickly as possible (in any case within two hours). In addition,
the airline must provide information to the government that is necessary to inform
relatives and the public.
C.2 Amsterdam Airport Schiphol
Amsterdam Airport Schiphol is the largest Dutch airport, serving close to 55 million
passengers in 2014. According to the Population Management Sub-plan108 (a more
detailed version of the Kennemerland Regional Crisis Plan), one of the airports tasks is to
set up a temporary reception centre and to ensure for the transportation to this centre of
uninjured people, lightly wounded people and relatives. Schiphol facilitates and provides
support for receiving and reuniting people.


106 See Section 3.2.
107 See Appendix D 2.2.
108 See Appendix D5

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C.3 Committee of Consultation
At Schiphol, the Committee of Consultation forms the internal crisis organisation.109 The
committees composition depends on the nature and scope of the calamity or disruption.
The Airport Manager, Airside Operations Manager and Operations Manager Passengers
have fxed seats on the Committee of Consultation. In addition, other offcials may also be
part of the committee, such as Schiphols public relations offcial and a representative of
the Municipality of Haarlemmermeer, of Air Traffc Control the Netherlands (Luchtverkeersleiding Nederland) or of the company involved (the airline, for example). If needed, the
Committee of Consultation can be expanded to include other experts as well as private
parties. The Committee of Consultation convenes when the routine operational processes
at Schiphol are disturbed by a calamity. The committee is primarily concerned with the
restarting and continuity of the primary processes and orderly operations and safety at
Schiphol. If the regional crisis organisation scales up, the Committee of Consultation
functions within it as the airports action centre. If Schiphol is involved in an accident or
disaster,110 the Committee of Consultation must provide aeroplane data to the Operations
Team according to a format (including the number of passengers and crew members). The
airline must make a passenger list available to the mayor within two hours after the
accident, via the committee.111
C.4 Municipality of Haarlemmermeer / Kennemerland Safety Region
The mayor and aldermen are responsible for organising disaster response and crisis
management at the regional level. The execution thereof is assigned to the safety region.
The municipalitys tasks within the safety region in case of aviation-related incidents at
Schiphol are specifed in the Population Management Sub-plan.
C.5 Operations Team
An (regional) Operations Team is one of the units of the main structure of disaster
response and crisis management. The Operations Team is charged with the operational
management, coordinating with other parties involved in the disaster or crisis, and
advising the municipal or regional policy team if present. The Operations Team is a
multidisciplinary group and consists of representatives from the fre brigade, the medical
emergency services for accidents and disasters, the police, and the municipality. The
Operations Team is led by the operational leader, who also participates in the policy
team. Other experts and/or private parties may also participate at the invitation of the
operational leader, such as the NCCs liaison.


109 Kennemerland Safety Region, Schiphol Crisis Response Plan, December 2013.
110 For example, if an aeroplane crashed at Schiphol or if an aeroplane that departed from or was heading to Schiphol
was involved in an accident.
111 See appendix D5.

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C.6 National authorities
The tasks of the Royal Netherlands Marechaussee, the LTFO/National Police, (the Ministry
of Foreign Affairs and the Ministry of Security and Justice (the NCTV and the NCC) are
thoroughly detailed in Chapter 4, Section 4.2 of this report.
C.7 Emergency Centres
The larger emergency centres (ANWB, SOS, Allianz and Eurocross) combine forces if
there are calamities abroad that involve at least eight Dutch citizens. Per year, one
organisation is the emergency centre on duty and coordinates the primary emergency
services. At the time of the crash of flight MH17, Eurocross was the emergency centre on
duty.
C.8 Travel organisations
A passenger can book a flight - either as part of a package holiday or not - with travel
organisations such as travel agencies, tour operators and online travel organisations.
When booking the flight, the travel organisation records passengers details and
sometimes also details of contact persons at home. The travel organisation then ensures
that the flight is reserved with the airline. Many travel organisations are members of an
association that liaises on their behalf with, among others, the authorities.

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APPENDIx D
FRAME OF REFERENCE
The Dutch Safety Board uses a frame of reference when assessing an incident or a series
of incidents. The frame of reference that was used for the investigation into the availability
of passenger information pertaining to flight MH17 is composed of four parts. The frst
part of the frame of reference describes what could, in the opinion of the Board, be
expected from the involved parties, as a supplement to the other parts of the frame of
reference. The second part discusses international legislation and regulations that apply
to the registration and exchange of passenger details and assistance to victims and
relatives. The third part discusses the internal guidelines and plans of Malaysia Airlines.
The fourth part of the frame of reference describes the agreements that have been made
in the Netherlands about the role that Dutch parties fulfl in the event of a national crisis,
in particular with regard to an aircraft accident abroad involving Dutch victims.
D.1 The Dutch Safety Boards frame of reference
Partly based on the above, the 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 persons on board of the aeroplane will be available as quickly as
possible in the event of an 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 board the aircraft quickly. This
means that, in addition to their names and initials, the information should also include at
least the nationality of those on board.112 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 the aeroplane.113 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 the 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.


