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» MH17: ? »  DSB JIT »  DSB 13.10.15: Crash MH17, 17 July 2014


DSB 13.10.15: Crash MH17, 17 July 2014

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MH17

MH17 Crash

https://d.radikal.ru/d08/1907/03/90e2a9a36352.png

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Crash of
Malaysia Airlines
flight MH17

Hrabove, Ukraine, 17 July 2014



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

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

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

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CONTENTS

Foreword....................................................................................................... 7
Summary ...................................................................................................... 9
1 Introduction..........................................................................................................14
1.1 The investigation .................................................................................................. 14
1.2 Purpose and scope of the investigation............................................................... 14
1.3 Investigation methodology and parties concerned ............................................. 15
1.4 Wreckage recovery............................................................................................... 16
1.5 Preliminary report................................................................................................. 17
1.6 Other investigations ............................................................................................. 18
1.7 Reading guide ...................................................................................................... 19
PART A: CAUSES OF THE CRASH..................................................................................22
2 Factual information.................................................................................................. 23
2.1 History of the flight............................................................................................... 23
2.2 Injuries to persons ................................................................................................ 27
2.3 Damage to the aircraft ......................................................................................... 28
2.4 Other damage...................................................................................................... 28
2.5 Personnel information .......................................................................................... 28
2.6 Aircraft information .............................................................................................. 30
2.7 Meteorological information.................................................................................. 32
2.8 Aids to navigation ................................................................................................ 35
2.9 Air Navigation Service Provider information and other data ............................... 35
2.10 Aerodrome information........................................................................................ 44
2.11 Flight recorders, satellite and other data ............................................................. 44
2.12 Wreckage and impact information ...................................................................... 52
2.13 Medical and pathological information ................................................................. 83
2.14 Fire........................................................................................................................ 86
2.15 Survival aspects.................................................................................................... 87
2.16 Tests and research ............................................................................................... 88
2.17 Organisational and management information ..................................................... 95
2.18 Additional information ......................................................................................... 96
2.19 Useful or effective investigation techniques ...................................................... 101
3 Analysis..............................................................................................................104
3.1 Introduction........................................................................................................ 104
3.2 General............................................................................................................... 104
3.3 The flight before the in-flight break-up.............................................................. 106
3.4 The moment of the in-flight break-up.................................................................110

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3.5 Possible sources of damage................................................................................116
3.6 Weapon systems .................................................................................................126
3.7 Source of the damage........................................................................................ 136
3.8 Simulations to assess the origin of the damage..................................................137
3.9 Blast damage.......................................................................................................147
3.10 Summary of the results of the simulations into the causes of the crash .............149
3.11 The in-flight break-up and its aftermath ............................................................ 150
3.12 Passenger oxygen system .................................................................................. 163
3.13 Recovery and identifcation of victims flight MH17 ............................................ 164
3.14 Survival aspects.................................................................................................. 165
3.15 Recording of radar data ..................................................................................... 166
INTRODUCTION TO PART B ........................................................................................170
4 Decision-making related to flight routes - the system.....................................................171
4.1 Introduction.........................................................................................................171
4.2 States and operators responsibilities ................................................................171
4.3 Frame of reference .............................................................................................175
5 The situation in the eastern part of Ukraine and signals for civil aviation........................177
5.1 Introduction.........................................................................................................177
5.2 Aeronautical information.....................................................................................177
5.3 Shootings involving military aircraft ...................................................................181
5.4 Public interpretations of the conflict by politicians and diplomats .................... 186
5.5 Reports in the media related to possible available weapons capability ............187
5.6 Non-public sources ............................................................................................ 188
5.7 Sub-conclusions ................................................................................................. 190
6 Flight MH17 on 17 july 2014 - Ukraines management of the airspace ..........................191
6.1 The organisation of Ukraines airspace management .........................................191
6.2 Restricting the use of the airspace below FL260 ................................................193
6.3 Restricting the use of the airspace below FL320 ................................................195
6.4 Consequences of the airspace restrictions .........................................................197
6.5 Airspace management in other conflict zones ................................................... 199
6.6 Analysis: Ukrainian airspace management ......................................................... 205
6.7 Sub-conclusions ................................................................................................. 209
7 Flying over Ukraine: what did Malaysia Airlines and others do? .....................................211
7.1 Introduction.........................................................................................................211
7.2 Flight MH17 .........................................................................................................211
7.3 Code sharing with KLM.......................................................................................213
7.4 Flight preparation at Malaysia Airlines ................................................................214
7.5 The risk assessment performed by Malaysia Airlines prior to flight MH17 ........217
7.6 What did ICAO and other states do?................................................................. 220
7.7 What did other operators do? ........................................................................... 223
7.8 Analysis: what did Malaysia Airlines do and what did others do?...................... 226
7.9 Sub-conclusions ................................................................................................. 229

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8 The state of departure of flight MH17 - the role of the Netherlands..............................231
8.1 Introduction........................................................................................................ 231
8.2 Formal responsibilities for flight MH17............................................................... 232
8.3 The options open to the Dutch State in relation to flight routes ....................... 233
8.4 What information did the Dutch State possess and what did it do with it?....... 237
8.5 Analysis............................................................................................................... 242
8.6 Sub-conclusions ................................................................................................. 243
9 Assessing the risks pertaining to conflict zones............................................................244
9.1 Introduction........................................................................................................ 244
9.2 MH17: no integrated risk assessment................................................................. 244
9.3 Aviation in relation to conflict zones: patterns of risk assessment ..................... 245
9.4 Sub-conclusions ..................................................................................................251
CONCLUSIONS AND RECOMMENDATIONS ......................................................................252
10 Conclusions .............................................................................................................253
10.1 Main conclusions ................................................................................................ 253
10.2 Supporting conclusions (causes of the crash) .................................................... 254
10.3 Excluding other causes of the crash................................................................... 256
10.4 Other fndings related to the crash .................................................................... 258
10.5 Supporting conclusions (MH17 flight route)....................................................... 259
10.6 Supporting conclusions (flying over conflict zones) .......................................... 262
11 Recommendations....................................................................................... 263
Level 1: Airspace management in conflict zones....................................................... 263
Level 2: Risk assessment............................................................................................ 265
Level 3: Operator accountability................................................................................ 266
12 Abbreviations and Defnitions .....................................................................................267
Abbreviations............................................................................................................. 267
Defnitions.................................................................................................................. 270
Conventions................................................................................................................276
13 List of appendices....................................................................................................277

