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civil aeroplane at cruising altitude prior to the crash. The CTIVD concluded that, based
on the available information, the MIVD and the AIVD could not have been expected to
identify any actual threat to civil aircraft above the eastern part of Ukraine or share it with
external parties. During the investigative period (January 2014 through 17 July 2014),
neither Service received an explicit or implicit warning from its foreign partner services
concerning a risk to civil aviation above the eastern part of Ukraine.
The CTIVD has also established that none of the Dutch operators contacted the MIVD or
the AIVD to enquire about the security situation in the eastern part of Ukraine prior to
17 July 2014.
8.4.2.2 Embassy of the Netherlands in Kyiv
The Dutch Safety Board investigated what information the Embassy of the Kingdom of
the Netherlands to Ukraine, including the defence attaché stationed there, possessed.
From the time when the internal tensions began to intensify in Ukraine (beginning of
2014) until the crash on 17 July, many hundreds of messages were sent from the embassy
to the Ministries of Foreign Affairs and Defence. From March 2014, the messages reveal
that, on weekdays, one or more updates related to the situation in Ukraine were sent
virtually daily. Initially, the emphasis was on the situation in the Crimea, but later, attention
shifted to the eastern part of Ukraine, where the conflict between armed groups and the
Ukrainian government escalated.
The reports mainly pertained to instability, developments in the fghting between
Ukrainian armed forces and the armed groups, and the possible role of the Russian
Federation therein. This was all viewed from a military-strategic and geopolitical
perspective: what were the consequences for Ukraine’s political (in)stability, and what
dangers did the Russian Federation’s troop movements and build-up of weapons pose
to the security of Ukraine and Europe?
None of the messages make any connection to risks posed by the conflict in the eastern
part of Ukraine to overflying civil aeroplanes.*194 Even the defence attaché who, as already
mentioned, was responsible for making an inventory of military developments, admitted
that he did not make any connection between the developments on the ground and
overflying civil aviation. The defence attaché participated in a weekly consultation with
defence attachés from other - mainly Western - states, also in the context of NATO, about
matters that included the military developments in the eastern part of Ukraine. They
noted that the fghting was expanding into the air, and that the armed groups were trying
to neutralise the air superiority of the Ukrainian armed forces from the ground. According
to the Dutch defence attaché, there was no mention of potential risks posed by this
escalation to civil aviation at any of these meetings. According to him, there was no
awareness that civil aviation routes existed above the conflict area. The defence attachés
from the different states jointly evaluated the crash of flight MH17. Their conclusion was
that nobody had considered the possibility of a civil aeroplane being shot down.
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*194 Section 5 explains that such a link does appear to have been made in an OSCE memorandum from March 2014
regarding Crimea, which also reached the Dutch embassy.

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that the groups fghting the Ukrainian government possessed at least one Buk-M1, which
probably originated from the Ukrainian air defence. As mentioned above, the CTIVD
established that the MIVD knew from several reliable intelligence sources that the system
was not operational.*199
In summary it can be stated that the Dutch authorities did not perceive any threat to civil
aviation above the conflict area in the eastern part of Ukraine. For this reason, they also did
not consider that there was any rationale for actively informing or warning operators. During
the period prior to the crash of flight MH17, operators did not request any information from
the AIVD or the MIVD about the security situation in the eastern part of Ukraine either.