112 Whether the obligation to register a passengers nationality applies depends on the destination of the passenger.
113 The authorities must issue a formal statement of death to a victims relatives after a fatality has been identifed.
Prior to this, the Board believes, it is important that relatives are informed by the authorities as soon as possible
whether their loved ones were actually on board of the aircraft.

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The Board expects the following from the parties comprising the Dutch crisis organisation:
Parties are familiar with the crisis system of which they are part and are therefore
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
relatives, 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 114 (Unity in Diversity) report on
cooperation between authorities in crisis management. This 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
concerns joint action by all the 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.
The Board considers it important that relatives of victims of an aircraft accident 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).115
D.2 International civil aviation legislation and regulations
Due to the international nature of aviation, many laws and regulations pertaining to
aviation (and aviation safety) are established in an international context. The global
framework comes from the International Civil Aviation Organization (ICAO), which is also


114 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).
115 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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an agency of the United Nations, and is set down in the Convention on International Civil
Aviation, usually referred to as the Chicago Convention,116 and the Annexes to this
Convention. The European framework consists of directives and regulations of the
European Union or the European Commission. In this section, the relevant parts of
international legislation, regulations, directives, standards and recommended practices
for this investigation are discussed.
D.2.1 ICAO
Nearly all nations have signed the Chicago Convention.117 The convention forms the basis
of the international regulations with regard to civil aviation and includes provisions that
are important for the development of international civil aviation. Nineteen Annexes have
been added to the Convention, in which varying topics are further set down in standards
and recommended practices. The member states must implement the standards as
closely as possible in their national regulations.118 If a standard is not followed or a
standard is not included in national regulations, this must be reported to ICAO.119
Member states do not have to include the recommended practices in their national
legislation. In addition, ICAO also makes other documents available, such as manuals
and guidelines that provide guidance for the implementation of the standards and
recommended practices.
Provision of passenger information
Article 29 of the Chicago Convention sets down that an airline must have a list containing
passenger names and the locations of departure and destination on board the aircraft if
it transports passengers.120 Annex 9121 of the Convention has the objective of contributing
to an effcient course of cross-border air traffc and describes, among other things, the
measures that must be taken to ensure that border control can assess the aeroplane, the
persons and the cargo correctly without interfering with other air traffc. Standard 2.13 of
Annex 9 states that, if a passenger manifest (passenger list) is required by a member
state, this passenger list must only consist of the elements specifed in Appendix 2.
Appendix 2 contains a format for a passenger list. The following elements are mentioned
in the format: the operator, nationality and the registration (when requested by the state),
the flight number, the date, the departure point of the flight and the destination of the
flight. There are also columns to list the surnames and the initials of the passengers, and
columns headed for use by the operator only and for offcial use only. The information
may be supplied either electronically or on paper.122
Annex 9 also contains a number of standards and recommended practices regarding the
system for Advance Passenger Information (API). Every member state that introduces an
API system in its national legislation must take up the internationally recognised standards
for sending API data.123 The relevant standards and recommended practices are further


116 Convention on International Civil Aviation, ICAO Doc 7300, Chicago, 7 December 1944.
117 Currently, 191 countries have signed the Chicago Convention.
118 Article 37, Chicago Convention.
119 Article 38, Chicago Convention.
120 Article 29 (f), Chicago Convention.
121 Annex 9 (Facilitation), Chicago Convention, thirteenth edition, July 2011.
122 Standard 2.13 of Annex 9, last sentence.
123 Standard 3.47 of Annex 9.