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FOREWORD

On 17 July 2014, 298 people lost their lives when the Malaysia Airlines aeroplane they
were in crashed near Hrabove, a village in the eastern part of Ukraine. The crash of flight
MH17 caused the relatives of the occupants profound grief. There was also considerable
dismay all over the world, especially when it became apparent that the aeroplane had
presumably been shot down. The questions evoked by the crash were penetrating: Was
the aeroplane actually shot out of the sky? And, if so, why was the aeroplane flying over
an area where there was an on-going armed conflict?
Four days after the crash, the United Nations Security Council unanimously adopted
Resolution 2166, in which the Security Council expresses its support for an independent
international aviation investigation into the crash. The Dutch Safety Board has investigated
the causes of the MH17 crash and why the aeroplane was flying over the eastern part of
Ukraine. This report contains the results of that investigation. The Board is aware that this
does not answer one important question - the question of who is to blame for the crash.
It is the task of the criminal investigation to provide that answer.
International cooperation
This investigation into the crash of flight MH17 was conducted by the Dutch Safety Board
in accordance with the international regulations that apply to independent accident
investigation, laid down in Annex 13 of the Convention on International Civil Aviation.
Although it soon became clear that the crash of flight MH17 was probably no ordinary
aviation accident, this framework proved to be of great value to this investigation. It
formed the basis for a constructive cooperation between the states involved in the
investigation: the Netherlands, Ukraine, Malaysia, the United States, the United Kingdom,
Australia and the Russian Federation. The representatives of these states, who were
members of the international investigation team, had access to the investigation
information and were able to study and verify it.
This report contains the investigations facts, analysis, conclusions and recommendations.
The Dutch Safety Board would like to highlight two themes, which transcend the
investigated crash but which the Board believes could contribute to improving safety in
international civil aviation.
A blind spot in the risk assessment
The crash involving flight MH17 makes it clear that in its risk assessments, the aviation
sector should take more account of the changing world within which it operates. In this
world armed conflicts are ongoing between governments on the one hand and one or
more non-governmental groups on the other. As a rule, such conflicts are more disorderly
and less predictable than traditional wars between states. The existence and the spread
of advanced weapon systems means that the parties involved in these conflicts may

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possess these types of weapon systems and therefore are able to hit targets at great
distances and altitudes. The aviation sector should take urgent measures to identify,
assess and manage the risks associated with flying over conflict zones more effectively.
Even though flying is a relatively safe form of transport, it still involves risks. Therefore,
the civil aviation sector will always have to fnd a balance between safety and the price
people are willing to pay for it. These considerations will have to be made as carefully as
possible. It is therefore important that the sector innovates when estimating and
assessing statistically improbable scenarios with a major impact. Risk assessments should
not only focus on phenomena that have threatened civil aviation in the past but also
devote attention to new and thus unfamiliar threats in a changing world. The challenge is
to stimulate the imagination of the parties concerned in such a way that improbable
scenarios are also at the forefront of their minds and receive suffcient attention.
No conclusive system of responsibilities
The system of responsibilities for civil aviation safety is not conclusive. In the system,
states have sovereignty over their airspace and are responsible for operators being able
to safely fly through that airspace. However, the crash involving flight MH17 demonstrates
that an unrestricted airspace is not, by defnition, safe. In practice, states embroiled in an
armed conflict rarely close their airspace. Therefore, it is important that these states
responsibility for closing parts of their airspace above an armed conflict is formulated in
a clearer and less non-committal manner.
Since, in the case of flying over conflict zones, one cannot simply rely on an unrestricted
airspace being safe, other parties in the system also bear a major responsibility: airline
operators, other states and international organisations such as ICAO and IATA. They
should form a second barrier, because the principle of sovereignty may give rise to
vulnerabilities. It is up to the parties cited to jointly ensure that the decision-making
process related to flight routes is improved. No single party can achieve this alone. It
requires new structures for cooperation between states and operators, as well as for
mutually sharing information, even if it is meant to be confdential. International
organisations should facilitate these parties in developing these structures.
The Dutch Safety Board is aware that there is no such thing as a perfect risk assessment,
that a comprehensive system of responsibilities is impossible and that not all crashes and
accidents can be prevented. There are, however, possibilities to improve civil aviation
safety. The ball is now in the court of the states and the aviation sector.

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SUMMARY

The crash of flight MH17 raised many questions. What happened exactly? Why was the
aeroplane flying across an area where an armed conflict was being fought? The Dutch
Safety Board answers these questions in this report; it does not address questions of
blame and liability.
Causes of the crash
On 17 July 2014, at 13.20*1 (15.20 CET) a Boeing 777-200 with the Malaysia Airlines
nationality and registration mark 9M-MRD disappeared to the west of the TAMAK air
navigation waypoint in Ukraine. A notifcation containing this information was sent by the
Ukrainian National Bureau of Air Accident Investigation (NBAAI) on 18 July 2014, at
approximately 06.00 (08.00 CET). The NBAAI was notifed by the Ukrainian State Air
Traffc Service Enterprise (UkSATSE) that communication with flight MH17 had been lost.
A signal from the aeroplane´s Emergency Locator Transmitter had been received and its
approximate position had been determined.
The aeroplane impacted the ground in the eastern part of Ukraine. The wreckage was
spread over several sites near the villages of Hrabove, Rozsypne and Petropavlivka. Six
wreckage sites were identifed, spread over about 50 km2. Most of the wreckage was
located in three of these sites to the south-west of the village of Hrabove. This is about
8.5 km east of the last known position of the aeroplane in flight. At two sites, post-impact
fres had occurred.
All 298 persons on board lost their lives.
The in-flight disintegration of the aeroplane near the Ukrainian/Russian border was the
result of the detonation of a warhead. The detonation occurred above the left hand side
of the cockpit. The weapon used was a 9N314M-model warhead carried on the 9M38-
series of missiles, as installed on the Buk surface-to-air missile system.
Other scenarios that could have led to the disintegration of the aeroplane were
considered, analysed and excluded based on the evidence available.
The airworthy aeroplane was under control of Ukrainian air traffc control and was
operated by a licensed and qualifed flight crew.
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*1 All times in this report, unless otherwise indicated are in UTC and Central European (Summer) Time (CET). CET in
the summer is UTC +2. See Section 12 - Abbreviations and Defnitions, for further explanation.