8.5 Analysis

In the system of responsibilities there are explicit responsibilities related to states’
management of the airspace, to operators operating a flight, and to the supervision of
the operators based in the state concerned. The state of departure as such does not
feature in this explicit distribution of responsibilities (see also Figure 76 in Section 4).
The Chicago Convention and its Annexes do not hinder ICAO Member States in the
provision of advice to foreign operators about flying through the airspace of an other
state. This also applies to the state of departure and foreign operators departing from
that state. The ICAO framework offers states the possibility of promulgating legislation
that makes flight prohibitions for foreign airspace possible for operators and airmen from
that state. Section 7 describes how a number of states, for example the U.S., the U.K. and
Germany, make use of the possibility to promulgate a flight prohibition.
The Dutch Services did not possess any information that indicated an actual threat to
civil aviation above the conflict area in the eastern part of Ukraine. There were no
indications that the groups involved in the armed conflict had the intention of targeting
civil aviation and there were no indications that the groups that fought against the
Ukrainian government possessed the capability to hit aeroplanes at cruising altitude. For
that reason, no warning was issued to the operators. Nor did other states issue warnings
to operators about flying over the conflict area in the eastern part of Ukraine.
The Dutch information position in the spring of 2014 regarding the eastern part of Ukraine
was still being built up and the focus was predominantly on developments related to the
Russian Federation. This was not relevant to flight MH17: states with a more effective
information position did not establish any actual threat either (see Section 7).
The Dutch State considers it its responsibility to actively inform operators based in its
state in case of an actual threat. Foreign operators that depart from the Netherlands do
not receive such information from the Dutch State. Moreover, Dutch operators have the
possibility of requesting security information about other states (demand-driven). The
AIVD and the MIVD both play a role in this respect. The Dutch authorities do not consider
it their task to advise operators or to prohibit them from flying over a conflict area.
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*199 See Appendix T.

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9 ASSESSING THE RISKS PERTAINING
TO CONFLICT ZONES

9.1 Introduction

In order to be able to learn from the crash of flight MH17, it is important to investigate
whether general factors, that go beyond this particular case, play a role. In this Section,
the Dutch Safety Board identifes factors that play a role in the risk assessment process
related to flying over conflict areas and that are not unique to the crash of flight MH17.
This Section begins with a summary of the fndings pertaining to the crash, followed by an
analysis of risk assessment processes in relation to flying over conflict areas. This is
intended as a preamble to this report’s fnal conclusions and recommendations.
In addition to information from previous Sections, the Dutch Safety Board for this Section
used supplementary information about the practices that states and operators generally
employ in their risk assessments (see Appendix U).

9.2 MH17: no integrated risk assessment

This investigation reveals that, prior to the crash of flight MH17, none of the parties
involved adequately identifed potential threats that the conflict in the eastern part of
Ukraine posed to civil aviation flying over the area.
• The decision-making process related to Ukrainian airspace was dominated by the
military authorities and the interests of military aviation. The Ukrainian authorities did
not adequately assess the risk for civil aviation.
• Most operators assumed that an airspace which is not closed must be safe. Operators
adapted their flight plans to accommodate the airspace restrictions, but did not make
a connection with the armed conflict taking place below. Insofar as the Dutch Safety
Board has been able to ascertain, there was one operator that discontinued its flights
over that area out of caution due to the increasing unrest in Ukraine. But that was
already before the armed conflict had arisen in the eastern part of the country.
• Nor, insofar as the Dutch Safety Board has been able to ascertain, between the end
of April and 17 July 2014, was there any state that prohibited operators based in that
state from flying over the area, or explicitly warned of possible threats in the airspace
of the eastern part of Ukraine as a result of the conflict. There were states - although
certainly not all states - that collected information about the conflict; they did so from
a geopolitical and military perspective and did not make any connection to the risks
to civil aviation flying overhead.
The parties involved (Ukraine, operators, other states and international organisations)
viewed the armed conflict from their own respective domains, with their own specifc
focus. In their risk assessments, operators primarily focus on threats on the ground

