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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 Board’s website wwwsafetyboard.nl.
Source photo cover: DCA Malaysia

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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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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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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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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.
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 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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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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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
--------------
*2 UN Security Council, Resolution 2166 (2014), S/res2166 (2014), 21 July 2014

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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 Board’s 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.
----------------------
*3 Dutch Safety Board, MH17 - About the investigation, October 2015.

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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 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 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 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 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

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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: wwwsafetyboard.nl.
Section 13 gives an overview of the appendices.

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PART A: CAUSES OF THE CRASH

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

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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 airline’s
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.

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

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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.

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 video’s from the media, local habitants described parts of the aeroplane

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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