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elaborated in the Guidelines on Advance Passenger Information (API).124 These guidelines
were drawn up for the frst time in 1993 by the World Customs Organization (WCO) and
the International Air Transport Association (IATA), and provide guidance for member
states that want to implement an API system. Since 2003, ICAO has also been involved in
the further development of these guidelines. These guidelines indicate, among other
things, which data elements (at most 39) pertaining to a passenger can be registered.125
Assistance to victims and relatives after an accident
ICAO documents 9973 and 9998126 provide further guidelines for assistance to victims
and their relatives after an aircraft accident. Effective coordination between the parties
involved is deemed essential within this context. The information that relatives will need
to have frst is confrmation whether a particular family member was involved in an
accident.127 The airline is the frst party designated to provide an accurate passenger list
of the people who are involved in an aircraft accident.128 Often, there will be tension
between the priorities of accuracy and promptness when supplying the passenger list.
Accuracy comes before promptness. Some countries have national regulations that
oblige the airline to provide a passenger list to specifc authorities within a specifc period
of time. In accordance with ICAO, the airline is also the frst party designated to inform
victims relatives and to supply passenger information to other authorities that play a role
in providing assistance to victims and relatives.129 For this, the airline must use information
that is provided by passengers, such as frequent flyer data, credit card details and any
emergency numbers, that can be found in the computer system of the airline.130 The
airline must also provide a free telephone number where relatives can get information
about whether or not their loved ones are listed on the passenger list. The telephone
system must be able to handle a signifcant number of calls.131
According to ICAO, a coordinating organisation must be appointed by the member
states because a great number of organisations and authorities are involved when
providing assistance to victims and relatives. This organisation must be involved in the
planning and must be called in immediately after the incident. A coordinating organisation
is essential to ensure that the different organisations work together in offering the best
possible assistance to victims and their relatives. This coordinating organisation can also
serve as a point of contact between relatives and the authorities.132


124 Guidelines on Advance Passenger Information (API), WCO-IATA-ICAO, 2013.
125 Point 8.1.5 of the Guidelines on Advance Passenger Information.
126 ICAO Doc 9973 AN/486, Manual on Assistance to Aircraft Accident Victims and their Families, First Edition, 2013
and ICAO Doc 9998 AN/499, Policy on Assistance to Aircraft Accident Victims and their Families, First Edition, 2013.
127 Point 2.7, ICAO Doc 9998 and point 3.2, ICAO Doc 9973.
128 Point 2.18, ICAO Doc 9998.
129 Point 2.18, ICAO Doc 9998.
130 Point 3.3 (a), ICAO Doc 9973.
131 Point 3.3 (b), ICAO Doc 9973.
132 Point 2.13, ICAO Doc 9998.

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In summary, ICAO states that an airline must take a passenger list on to the aircraft,
listing the names of the passengers. ICAO also indicates that an airline must provide
an accurate passenger list after an aircraft accident. A further description of the
information that must be on such a list is not given. Only if the country of (fnal)
destination sets requirements (for example, additional API data) those data will have
to be passed on by the airline to the relevant country before departure, with the
consequence that detailed passenger data will certainly be available at the airline
after an accident. ICAO indicates that the accuracy of the passenger list is more
important than the timely availability of this list.

Code share
In ICAO´s guidelines133 the following has been set down about code sharing. Under a
code share agreement, an airline sells tickets under its own name for flights that are in
practice operated by another airline. The airline where a ticket is bought is the contractual
operator of the flight, while the flight is operated by another airline (the actual operator).
In other words, several airlines offer tickets for the same flight, but under their own codes
and/or flight numbers. It has also been set down in an ICAO manual that in the context of
a code share flight the contractual operator must support the actual operator when
assisting passengers and relatives, especially if the aircraft accident does not occur in the
country in which the operators principal place of business is located of the airline that
operates the flight.134
D.2.2 EU regulations
The most important European rules are set down in European directives and regulations.
A directive must be implemented in Dutch legislation, while regulations will have
immediate effect on the Dutch system of law.
Provision of passenger information
Directive 2004/82/EC of the Council of the European Union (a directive pertaining to
API) applies within the European Union with regard to incoming flights. The objective of
this Directive is to improve the border control of the European Union and to control
illegal immigration to the European Union by ensuring that airlines can issue passenger
data to the competent national authorities in advance, if required. Since this legislation
mainly focuses on controlling illegal immigration to Europe/the Netherlands, it has been
incorporated in the Netherlands in the Aliens Act 2000 (Vreemdelingenwet 2000).
Passenger information and assistance after an accident
On 20 October 2010, EU Regulation no. 996/2010 on the investigation and prevention of
accidents and incidents in civil aviation came into force. This Regulation also contains
rules on the timely availability of information regarding people on board the aircraft.
Article 20 contains the following passages that are relevant to this investigation:


133 ICAO Circular 269/AT/110, Implications of Airline Code Sharing (1997). ICAO Doc 9626, Manual on the Regulation
of International Air Transport, Second Edition, 2004.
134 Point 5.12, ICAO Doc 9973.