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The risk assessment process can be divided into several steps. The frst step involves
gathering (and sharing) information, i.e. gathering information from various sources
related to a potential threat and sharing information with other parties*201 (‘what could
happen, is there intention and capability?’). After the information has been gathered, the
following steps take place:
• Threat analysis: determining the probability of a threat occurring;
• Risk analysis: the assessment of the risks for the operator, based on vulnerability and
consequences;
• Decision-making: deciding whether or not to fly. If so, are additional measures necessary?
As described in Section 6, armed conflicts are characterised by a high degree of
unpredictability. The state responsible for the management of the airspace does not, in
the event of a conflict, always have control of the territory under the airspace. It is often
unclear who possesses which types of weapon systems and whether or how they will be
used in the conflict. If non-state related parties are involved, they may not always regard
themselves as bound by international treaties and conventions. As a result, such conflicts
could constitute a risk to civil aviation.
There are areas in the world other than the eastern part of Ukraine where armed conflicts
are occurring. The lessons that can be learned from the crash of flight MH17 can
contribute to a more effective risk assessment, also for these areas.
9.3.1 Information gathering
Although operators can gather information about what is going on in a conflict area with
the help of public information, this information also has its limitations. For information
from intelligence sources, the operators are dependent on intelligence services of states.
Although operators also have security departments, these do not beneft from the
resources and powers of the intelligence services.
There turn out to be major differences in the extent to which states gather intelligence
that may concern the safety of the operators under their control (see Section 7). There
are states that only do this within their borders (such as Malaysia); there are states that
gather intelligence beyond their borders on a limited scale, but which in principle do not
consider themselves as having an active responsibility in relation to civil aviation (such as
the Netherlands), and there are states that regard protecting civil aviation as a
responsibility, passing on information and/or issuing flight prohibitions if necessary (such
as the United States). These differences are related to states’ abilities to secure an
intelligence position (capacity, diplomatic relationships with states, geopolitical position),
but are also the result of choices the states make with respect to responsibility for the
safety of operators. The willingness to become involved in the decision by sovereign
states to keep their airspace open also varies. In the crash involving flight MH17, it
appeared that the various roles adopted by states did not make any difference. However,
since operators rely on information gathered by states, the crash could still be reason to
reconsider the choices involved.
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*201 As far as the parties involved are concerned, they predominantly share information if this action is reciprocated.

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9.3.3 Risk analysis: factors that increase risk
To facilitate a more effective assessment of the risks posed by conflict areas based on
the threat analysis, ICAO,*204 in 2015, identifed a number of factors that may increase
these risks for civil aviation. The application of these factors that increase risk could result
in the risk assessment producing a different outcome. ICAO has restricted itself to
situations in which possible medium or long-range surface-to-air missiles are present,
because these form the largest risk for civil aviation at cruising level.
The factors that ICAO believes contribute to risks, and should therefore weigh more
heavily in determining the threat and the risk of civil aircraft being shot down, are:
• Civil aviation is the target of one of the fghting parties;
• Those operating the anti-aircraft missiles are poorly trained or inexperienced (possibly
in combination with the absence of a properly functioning command structure);
• Flights involving military aeroplanes in a combat role are taking place;
• Military transport flights are taking place;
• Flight routes run through or close to locations of strategic importance, which can be
attacked from the air;
• The absence of effective air traffc management above the area, for example because
the state in which the armed conflict is occurring does not have complete control
over its territory.
The Dutch Safety Board believes that these criteria can be used to obtain a more effective
analysis of the risks posed by conflict areas to civil aviation flying over them. The Board
also points out that not all the factors need to be present at the same time in order to
speak of an increased risk. Each separate factor deserves attention. According to the
Board, such an analysis should adequately focus on the trends that are observed in a
certain period: are, for example, the air operations or shootings of military aircraft,
particularly by non-state actors,*205 increasing? Is the altitude at which military aircraft are
operating increasing? Although this still only entails a low probability that civil aeroplanes
will be hit, these are not inconceivable events. Given the severity of the consequences
and the possibilities for managing the risk, these small probabilities deserve
attention - and not or not solely in a strictly quantitative, but in a qualitative manner. This
subject will return in the next paragraph.
9.3.4 Risk analysis: the role of probability
In the feld of risk analysis, statistical data constitute the basis for determining the probability
of a particular incident occurring: has the incident already occurred in the past, and if so,
how often? Moreover, the potential impact is important, i.e. the expected severity and
scope of the damage. With the help of a risk matrix, both factors (likelihood and severity)
are combined, resulting in risk categories that can be linked to mitigating measures. This is
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*204 ICAO Working Group on Threat and Risk (WGTR), HLSC/15- WP/10, 7 January 2015.
*205 In its summary of the risk-increasing factors, ICAO indicates that the chance of misidentifcation of military
aeroplanes in the use of long-range surface-to-air missiles is the greatest with non-state groups