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Flight route over conflict zone
Flight MH17 was shot down over the eastern part of Ukraine, where an armed conflict
broke out in April 2014. At frst this conflict took place mainly on the ground, but as from
the end of April 2014 it expanded into the airspace over the conflict zone: Ukrainian
armed forces helicopters, transport aeroplanes and fghters were downed.
On 14 July, the Ukrainian authorities reported that a military aeroplane, an Antonov An-26,
had been shot down above the eastern part of Ukraine. On 17 July, the authorities
announced that a Sukhoi Su-25 had been shot down over the area on 16 July. According
to the authorities, both aircraft were shot down at an altitude that could only have been
reached by powerful weapon systems. The weapon systems cited by the authorities, a
medium-range surface-to-air missile or an air-to-air missile, could reach the cruising
altitude of civil aeroplanes. Consequently they pose a threat to civil aviation.
Although (Western) intelligence services, politicians and diplomats established the
intensifcation of fghting in the eastern part of Ukraine, on the ground as well as in the
air, it was not recognised that as a result there was an increased risk to civil aeroplanes
flying over the conflict zone at cruising altitude. The focus was mainly on military activities,
and the geopolitical consequences of the conflict.
Ukraines airspace management
With regard to airspace management Ukraine is responsible for the safety of aeroplanes
in that airspace. On 6 June 2014, the airspace above the eastern part of Ukraine was
restricted to civil aviation from the ground up to an altitude of 26,000 feet (FL260). This
enabled military aeroplanes to fly at an altitude that was considered safe from attacks
from the ground and eliminated the risk that they would encounter civil aeroplanes,
which flew above FL260. The authorities automatically assumed that aeroplanes flying at
a higher altitude than that considered safe for military aeroplanes, were also safe.
On 14 July 2014, the Ukrainian authorities increased the upper limit of the restricted
airspace imposed on civil aviation to an altitude of 32,000 feet (FL320). The exact underlying reason for this decision remains unclear.
The Ukrainian authorities did not consider closing the airspace over the eastern part of
Ukraine to civil aviation completely. The statements made by the Ukrainian authorities on
14 and 17 July 2014, related to the military aeroplanes being shot down, mentioned the
use of weapon systems that can reach the cruising altitude of civil aeroplanes. In the
judgment of the Dutch Safety Board, these statements provided suffcient reason for
closing the airspace over the conflict zone as a precaution.
Choice of flight route by Malaysia Airlines and other airlines
Malaysia Airlines assumed that the unrestricted airspace over Ukraine was safe. The
situation in the eastern part of Ukraine did not constitute a reason for reconsidering the
route. The operator stated that it did not possess any information that flight MH17, or
other flights, faced any danger when flying over Ukraine.

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Not only Malaysia Airlines, but almost all airlines that used routes over the conflict zone
continued to do so during the period in which the armed conflict was expanding into the
airspace. On the day of the crash alone, 160 flights were conducted above the eastern
part of Ukraine - until the airspace was closed.
Other states and the state of departure (the Netherlands)
The Chicago Convention provides states with the option of imposing a flight prohibition
or restrictions on airlines and issuing recommendations related to the use of foreign
airspace. Some states, such as the United States, the United Kingdom, France and
Germany, use this option with regard to their resident airlines. Although flight MH17 took
off from Dutch soil the Netherlands did not bear any formal responsibility for the flight,
because it concerned a non-Dutch airline. The fact that Malaysia Airlines was operating
the flight as KLMs code share partner did not provide any legal authority either.
During the period in which the conflict in the eastern part of Ukraine expanded into the
airspace over the conflict zone, from the end of April 2014 up to the crash of flight MH17,
not a single state or international organisation explicitly warned of any risks to civil
aviation and not a single state prohibited its airlines or airmen from using the airspace
over the area or imposed other restrictions.
At the Dutch Safety Boards request, the Dutch Review Committee for the Intelligence
and Security Services (CTIVD) examined whether the Dutch intelligence and security
services possessed any information that could have been important for the safety of
flight MH17. The services had no indication that the warring factions intended to shoot
down civil aeroplanes. The services did not have any information that the groups that
were fghting against the Ukrainian government in the eastern part of Ukraine possessed
medium or long-range surface-to-air missiles.
Possibilities for improvement
The crash of MH17 demonstrates than an unrestricted airspace is not, by defnition, safe
if the state managing that airspace is dealing with an armed conflict. The reality is that
states involved in an armed conflict rarely close their airspace. This means that the
principle of sovereignty related to airspace management can give rise to vulnerability. In
the Boards opinion, states involved in armed conflicts should give more consideration to
closing their airspace as a precaution. More effective incentives are needed to encourage
them to do so.
Airline operators may not assume in advance that an unrestricted airspace above a
conflict zone is safe. The fundamental principle currently adopted by operators is that
they use the airspace, unless doing so is demonstrably unsafe. In their risk analyses,
operators should take greater account of uncertainties and risk-increasing factors, such
as when a conflict expands into the airspace. The current regulations do not stipulate
that operators shall assess the risks involved in overflying conflict areas.
Operators themselves should gather more information to be able to perform an adequate
risk assessment. This information can largely be acquired by consulting open sources,
but in the case of conflict zones operators also need confdential information from states

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with intelligence capabilities. Vital in this respect is the sharing of information between
states, between states and operators and between operators.
Not only the gathering of information, but also combining information in the felds of
safety and security, as well as on developments on the ground and in the air proves
important. In this regard, international regulations (the Chicago Convention) are currently
too divided across these different felds. It was established that there are gaps between
the various responsibilities, for which a solution should be found.
Recommendations
Level 1: Airspace management in conflict zones
To ICAO:

