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 13.201 (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 notification 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 notified by the Ukrainian State Air Traffic 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 identified, 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 fires 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 traffic control and was operated by a licensed and qualified flight crew. 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 Definitions, for further explanation. 9 of 279 Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
10. 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 first 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 fighters 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 intensification of fighting 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. Ukraine’s 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 under lying 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 sufficient 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. 10 of 279 Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
11. 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 KLM’s 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 Board’s 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 fighting 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 definition, 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 Board’s 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 confidential information from states 11 of 279 Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
12. 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 fields 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 fields. 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 specific as possible regarding the nature and extent of threats of that conflict and its consequences for civil aviation. Provide clear definitions 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 sufficiently fulfil 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 defined 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. 12 of 279 Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
13. 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 notifications 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 M. Visser Chairman, Dutch Safety Board General Secretary 13 of 279 Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
14. 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 first part focuses on the causes of the crash. The second part addresses the flight route of flight MH17 on July 17 2014, and the decision- making 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 first 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 decision- making related to flight routes, and to present the findings 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 2 UN Security Council, Resolution 2166 (2014), S/res2166 (2014), 21 July 2014. 14 of 279 Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
15. 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 MH17’s 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); 15 of 279 Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
16. 16 of 279 • 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 communi cation 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 significant 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 first opportunity that was deemed sufficiently 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 Board’s first priority was to recover parts that were of specific importance to the investigation. The majority of the wreckage that was recovered from flight MH17 was secured during the first recovery mission. In addition, some wreckage parts, recovered during the second and third recovery missions, were used during the investigation. 3 Dutch Safety Board, MH17 - About the investigation, October 2015. Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
17. 17 of 279 1.5 Preliminary report The Dutch Safety Board published a Preliminary Report on 9 September 2014. The findings 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 certificates 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 Definitions 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 Traffic 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 traffic 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 traffic 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 Definitions) 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 findings 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. Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
18. 18 of 279 The Preliminary Report stated that the findings 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 traffic 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 operator’s and State of Occurrence’s management of flight safety over a region of conflict or high security risk; • Any other aspects that are identified 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 findings from the investigation into passenger information are published simultaneously in a separate report; the findings 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 Board’s 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 officers and public prosecutors from Australia, Belgium, Malaysia, the Netherlands, and Ukraine. It is being coordinated by the public prosecutor from the Netherlands. • Victim identification investigation - The victims were transported from Ukraine to the Netherlands by the Royal Netherlands Air Force and Royal Australian Air Force. The Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
19. 19 of 279 identification of all the victims took place at the Korporaal van Oudheusden barracks in Hilversum. The identification 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 findings of the investigation into the causes of the crash of the aeroplane. • Part B: containing the findings 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 qualifications, aeroplane information, flight recorders, air traffic services and radars, weather, flight route information, the wreckage, medical and pathological information, and tests and research. Following the factual material, the significance 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 crew’s qualifications 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 findings and analysis. Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
20. 20 of 279 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 Board’s website:
www.safetyboard.nl. Section 13 gives an overview of the appendices. Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
21. 21 of 279 MH17 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. Foreword Contents 1 Introduction Summary Part A: 3 Analysis Part A: 2 Factual information Part B: 4 Decision making Part B: Introduction to Part B Part B: 6 Flight MH17 Part B: 5 The situation Part B: 8 The state of departure Part B: 7 Flying over Ukraine 10 Conclusions Part B: 9 Assessing the risks 12 Abbreviations and Definitions 11 Recommendations 13 List of appendices
Тема: Загадочные авиакатастрофы прошлого и настоящего (Прочитано 982376 раз)