MH17 Passenger
information

3

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: wwwsafetyboard.nl

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

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

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9

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

19 Dutch Safety Board, Preliminary report: Crash involving Malaysia Airlines Boeing 777­200 flight MH17,
September 2014.
20 Malaysia Airlines, Media Statement & Information on Flight MH17. Media Statement 1: “MH17 incident”,
wwwmalaysiaairlines.com/mh17.
21 It was also announced that the other passengers originated from the following countries: 27 from Australia, 23
from Malaysia, 11 from Indonesia, 6 from the United Kingdom, 4 from Germany, 4 from Belgium, 3 from the
Philippines and 1 from Canada. The nationalities of 47 passengers were not yet clear. The three children without
their own seats were not included in the list.
22 Malaysia Airlines, Media Statement & Information on Flight MH17. Media Statement 2 and Media Statement 4,
wwwmalaysiaairlines.com/mh17.

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

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