1. Incorporate in Standards that states dealing with an armed conflict in their territory
shall at an early stage publish information that is as specifc as possible regarding the
nature and extent of threats of that conflict and its consequences for civil aviation.
Provide clear defnitions of relevant terms, such as conflict zone and armed conflict.
2. Ask states dealing with an armed conflict for additional information if published
aeronautical or other publications give cause to do so; offer assistance and consider
issuing a State Letter if, in the opinion of ICAO, states do not suffciently fulfl their
responsibility for the safety of the airspace for civil aviation.
3. Update Standards and Recommended Practices related to the consequences of
armed conflicts for civil aviation, and convert the relevant Recommended Practices
into Standards as much as possible so that states will be able to take unambiguous
measures if the safety of civil aviation may be at issue.
To ICAO Member States:
4. Ensure that states responsibilities related to the safety of their airspace are stricter
defned in the Chicago Convention and the underlying Standards and Recommended
Practices, so that it is clear in which cases the airspace should be closed.
The states most closely involved in the investigation into the crash of flight MH17
could initiate this.
Level 2: Risk assessment
To ICAO and IATA:
5. Encourage states and operators who have relevant information about threats within a
foreign airspace to make this available in a timely manner to others who have an
interest in it in connection with aviation safety. Ensure that the relevant paragraphs in
the ICAO Annexes concerned are extended and made more strict.

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To ICAO:
6. Amend relevant Standards so that risk assessments shall also cover threats to civil
aviation in the airspace at cruising level, especially when overflying conflict zones. Risk
increasing and uncertain factors need to be included in these risk assessments in
accordance with the proposals made by the ICAO Working Group on Threat and Risk.
To IATA:
7. Ensure that the Standards regarding risk assessments are also reflected in the IATA
Operational Safety Audits (IOSA).
To states (State of Operator):
8. Ensure that airline operators are required through national regulations to make risk
assessments of overflying conflict zones. Risk increasing and uncertain factors need
to be included in these assessments in accordance with the proposals made by the
ICAO Working Group on Threat and Risk.
To ICAO and IATA:
9. In addition to actions already taken, such as the website (ICAO Conflict Zone
Information Repository) with notifcations about conflict zones, a platform for
exchanging experiences and good practices regarding assessing the risks related to
the overflying of conflict zones is to be initiated.
Level 3: Operator accountability
To IATA:
10. Ensure that IATA member airlines agree on how to publish clear information to
potential passengers about flight routes over conflict zones and on making operators
accountable for that information.
To operators:
11. Provide public accountability for flight routes chosen, at least once a year.
In Section 11 the recommendations are described in more detail.

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

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1 INTRODUCTION

This report contains the product of the investigation that was conducted by the Dutch
Safety Board and its international partners into the crash of flight MH17 on 17 July 2014.
The report consists of two parts. The frst part focuses on the causes of the crash. The
second part addresses the flight route of flight MH17 on July 17 2014, and the decisionmaking processes regarding flying over conflict areas.
1.1 The investigation
Following the crash of Malaysia Airlines flight MH17 near the village of Hrabove (in the
eastern part of Ukraine), the Ukrainian authorities initiated an investigation into the accident,
in accordance with ICAO Annex 13. During the frst days of the investigation, the Ukrainian
authorities requested the Netherlands, the state with the largest number of nationals on
board the aeroplane, to take over the investigation. The Netherlands granted the request
made by the Ukrainian authorities. On 23 July 2014, Ukraine delegated the investigation to
the Netherlands. Following the provisions of ICAO Annex 13, from that date the Netherlands
was the State conducting the investigation. As the accident investigation authority of the
Netherlands, the Dutch Safety Board was tasked to conduct the investigation.
A few days before, on 18 July 2014, the Dutch Safety Board had already launched an
investigation into the decision-making related to flying over conflict zones, because
questions were raised over whether civil airline operators should have been flying over
the eastern part of Ukraine, an area in which an armed conflict had been ongoing for
several months. As the route of flight MH17 is one of the circumstances contributing to
the crash of flight MH17, the Dutch Safety Board decided to combine the investigation
into the causes of the crash with the already ongoing investigation into the decisionmaking related to flight routes, and to present the fndings in one report.
The investigation was performed in accordance with the provisions of Annex 13 - Aircraft
Accident and Incident Investigation to the Convention of International Civil Aviation. The
Standards and Recommended Practices in Annex 13 are prescribed for the conduct of
civil aviation accident investigation.
1.2 Purpose and scope of the investigation
The purpose of this investigation was to establish the causes of the crash and the factors
that contributed to the crash. On 21 July 2014, the United Nations Security Council
unanimously adopted a resolution, concerning the crash of flight MH17.*2 The resolution
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*2 UN Security Council, Resolution 2166 (2014), S/res2166 (2014), 21 July 2014

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expressed support for the efforts to establish a full, thorough and independent
international investigation into the incident in accordance with international civil aviation
guidelines and called on all United Nations Member States to provide any requested
assistance to civil and criminal investigations.
This investigation had two objectives. Firstly, the Dutch Safety Board wanted to establish
the causes of the crash and wished to inform the relatives of the crew and the passengers,
other parties concerned, and those having a special interest in the circumstances of the
crash and the investigation accordingly. Secondly, the Dutch Safety Board intended to
initiate appropriate safety actions in order to minimise the chance of similar occurrences
in the future.
The investigation report provides a detailed description of the sequence of events of
flight MH17 from the departure airport up to and including the ground impact. It
describes and analyses how the flight was conducted, how the decisions related to the
use of its airspace were taken by Ukraine, how the decision related to flying over the
eastern part of Ukraine were taken by Malaysia Airlines, and other airline operators, and
how the decision-making pertaining to flying over conflict areas is generally made.
Finally, it also addresses the role of the Netherlands, as the state of departure of flight
MH17, and other states with regard to flying over conflict areas.
The key questions are:

What caused the crash of flight MH17?
How and why were decisions made to use MH17s flight route?
How is the decision-making process related to flying over conflict zones generally
organised?
What lessons can be learned from the investigation to improve flight safety and
security?