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a scenario’s conceivability, ICAO’s risk factors for assessing armed conflicts (see previous
paragraph) are useful. Per conflict area, an assessment can then be performed which, as
mentioned in the previous paragraph, should also focus on an analysis of the manner in
which a conflict develops as advised by the Dutch Safety Board.*207
The application of this working method in the case of the eastern part of Ukraine could
have led to a shift in the assessment of the likelihood. As a result, the risk category would
shift too, meaning that the urgency of measures becomes greater.
To summarise: this method of approaching risks implies that the parties involved in flying
over conflict areas should not limit themselves strictly to examining the statistical
probability of scenarios. They would have to arrive at an informed judgement related to
the possibility of a scenario based on risk-increasing factors and a trend analysis.
9.3.5 Decision-making: the pressure to carry on flying
The international system for civil aviation is based on the assumption that, in principle,
civil aviation is always possible: By default, flights take place. As stated in Section 4,
states that manage their airspace shall impose as few restrictions on civil aviation as
possible. This system can provide an incentive to keep the airspace open if potential
dangers to air traffc are not yet entirely clear.
Flying is also the default for operators. When it comes to new flight routes, they assess
whether they want to fly somewhere, whereas continuing to fly along existing routes over
conflict areas is a ‘non-decision’ in most cases. The investigation revealed that operators
only reassess existing routes for safety reasons if there are specifc indications of danger.
This has an impact on the risk assessment process, however. It determines how operators
collect and interpret threat-related information. They use available information to justify
continuing to fly and to carry on doing what they were doing already. This was the
perspective with regard to flying over the eastern part of Ukraine: the operators viewed
the NOTAMs issued by Ukraine prior to 17 July 2014 as a sign that Ukraine was controlling
the airspace, not as an indicator of a deteriorating security situation in the air.
9.3.6 Consequences for the risk analysis
The above shows that current armed conflicts can pose risks to civil aviation due to their
unpredictability, and that the system of responsibilities and the risk assessment process
are still inadequately equipped in this respect. In states that have to cope with an armed
conflict, the safety of the airspace above the conflict cannot be guaranteed in advance,
not even at cruising altitude. The Dutch Safety Board is of the opinion that states should
also assume their responsibilities for the safety of the airspace in a conflict situation, but
that additional action may also be required from other parties.
Firstly, it requires an integrated risk assessment to be performed. Parties that view the
conflict from a military or geopolitical angle should be more aware of potential secondary
effects on civil aviation. Knowledge of the main flight routes could increase this
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*207 ICAO Doc 9859, Chapter 2, Paragraph 14.6 supports this: ‘Organisations may include both qualitative and
quantitative criteria…

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Conclusions and
Recommendations

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3. Conclusions regarding flying over conflict zones
a. The current system of responsibilities for safeguarding civil aviation does not
provide suffcient means to adequately assess the risks associated with flying over
conflict areas.
b. Risk assessment for civil aviation using the airspace over conflict areas should not
only consider actual threats but should also include risks of which the intention or
capability is uncertain.

10.2 Supporting conclusions (causes of the crash)

The cause that the Dutch Safety Board has identifed is supported by the following
fndings.
1. Moment of the in-flight break-up
The establishment of the moment of the in-flight break-up of the aeroplane is
supported by the following fndings:
a. The Cockpit Voice Recorder and Flight Data Recorder stopped abruptly at
13.20:03 (15.20:03 CET) because the power supply was interrupted.
b. The fxed Emergency Locator Transmitter activated automatically within two
seconds of the Cockpit Voice Recorder and Flight Data Recorder ceasing to record.
c. The raw secondary surveillance radar data from the Ukrainian air navigation
service provider and the radar screen video replay of the combined primary and
secondary radar data from the Russian Federation’s air navigation service provider
showed that flight MH17 was in straight and level flight at FL330 until 13.20:03
(15.20:03 CET).
d. The raw secondary surveillance data from the Ukrainian air navigation service
provider showed that flight MH17 was not transmitting any secondary surveillance
data from 13.20:03 (15.20:03 CET) onwards.
e. The Russian Federation’s air navigation service provider radar screen video replay
of the combined primary and secondary radar data showed target tracks from the
aeroplane from 13.20:03 (15.20:03 CET) onward which were the result of coasting
and of falling debris.
2. Sound peak
The Cockpit Voice Recorder recorded a 2.3 millisecond sound peak. Signal
triangulation showed that the noise originated from outside the aeroplane, starting
from a position above the left hand side of the cockpit, propagating from front to aft.
3. No other aeroplanes
There was no evidence of other aircraft, civil or military, in the direct vicinity of flight
MH17. According to radar data three other aeroplanes were in Sector 4 of
Dnipropetrovsk Area Control Centre at the time of the crash, all commercial air
transport category aeroplanes. Two were flying eastbound, one was flying westbound.
All were under control of Dnipro Radar. At 13.20 (15.20 CET) the distance between
the closest of these aeroplanes and flight MH17 was 33 km.