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European Union airlines operating flights arriving to or departing from, and third country
airlines operating flights departing from an airport located in the territories of the
Member States to which the Treaties apply, shall implement procedures which allow for
providing, as soon as possible and at the latest within two hours of the notifcation of the
occurrence of an accident involving the aircraft, a validated list, based on the best
available information, of all the persons on board (paragraph 1(a));
These lists shall be made available to the safety investigation authority in charge, the
authority designated by each Member State to liaise with the relatives of the persons on
board and, where necessary, with medical units which may need the information for the
treatment of victims (paragraph 2);
In order to allow passengers relatives to obtain information quickly concerning the
presence of their loved ones on board a crashed aircraft, airlines shall offer travellers the
opportunity to give the name and contact details of a person to be contacted in the
event of an accident. This information may be used by the airlines only in the event of an
accident and shall not be communicated to third parties or be used for commercial
purposes (paragraph 3);
The name of a person on board shall not be made public before the relatives of that
person have been informed by the relevant authorities (paragraph 4). The passenger list
referred to in the frst paragraph shall only be published in so far as the relatives of the
respective persons on board have not objected.

In summary, the European Union requires airlines that fly from the European Union
to hand over a verifed list of all people on board available to the authority of an
involved country within two hours after having received information that the aircraft
has been involved in an accident. This list must be based on the best available
information. What information the list must contain, is not specifed.

Based on Article 21, paragraph 1, every EU Member State must draw up an emergency
plan that is also relevant to providing assistance to victims of aircraft accidents and their
relatives. The third paragraph of the same article provides that upon the occurrence of
an accident, the Member State conducting the investigation, or the Member State where
the airline whose aeroplane crashed is registered or a Member State that has a large
number of people on board designates a consultant to act as a contact and information
point for the victims and their relatives.
D.3 National regulations
The Ministry of Infrastructure and the Environment has drawn up a draft National
Emergency Plan for civil aviation accidents (concept Nationaal Noodplan voor burgerluchtvaartongevallen),135 including assistance to victims of civil-aviation accidents and


135 Version of 13 March 2014.

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their relatives based on Articles 21 and 23 of EU Regulation No. 996/2010 (see before).
This plan has not yet been fnalised and therefore is not used as such.
The objective of this emergency plan is to indicate the framework that will ensure that
the consequences of an accident in civil aviation within the Netherlands are limited as
much as possible. The only issue mentioned in the plan regarding an accident abroad is
that the provision of information to victims and their relatives will be seen to by the
Ministry of Foreign Affairs.
D.4 Internal guidelines and plans of Malaysia Airlines
Recording passenger information
As of 1 October 2008, Malaysia Airlines internally mandated that for all flights, including
the flights to countries that are not API countries, in addition to the name and initials, the
nationality of every passenger must be recorded in the Departure Control System.136
Malaysia Airlines imposed this obligation to speed up the identifcation of passengers
nationalities in the event of any irregularities regarding a flight.137
After the crash of flight MH17, Malaysia Airlines further expanded its internal requirements
with regard to the registration of data of passengers travelling to countries that are not
API countries on 24 July 2014. As of this date, passport details (nationality, passport
number and date of birth) must be recorded during check-in, either manually or by
swiping the passport. If this is not done at check-in, it must be done during boarding.
The flight may only depart after checking that the aforementioned passport information
has been recorded for all passengers.138
Using passenger information after an incident
Malaysia Airlines manual for dealing with emergencies139 specifes that, among other
things, digital information pertaining to a flight shall be sealed as soon as Malaysia
Airlines becomes known that the aircraft is involved in an accident. Only authorised
persons of the airline can access the information from this point on. The confdentiality of
the information is very important. Malaysia Airlines shall supply the authorities with a
provisional/unconfrmed passenger list and a list of crew members as soon as possible.
Next, Malaysia Airlines shall supply an authorised passenger list to the authorities.
The verifcation of the passengers on board shall take place by checking passengers with
a confrmed reservation, passengers who have checked in without a reservation, including
passengers who were on standby, passengers who had made a reservation but did not
check in, checked-in passengers who did not go on board the aeroplane and crew
members who changed their work schedule. The list will be further confrmed by
comparing the collected stubs from boarding passes with the names of the passengers
who checked in. The passenger information can also be compared with calls that are
received at the airline. Other sources of information include the booking history of a


136 Malaysia Airlines, Ground Operations Manual.
137 Malaysia Airlines, Airport Service Notice of 18 November 2008.
138 Malaysia Airlines, Airport Service Notice of 24 July 2014.
139 Malaysia Airlines, Corporate Emergency Operations Manual, September 2013.


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