In accordance with Annex 13, it is not the purpose of this investigation to apportion
blame or liability. The sole objective of the Annex 13 investigation and the Final Report is
the prevention of accidents and incidents.
1.3 Investigation methodology and parties concerned
The investigation was conducted by the Dutch Safety Board. In addition to investigators
from the Dutch Safety Board, the states listed below participated in the investigation and
appointed an Accredited Representative:
Ukraine (State of Occurrence);
Malaysia (State of the Operator and State of Registry);
United States of America (State of Design and Manufacture of the aeroplane);
United Kingdom (State of Design and Manufacture of the engines);

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Australia (State that provided information on request - photographs of aeroplane
wreckage parts at the crash area), and
Russian Federation (State that provided information on request - radar and communication data and information on weapon systems).
In addition to the states mentioned above, other states also had a special interest in the
investigation because they lost citizens in the crash. In accordance with paragraph 5.27
of Annex 13, experts from the following states were invited to view the recovered
wreckage parts: Belgium, Canada, Germany, Indonesia, Israel, Italy, New Zealand,
the Philippines, and Vietnam. Some of these states were included because some
passengers held multiple nationalities.
In accordance with paragraph 6.3 of Annex 13, the Dutch Safety Board sent the draft
Final Report to the Accredited Representatives of the states participating in the
investigation, inviting their signifcant and substantiated comments. In addition, (sections
of) the draft Final Report were sent to other parties involved in the investigation (see
Appendices V and W).
Simultaneously with this investigation report the Dutch Safety Board has published a
separate document in which the investigation methodology used, and the choices that
were made in the process are accounted for.*3
1.4 Wreckage recovery
As the crash area was in an area of armed conflict, it was for a long time not safe for the
investigators to travel to the crash area to perform an investigation and to recover the
wreckage. The frst opportunity that was deemed suffciently safe was from 4 to
22 November 2014, about four months after the crash. The second opportunity was from
20 to 28 March 2015 and the third opportunity from 19 April to 2 May 2015. These
recovery missions were organised by the Dutch Ministry of Defence. At the crash area,
assistance was provided by the Organisation for Security and Cooperation in Europe
(OSCE), the State Emergency Service (SES), and local residents.
Due to the limited time investigators had access to the wreckage area and because the
wreckage was located in six sites spread out in an area of approximately 50 km2, the
Dutch Safety Boards frst priority was to recover parts that were of specifc importance
to the investigation. The majority of the wreckage that was recovered from flight MH17
was secured during the frst recovery mission. In addition, some wreckage parts,
recovered during the second and third recovery missions, were used during the
investigation.
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*3 Dutch Safety Board, MH17 - About the investigation, October 2015.

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1.5 Preliminary report
The Dutch Safety Board published a Preliminary Report on 9 September 2014. The fndings
published in the Preliminary Report are listed below:
1. According to the information received from Malaysia Airlines the crew was properly
licensed and had valid medical certifcates to conduct the flight.
2. According to the documents, the aircraft was in an airworthy condition at departure
from Amsterdam Airport Schiphol. There were no known technical malfunctions.
3. No technical malfunctions or warnings in relation to the event flight were found on
Flight Data Recorder data.
4. The engine parameters were consistent with normal operation during the eventflight.
No engine or aircraft system warnings or cautions were detected.
5. No aural alerts or warnings of aircraft system malfunctions were heard on the Cockpit
Voice Recorder. The communication between the flight crew members gave no
indication of any malfunction or emergency prior to the occurrence.
6. At the time of the occurrence, flight MH17 was flying at Flight Level 330 (FL330) (See
Abbreviations and Defnitions for explanation on Flight Level/FL) in unrestricted
airspace of the Dnipropetrovsk (UKDV) Flight Information Region (FIR) in the eastern
part of Ukraine. The aircraft flew on a constant heading, speed and altitude when the
Flight Data Recording ended. Ukrainian State Air Traffc Service Enterprise (UkSATSE)
had issued NOTAMs of restricted access to the airspace below FL320.
7. The last radio transmission by the flight crew began at 13.19:56 (15.19:56 CET) and
ended at 13.19:59 (15.19:59 CET).
8. The last radio transmissions made by Dnipropetrovsk air traffc control centre to flight
MH17 began at 13.20:00 (15.20:00 CET) and ended at 13.22:02 (15.22:02 CET). The
crew of flight MH17 did not respond to these radio transmissions.
9. No distress messages were received by the air traffc control.
10. According to radar data, three commercial aircraft were in the same Control Area as
flight MH17 at the time of the occurrence. All were under control of Dnipro Radar. At
13.20 (15.20 CET) the distance between the closest aircraft and MH17 was
approximately 30 km.
11. Damage observed on the forward fuselage and cockpit section of the aircraft appears
to indicate that there were impacts from a large number of high-energy objects (See
Section 12, Abbreviations and Defnitions) from outside the aircraft.
12. The pattern of damage observed in the forward fuselage and cockpit section of the
aircraft was not consistent with the damage that would be expected from any known
failure mode of the aircraft, its engines or systems.
13. The fact that there were many pieces of aircraft structure distributed over a large
area, indicated that the aircraft broke up in the air.
14. Based on the preliminary fndings to date (9 September 2014), no indications of any
technical or operational issues were found with the aircraft or crew prior to the ending
of the CVR and FDR recording at 13.20:03 (15.20:03 CET).
15. The damage observed in the forward section of the aircraft appears to indicate that
the aircraft was penetrated by a large number of high-energy objects from outside the
aircraft. It is likely that this damage resulted in a loss of structural integrity of the
aircraft, leading to an in-flight break-up.