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9. Failure sequence
After the initial impact, the aeroplane broke up as follows:
a. There was an almost instantaneous separation of the cockpit from the forward
part of the fuselage when the pre-formed fragments penetrated the cockpit. The
cockpit came to rest 2.3 kilometres from the last position recorded on the Flight
Data Recorder.
b. The aeroplane without its forward section continued flying along an undetermined
flight path for about 8.5 kilometres to the east before breaking up further. The
centre section travelled further than the rear part of the fuselage. This centre
section came to rest upside down. Parts of the wreckage caught fre.
c. The time between the start of the break-up and the impact with the ground could
not be accurately determined, but the centre and rear parts of the aeroplane were
estimated to have taken about 1-1.5 minutes to reach the ground. Other, lighter
parts, will have taken longer.
10.Weapon used
The aeroplane was struck by a 9N314M warhead as carried on a 9M38-series missile
and launched by a Buk surface-to-air missile system. This conclusion is based on the
combination of the following; the recorded sound peak, the damage pattern found
on the wreckage caused by the blast and the impact of fragments, the bow-tie and
cubic shaped fragments found in the cockpit and in the bodies of the crew members
in the cockpit, the injuries sustained by three crew members in the cockpit, the
analysis of the in-flight break-up, the analysis of the explosive residues and paint
found and the size and distinct, bow-tie, shape of some of the fragments.
11. Missile flight paths
The area from which the possible flight paths of a 9N314M warhead carried on a
9M38-series missile as installed on the Buk surface-to-air missile system could have
commenced measures about 320 square kilometres in the east of Ukraine. Further
forensic research is required to determine the launch location. Such work falls outside
the mandate of the Dutch Safety Board, both in terms of Annex 13 and the Kingdom
Act ‘Dutch Safety Board’.

10.3 Excluding other causes of the crash

The Dutch Safety Board has investigated and analysed a number of different possible
causes of the crash. The Safety Board excluded the following issues as being factors in
the crash of flight MH17.
1. Flight crew
The flight crew members were properly licensed and qualifed to conduct the flight.
There is no evidence that the crew handled the aeroplane inappropriately or their
flying skills being affected by alcohol, drugs or medicine.

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10.Other weapons
a. Air-to-air gunfre
The high-energy object damage was not caused by an air-to-air gun or cannon
because the number of the perforations was not consistent with gunfre, and
because air-to-air gun/cannon fre does not produce fragments with the distinctive
forms that were found in the wreckage and in the bodies of three of the crew
members in the cockpit.
b. Air-to-air missile
None of the air-to-air missiles in use in the region have the distinctly formed
bow-tie shaped fragments in their warhead.
c. The aeroplane was not struck by more than one weapon considering the wreckage
distribution, the damage patterns and the fact that only once source of damage
was found.

11. Other scenarios

Other possible scenarios that could have led to the disintegration of the aeroplane
were considered and analysed. These scenarios were an on-board fre or a fuel tank
explosion, the detonation of an explosive device inside the aeroplane, lightning strike,
and impact by a meteor or space debris re-entering the atmosphere. All of them
were excluded based on the available evidence.

10.4 Other fndings related to the crash

1. Oxygen
The emergency oxygen masks in the passenger cabin fell out of their overhead
storage containers and the chemical oxygen generators were activated as the result
of the in-flight break-up or ground impact. It is unlikely that the oxygen masks were
deployed before the power supply was interrupted.
2. Survival aspects (cockpit occupants)
Hundreds of metal fragments were found in the bodies of the two pilots and the
purser present in the cockpit at the time of the crash. These originated in part from
the missile. The location in the bodies where the missile particles were found and the
force with which they had penetrated them caused the three people in the cockpit to
die instantly after the impact of the missile particles.
3. Survival aspects (other occupants)
a. There were no pre-formed fragments found in the bodies of the other occupants.
As a result of the impact, they were exposed to extreme and many different,
interacting factors: abrupt deceleration and acceleration, decompression and
associated mist formation, decrease in oxygen level, extreme cold, strong airflow,
the aeroplane’s very rapid descent and objects flying around.
b. As a result, some occupants suffered serious injuries that were probably fatal. In
others, the exposure led to reduced awareness or unconsiousness within a very

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2. Ukraine’s airspace management
a. The decision-making processes related to the use of Ukraine’s airspace was
dominated by the interests of military aviation. The initiative to restrict the airspace
over the eastern part of Ukraine below FL260 originated from the military
authorities. The objective of the measure was to protect military aeroplanes from
attacks from the ground and to separate military air traffc from civil aviation. The
Ukrainian authorities assumed that by taking this measure, civil aeroplanes flying
over the area above FL260 were automatically safe too.
b. The initiative to change the restriction to FL320 on 14 July 2014 came from civil air
traffc control. The underlying reason for this change remains unclear.
c. The NOTAMs did not contain any substantive reason for the altitude restrictions.
Therefore, Ukraine did not act in accordance with the guidelines in ICAO Doc
9554-AN/932.
d. When implementing the above measures, the Ukrainian authorities took insuffcient
notice of the possibility of a civil aeroplane at cruising altitude being fred upon.
This was also the case, when, according to the Ukrainian authorities, the shootingdown of an Antonov An-26 on 14 July 2014 and that of a Sukhoi Su-25 on 16 July
2014 occurred while these aeroplanes were flying at altitudes beyond the effective
range of MANPADS. The weapon systems mentioned by the Ukrainian authorities
in relation to the shooting down of these aircraft can pose a risk to civil aeroplanes,
because they are capable of reaching their cruising altitude. However, no measures
were taken to protect civil aeroplanes against these weapon systems.
3. Operators
a. Malaysia Airlines
As operating carrier, Malaysia Airlines was responsible for the safe operation of
flight MH17 and therefore for the choice of the flight route on 17 July 2014. The
way in which Malaysia Airlines prepared and operated the flight complied with the
applicable regulations. Malaysia Airlines relied on aeronautical information and
did not perform any additional risk assessment. Malaysia Airlines did not receive
signals from other operators or via any other channels indicating that the airspace
above the eastern part of Ukraine was unsafe.
b. Codeshare partnership
Malaysia Airlines was also responsible for the safety of the passengers that had
booked via its code share partner KLM. Since KLM, just like other operators, saw
no safety reason to avoid the airspace above the eastern part of Ukraine, Malaysia
Airlines and KLM did not exchange any information about the armed conflict.
c. Other operators
– A single operator decided to stop flying over Ukraine because of growing
unrest in the country. This decision was made in March 2014, i.e. before the
armed conflict broke out in the eastern part of Ukraine.
– Insofar as the Dutch Safety Board was able to ascertain, no other operators
changed their flight routes for safety reasons related to the conflict in the
eastern part of Ukraine after this. This did not change after the Antonov An-26
had been shot down on 14 July 2014, which, according to the Ukrainian

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10.6 Supporting conclusions (flying over conflict zones)