19

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The Preliminary Report stated that the fndings were preliminary and that further work
was required to be performed, in order to substantiate factual information regarding:
Analyses of data, including Cockpit Voice Recorder, Flight Data Recorder and other
sources, recorded onboard the aeroplane;
Analyses of recorded air traffc control surveillance data;
Analysis of meteorological circumstances;
Forensic examination of wreckage recovered and possible foreign objects, if found;
Results of the pathological investigation;
Analyses of the in-flight break-up sequence;
Assessment of the operators and State of Occurrences management of flight safety
over a region of conflict or high security risk;
Any other aspects that are identifed during the investigation.
On 10 September 2014, one day after the publication of the report, an amendment was
made to the Dutch translation of the English report. On page 14, the following sentence
was deleted: De NOTAM met luchtruimbeperking was uitgevaardigd in reactie op het
neerschieten van een Antonov 24 vliegtuig op 14 juli dat op een hoogte van FL210 vloog.
[translated: The restricted area NOTAM was issued in response to the loss of an Antonov
24 aeroplane that was shot down at FL210 on 14 July.] The sentence was deleted because
during this stage of the investigation it could not be established with complete certainty
whether this information was accurate. When translating the original English report into
Dutch, the relevant sentence was accidentally not removed. However, this did not affect
the provisional conclusions in the preliminary report.
1.6 Other investigations
In addition to the investigation discussed above, several other investigations were
initiated, both by the Dutch Safety Board and other organisations:
Dutch Safety Board investigations - The Dutch Safety Board initiated two other
investigations related to the crash of flight MH17. One focused on the availability of
passenger information following the crash of flight MH17. The other was aimed at
answering the question whether or not the occupants of flight MH17 were aware of
the crash, and how their remains were recovered. The fndings from the investigation
into passenger information are published simultaneously in a separate report; the
fndings regarding awareness of occupants were published in this report. The
investigation reports of the Dutch Safety Board were published simultaneously and
are available on the Boards website.
Criminal investigation into flight MH17 - Parallel to and separately from the work of
the Dutch Safety Board, the Joint Investigation Team is conducting a criminal
investigation into the crash in order to gather evidence and to bring the perpetrators
to justice. The Joint Investigation Team consists of police offcers and public
prosecutors from Australia, Belgium, Malaysia, the Netherlands, and Ukraine. It is
being coordinated by the public prosecutor from the Netherlands.
Victim identifcation investigation - The victims were transported from Ukraine to the
Netherlands by the Royal Netherlands Air Force and Royal Australian Air Force. The

20

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identifcation of all the victims took place at the Korporaal van Oudheusden barracks
in Hilversum. The identifcation was carried out by a team of 120 forensic specialists.
In addition to the National Forensic Investigation Team of the Netherlands (LTFO),
80 forensic specialists from Australia, Belgium, Germany, United Kingdom, Indonesia,
Malaysia and New Zealand participated.
1.7 Reading guide
The report is divided into:
Part A: containing the fndings of the investigation into the causes of the crash of the
aeroplane.
Part B: containing the fndings of the investigation into flying over conflict areas.
The conclusions and recommendations made as a result of the investigation.
Part A contains a record of the facts and circumstances established in the investigation:
the sequence of events, flight crew qualifcations, aeroplane information, flight recorders,
air traffc services and radars, weather, flight route information, the wreckage, medical
and pathological information, and tests and research. Following the factual material, the
signifcance of the relevant facts and circumstances presented are analysed, in order to
determine which events contributed to the crash. The analysis is primarily divided into six
subjects:
1. General matters, including the flight crews qualifcations and the airworthiness of the
aeroplane;
2. The flight before the in-flight break-up, including pre-flight planning, weather
considerations and flight operations;
3. The moment of the in-flight break-up;
4. The in-flight break-up, its aftermath, and causes of the crash;
5. Survival aspects;
6. The recording of radar surveillance data.
Part B concerns the decision-making process related to flight MH17. This part contains
six sections:
1. A description of the system of responsibilities of parties involved;
2. Indicators related to the situation in the eastern part of Ukraine in the months prior to
the crash of flight MH17;
3. The airspace management by Ukraine in the period up to and including 17 July 2014;
4. The route and flight operations of flight MH17, the decisions made by the airline,
Malaysia Airlines, and the decisions made by other airlines and other states with
regard to flying over the conflict area in the eastern part of Ukraine;
5. The role of the Netherlands, as the state of departure of flight MH17, with regard to
flying over conflict areas;
6. Risk assessment related to flying over conflict zones.
Each of these sections contains both fndings and analysis.

21

.20
The appendices that were produced as a part of this report are either published separately
in an appendix to this report or on the Dutch Safety Boards website: safetyboard.nl.
Section 13 gives an overview of the appendices.

22

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PART A:
Causes of the crash

This part of the report focuses on the causes of
the crash of Malaysia Airlines Boeing 777-200,
9M-MRD, flight MH17 on 17 July 2014.

23

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PART A: CAUSES OF THE CRASH

2 Factual information.............. 23
3 Analysis.............................104

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2 FACTUAL INFORMATION

2.1 History of the flight
On 17 July 2014, the day of the crash, the subject aeroplane, a Malaysia Airlines Boeing
777-200 with nationality and registration marks 9M-MRD, had arrived at its gate at
Amsterdam Airport Schiphol (hereafter, Schiphol) in the Netherlands at 04.36 (06.36 CET)
from Kuala Lumpur International Airport (hereafter, Kuala Lumpur) in Malaysia.
At 10.13 (12.13 CET), after having been serviced and prepared for flight, the aeroplane
left gate G3, thirteen minutes later than planned, primarily due to overbooking and the
late arrival of some transfer passengers, on a scheduled passenger flight to Kuala Lumpur
with flight number MH17.
Malaysia Airlines had prepared and fled an air traffc control flight plan. The flight crew
was provided by the ground handling agent with an operational flight plan, NOTAMs,*4
load information and weather information prior to departure. The material had been
prepared in Kuala Lumpur by Malaysia Airlines. The operational flight plan contained
detailed route information, a summary of the mass data, fuel information and information
on the winds and temperatures along the route. It was standard practice for the flight
crew to study the material provided in order to adjust the fuel load or route planned if
the pilot in command deemed this necessary.
There were 298 persons, including 283 passengers on board the aeroplane. The crew
was composed of four flight crew members and 11 cabin crew members.
The aeroplane took off from Schiphol on runway 36C at 10.31 (12.31 CET). The aeroplane
flew to the north of Amsterdam, and followed standard instrument departure route
NYKER 3W to a south-easterly direction towards Germany. The aeroplane climbed in a
series of steps to FL250 before crossing the Dutch/German border at air navigation
waypoint SONEB. From SONEB the route continued south-east towards Poland. The
aeroplane then continued, in accordance with the air traffc control flight plan, across
Poland. After passing overhead Warsaw, the flight continued into Ukrainian airspace.
The flight was planned to initially cruise at FL310, climbing to FL330 in Polish airspace
and climbing further to FL350 when passing air navigation waypoint PEKIT in Ukrainian
airspace. After having crossed Ukrainian airspace, the flight was planned to continue over
the Russian Federation towards the Caspian Sea, over north-east Iran, Afghanistan and
Pakistan before passing overhead Delhi, India and then crossing the Bay of Bengal
--------------------
*4 A notice distributed by means of telecommunication containing information concerning the establishment,
condition or change in any aeronautical facility, service, procedure or hazard, the timely knowledge of which is
essential to personnel concerned with flight operations.