1. Airspace management
a. In the international system of responsibilities, the sovereign state bears sole
responsibility for the safety of the airspace. The fundamental principle of
sovereignty can give rise to vulnerability when states are faced with armed
conflicts on their territory and in their airspace.
b. Such states rarely close their airspace or provide aeronautical information with
specifc information or warnings about the conflict. In some cases, other states
issue restrictions or prohibit their operators and pilots from using the airspace
above these conflict areas.
c. There is a lack of effective incentives to encourage sovereign states faced with
armed conflicts to assume their responsibility for the safety of the airspace.
d. Given the vulnerability of states facing an armed conflict, operators and other
aviation parties cannot take it for granted that the airspace above the conflict
zone is safe. They should perform their own risk assessment of the risks involved
in overflying conflict areas.
e. Whenever states (can) have access to information that is relevant to that risk
assessment, they should share this information with operators in a structured
manner. States that collect information about conflict areas could take account of
airspace usage patterns for civil aviation.
2. Risk assessment
Existing threat analyses only consider a threat to be actual if both capability and
intention have been established with suffcient certainty. Even if there is no certainty
with regard to these factors, an armed conflict may still pose risks to civil aviation. In
the current practice of risk assessment, these risks are too soon considered unlikely.
3. Risk-increasing factors
The identifcation and the use of risk-increasing factors are important for obtaining a
better understanding of the likelihood of scenarios in an armed conflict.

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situations should be given more incentives and support in fulflling this responsibility. On
the one hand, the Dutch Safety Board is thinking of a stricter redefnition of the
responsibility of states for their airspace and, on the other hand, a stronger, more proactive role for the International Civil Aviation Organization, ICAO. The second
consideration also requires States to take a more active role towards ICAO.
In this respect, the following topics require attention:
• The timely closure or restriction of the use of the airspace;
• Providing information to third parties as quickly as possible in the event of an armed
conflict with possible risks for civil aviation;
• Such coordination between civil and military air navigation service providers during
an armed conflict that the state can fulfl its responsibility for the safety of civil aviation
in the airspace.
This requires amendments to the Chicago Convention and in Standards and
Recommended Practices. To this end, the Dutch Safety Board makes the following
recommendations.
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.

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To states (State of Operator):
8. Ensure that operators are required through national regulations to make risk
assessments of overflying conflict zones. Risk increasing and uncertain factors need
to be included in these assessments in accordance with the proposals made by the
ICAO Working Group on Threat and Risk.
To ICAO and IATA:
9. In addition to actions already taken, such as the website (ICAO Conflict Zone
Information Repository) with notifcations about conflict zones, a platform for
exchanging experiences and good practices regarding assessing the risks related to
the overflying of conflict zones is to be initiated.
Level 3: Operator accountability
It is not clear which flights pass over which conflict zones. Ideally, operators should have
to actively provide information about routes to be flown and routes recently flown, so
that everyone can form a judgement, thereby increasing public attention for this issue. A
frst step towards this would be to require operators to provide public accountability on
a regular basis for routes over conflict zones selected by them. On the basis of this, the
Dutch Safety Board makes the following recommendations:
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.

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CVR                Cockpit Voice Recorder
DCA                Department of Civil Aviation Malaysia
Defat              Defence attaché
DfT                 Department for Transport, United Kingdom
DOF                direction of flight
DSB                Dutch Safety Board (Onderzoeksraad voor Veiligheid, Investigation
                      organisation, the Netherlands)
EASA              European Aviation Safety Agency
ECAC              European Civil Aviation Conference
EDX                energy dispersive X-ray analysis
EHAM              ICAO code for Amsterdam Airport Schiphol, the Netherlands
ELT                 Emergency Locator Transmitter
EUROCONTROL European organisation for the safety of air navigation
FAA                 Federal Aviation Administration, United States of America
FATA                Federal Air Transport Agency, Russian Federation (Rosaviatsia)
FDC                 Flight Data Center
FDR                 Flight Data Recorder
FIB                  Focused Ion Beam
FIR                  Flight Information Region
FL                    flight level
FRG Federal Republic of Germany
ft foot or feet
g force due to acceleration
GKOVD State Air Traffc Management Corporation, Russian Federation
GND ground level
GPS Global Positioning System
HCSS The Hague Centre for Strategic Studies
HP high pressure
hPa hectopascal(s)
IAC Interstate Aviation Committee
IATA International Air Transport Association
ICAO International Civil Aviation Organization
ICCb Interdepartmental Crisis Management Committee, Netherlands
(Interdepartementale Commissie Crisisbeheersing)
IFALPA International Federation of Air Line Pilot’s Associations
IFATCA International Federation of Air Traffc Controllers Associations
IOSA IATA Operational Safety Audit
JTAC Joint Terrorism Analysis Centre
kg kilogramme(s)
km kilometre(s)