25

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towards Thailand before turning south towards Kuala Lumpur in Malaysia. The flight
would remain at FL350 until Thai airspace when a climb to FL370 would be made before
the top of descent prior to the landing at Kuala Lumpur (see Figure 1) after a flight of
approximately eleven and a half hours.
In the air traffc control flight plan (see Appendix C), a climb on airway L980 from FL330
to FL350 was planned for at air navigation waypoint PEKIT. It was noted that the airlines
operational flight plan called for the climb from FL330 to FL350 to be made at air
navigation waypoint EDIMI, 74 NM before PEKIT. The reason for having planned two
different positions to climb in the two flight plans is explained in paragraph 3.3.2.1.

https://d.radikal.ru/d06/1907/94/b2d324b2e0d6.png
Figure 1: Diagram of the route planned. (Source: Google, INEGI)

According to data from the Ukrainian State Air Traffc Service Enterprise, the aeroplane
was flying at FL330 and, at about 12.53 (14.53 CET), entered Dnipropetrovsk Radar
Control (Dnipro Radar) Sector 2 of the Dnipropetrovsk (UKDV) Flight Information Region
(FIR). Dnipro Radar Sector 2 is a part of Ukrainian airspace. Figure 2 shows the details of
the airspace structure in Ukraine

26

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https://c.radikal.ru/c42/1907/22/ad4354cb5a93.png
Figure 2: Ukrainian FIRs and Sectors in UKDV FIR. (Source: Google, Landsat)

On establishing initial contact with the flight crew, at 12.53 (14.53 CET) and at a position
about 6 NM before PEKIT, Dnipro Radar asked whether the aeroplane could climb to
FL350 in accordance with the air traffc control flight plan. The flight crew responded,
without providing a specifc reason (see Table 1 for an extract of the air traffc control
transcript), that they were unable to comply with the request and requested to remain at
FL330. This matter is discussed and analysed in paragraph 3.3.2.1.

Parties communicating         Text
------------------------------------------
ATC to MH17                      Malaysian one seven, Dnipro Radar, hello, identifed, advise able to climb
                                        flight level three fve zero?
---------------------------------------------------------------------
MH17 to ATC                      Malaysian one seven, negative, maintain three three zero
---------------------------------------------------------------------
ATC to MH17                     Malaysian one seven, roger
---------------------------------------------------------------------

Table 1: Extract from Air Traffc Control (ATC) transcript. (See Appendix G for a full transcript of the communications)

Dnipro Radar had identifed a potential loss of separation between flight MH17 and another
Boeing 777 aeroplane also flying at FL330 approaching flight MH17 from behind. In order
to solve the potential conflict, Dnipro Radar cleared the other traffc to climb to FL350.
At 13.00 (15.00 CET), at a position about 40 NM after waypoint PEKIT, the flight crew of
MH17 made a request to Dnipro Radar to change their track by turning to the left and
deviating 20 NM north, in order to avoid the weather associated with the cumulonimbus
clouds on the aeroplanes track. The flight crew also inquired whether FL340 was
available. Dnipro Radar cleared the aeroplane to deviate around the weather as requested,
but instructed the aeroplane to remain at FL330 due to conflicting civil aviation.

27

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Flight Data Recorder and radar data both show that after deviating from the route to the
left by about 6.5 NM (laterally from the centreline of the original track), the aeroplane
turned back towards airway L980 centreline at 13.05 (15.05 CET).
Two minutes later at 13.07 (15.07 CET), Sector 2 of Dnipropetrovsk Area Control Centre
transferred the flight to Sector 4 of Dnipropetrovsk Area Control Centre, a sector that
also uses the callsign Dnipro Radar.
After a further slight turn to the right at 13.15 (15.15 CET), radar data showed that at 13.19
(15.19 CET) the aeroplane was at a position 3.6 NM north of the centreline of airway L980,
almost back on its original course, between air navigation waypoint GANRA and waypoint
TAMAK. From this point, Dnipro Radar cleared the aeroplane to fly directly to air navigation
waypoint RND, about 45 NM south-east of TAMAK and south of the planned airway. The
boundary between Ukrainian and Russian Federation airspace on the airway is at air
navigation waypoint TAMAK. Figure 3 shows the route flown by MH17 across the eastern
part of Ukraine and the planned route into Russian Federation airspace.

https://b.radikal.ru/b31/1907/87/47ccb70ba558.png
Figure 3: Route of flight MH17 across the eastern part of Ukraine. The light grey shading shows the area that
              is 5 NM left and right of the centreline of airway L980. The black line shows flight MH17 deviating
              from airway L980 between air navigation waypoints PEKIT and TAGAN. (Source: Google, Landstat)

The clearance direct to air navigation waypoint RND was acknowledged by the flight crew
at 13.19:56 (15.19:56 CET). This was the last radio transmission from flight MH17. Dnipro
Radar immediately, at 13.20:00 (15.20:00 CET), advised flight MH17 to proceed to expect
a clearance direct to waypoint TIKNA after RND. TIKNA is an air navigation waypoint in
the Russian Federation located on airway A87. According to the air traffc control flight
plan, flight MH17 had planned to use airway A87 after crossing the Ukrainian/Russian
Federation border. No acknowledgement or further radio communication from flight
MH17 was received.
The aeroplane impacted the ground near the village of Hrabove in the eastern part of
Ukraine. The moment of impact could not be determined exactly. However, in various
articles and videos from the media, local habitants described parts of the aeroplane

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falling from the sky and some wreckage and human remains impacted houses and
gardens at about 16.30 local time (15.30 CET). Wreckage parts of the aeroplane were
spread over a number of sites, also near the villages of Rozsypne and Petropavlivka.
Wreckage was identifed within six different sites spread over an area of about 50 km2.
The majority of the wreckage was located in three sites (see paragraph 2.12.2) southwest of Hrabove. These three sites were located about 8.5 km on a bearing of 080 from
the last known position of the aeroplane in flight. At two of these sites, post-impact fres
had occurred.
2.2 Injuries to persons
Injuries  Flight crew   Cabin crew   Passengers   Others   Total
-------------------------------------------------------------------
Fatal                4                 11               283*5           0          298
--------------------------------------------------------------------
Serious            0                  0                 0                 0              0
--------------------------------------------------------------------------------
Minor/None      0                  0                 0                 0              0
--------------------------------------------------------------------------------
Total                4                11                283               0            298
--------------------------------------------------------------------------------
Table 2: Injury chart.
The occupants of the aeroplane were citizens of the following states:

Netherlands         193      Belgium        4
Malaysia                43      Philippines    3
Australia               27      Canada         1
Indonesia              12      New Zealand 1
United Kingdom     10           
Germany                4      Total          298

The nationalities indicated above reflect the information provided by the operator, based
on the passports that were used for check-in. 24 passengers had multiple nationalities
resulting in differences in nationality numbers published by other sources. These
nationalities were Australia, Belgium, Germany, Indonesia, Israel, Italy, Malaysia, the
Netherlands, United Kingdom, United States and Vietnam. Further information on the
nationalities of the occupants is included in the MH17 Passenger Information report.
No reports were received regarding injuries or fatalities to persons on the ground as a
result of the crash.
---------------------------
*5 Includes three infants who had not reached the age of 2 years.

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2.3 Damage to the aircraft

The aeroplane was destroyed.

2.4 Other damage

Damage was caused to houses, buildings, parts of the infrastructure and agricultural
ground as a result of a combination of the aeroplane wreckage, human remains, cargo
and baggage falling on the ground and the post-crash fre. This information was obtained
via photos taken by the investigators and police, as well as media information and
material published on the internet.

2.5 Personnel information

2.5.1 Flight crew
The flight crew consisted of two Captains and two First Offcers, all of whom were fully
qualifed to operate a Boeing 777-200. Further details are recorded in Table 3.
------------------------------------------------------------------------------
Flight crew member                     Qualifcation                 Data
Captain (Team A)                              License                      Airline Transport Pilot Licence
Malaysian nationality                         777 type rating          Valid to: 31 October 2014
male, age 44                                    Base check                Valid to: 29 October 2014
                                                       Line check                 Valid to: 31 October 2014
                                                       Medical certifcate       Class 1
                                                                                       Valid to: 31 October 2014
                                                       Flying experience       Total: 12,385.57 hours
                                                                                       777-200: 7,303.15 hours
                                                                                       Last 90 days: 116.02 hours
                                                                                       Last 30 days: 34.54 hours
                                                                                       Last 24 hours: 0.0 hours
----------------------------------------------------------------------------------------------------
First Offcer (Team A)                        License                      Airline Transport Pilot Licence
Malaysian nationality                        777 type rating          Valid to: 31 March 2015
male, age 26                                   Base check                Valid to: 13 December 2014
                                                      Line check                 Valid to: 28 February 2015
                                                      Medical certifcate       Class 1
                                                                                      Valid to: 31 March 2015
                                                      Flying experience       Total: 4,058.49 hours
                                                                                      777-200: 296.22 hours
                                                                                      Last 90 days: 117.58 hours
                                                                                      Last 30 days: 40.13 hours
                                                                                      Last 24 hours: 0.0 hours

30

.29
-----------------------------------------------------------------------------------------------------
Flight crew member                      Qualifcation                   Data
-----------------------------------------------------------------------------------------------------
Captain (Team B)                              License                         Airline Transport Pilot Licence
Malaysian nationality                         777 type rating              Valid to: 31 October 2014
male, age 49                                    Base check                    Valid to: 20 August 2014
                                                       Line check                     Valid to: 30 November 2014
                                                       Medical certifcate           Class 1
                                                                                           Valid to: 31 October 2014
                                                       Flying experience           Total: 13,239.08 hours
                                                                                           777-200: 7,989.14 hours
                                                                                           Last 90 days: 152.31 hours
                                                                                           Last 30 days: 62.21 hours
                                                                                           Last 24 hours: 0.0 hours
----------------------------------------------------------------------------------------------------
First Offcer (Team B)                         License                         Airline Transport Pilot Licence
Malaysian nationality                         777 type rating              Valid to: 30 November 2014
male, age 29                                    Base check                    Valid to: 6 January 2015
                                                       Line check                     Valid to: 31 March 2015
                                                       Medical certifcate           Class 1
                                                                                           Valid to: 30 November 2014
                                                       Flying experience           Total: 3,190.12 hours
                                                                                           777-200: 227.48 hours
                                                                                           Last 90 days: 138.14 hours
                                                                                           Last 30 days: 28.24 hours
                                                                                           Last 24 hours: 0.0 hours
-------------------------------------------------------------------------------------------------------------
Table 3: Flight crew information

The operators Operations Manual Part A sets out procedures to meet the applicable
flight time limitations regulations. For a flight of around 12 hours, four pilots, two of
whom are Captains, are required. On flight MH17, two captains and two First Offcers
were scheduled to operate the flight in two teams; Team A and Team B. Team A flew the
frst part of the flight and were at the controls at the time of the crash, the Captain in the
left pilot seat and the First Offcer in the right pilot seat. When not acting as pilots, it is
common practice for the other flight crew members (Team B, in this case) to rest in the
bunks that are located behind the cockpit, in a seat in business class or to occupy the
observer seats in the cockpit.
2.5.2 Cabin crew
There were eleven cabin crew members. The investigation did not consider cabin crew
training and qualifcation relevant for the investigation into the causes of the crash.
Hence, the cabin crew records were not reviewed and analysed.
Summary of the crew information

According to the documents and information received from Malaysia Airlines the
flight crew was properly licensed to conduct the flight. The flight crew consisted of
two Captains, two First Offcers and eleven cabin crew members.


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