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Injury information
The investigation into the occupants of the aeroplane (see Chapter 5) produced factual
information for the medical and pathological aspects and the survival aspects (from the
appendix to Annex 13). In addition, the injuries of the crew members that were in the
cockpit contributed to gain insight into the causes of the crash.
Fragments and information on weapons
The preliminary report states that the damage to the forward fuselage of the aeroplane
appears to be consistent with the aeroplane being perforated by a large number of highenergy objects from outside the aeroplane. In order to discover what kind of objects
perforated the aeroplane, the fragments found were analysed. A distinction was made
between metal and non-metal fragments. Of these, the metal fragments were relevant to
the investigation. These concerned objects found in and on the wreckage or found in
and on the human remains and that do not belong to the aeroplane or the personal
belongings and do not stem from the ground.
Certain fragments were only removed from the pieces of wreckage at a late stage in the
investigation, because the pieces of wreckage had to be kept intact for the accident
investigation and the criminal investigation, and removal without further damaging the
wreckage pieces was not possible.
Because the metal fragments could originate from a weapon, for the investigation into
this possible source of the fragments knowledge was needed about weapons, parts of
weapons and the damage pattern that weapons cause.
Eye witnesses
The safety situation in the eastern part of Ukraine meant that it was not possible to
interview eye witnesses in the days following the crash. The Dutch Safety Board chose
not to interview the witnesses at a later stage because the reliability of the statements
could be affected by the passage of time. Various people and organisations did, of their
own accord, share their fndings with the Dutch Safety Board and information was
gathered from the media. The Dutch Safety Board took note of those statements and, if
of value to the investigation, included them in the investigation.
Other information
For the investigation, the organisations involved were requested to provide information
about the maintenance and the equipment of the aeroplane and the functioning of
relevant components such as the engines. Information was also gathered with a view to
other possible explanations for the damage incurred. For instance, this involved
information about the presence of meteors and space debris.
3.3 Analysis and assessment
To determine what happened with flight MH17, the sequence of events and circumstances
were reconstructed, from the departure (including the airworthiness of the aeroplane
and data about the crew) up to and including the break-up and downing of the aeroplane.
The facts were compared with what is known about the usual course of events during a

34

Flight recorders
For the reconstruction of the flight, the time at which the flight recorders stopped
recording was relevant. It was clear that the causes of the crash must be sought for
around that time. In order to determine that time accurately, the recording by the flight
recorders were compared with other data sources, such as radar images, and satellite
communication data. In this way it was determined accurately at what time the ‘usual’
course of flight MH17 came to an end.
Just before the end of the sound recording, the cockpit voice recorder recorded a sound
peak. This did not ft with the noise that is customarily heard during a flight. It was a high
tone, not perceptible to the ear. The location of the source of the sound could be
determined roughly. The sound appeared to come from outside the aeroplane. Its cause
was determined later in the investigation.
Injury crew in the cockpit
The analysis of the injuries of the crew in the cockpit contributed to the determination of
the causes of the crash. From the injuries of both pilots and the purser present in the
cockpit, it was possible to deduce that the crew in the cockpit had been hit by metal
fragments travelling at high velocity.
Pieces of wreckage
The pieces of wreckage were an important source of information for determining what
had happened to the aeroplane. First, the damage to the wreckage pieces was relevant.
In order to interpret this damage, a distinction was made between damage that
originated in the air, damage that originated due to contact with the ground and damage
that was caused or arose later. In making this distinction, photographs of the wreckage
taken shortly after the crash were used. The distinction was made by aviation investigators,
by looking at the nature of the damage (length of tears, shape of the holes through the
various layers of material) and by interpreting this nature based on their expertise.
A part of the damage to the wreckage that originated in the air consisted of holes and
marks resulting from perforating by, penetrating of and ricocheting of high-energy
objects, also called the impact damage. The general direction from which the highenergy objects impacted the aeroplane was determined based on the shape of the
holes. To make the trajectories of the objects visible, lines were drawn (this technique is
called stringing) to roughly determine where the objects came from. The direction was
among others compared with the direction of the sound wave, which was recorded by
the cockpit voice recorder.
In addition to the impact damage to the pieces of wreckage, the fracture surfaces of the
broken-up pieces of the aeroplane were examined. The fracture surfaces provide
understanding in the sequence in which the aeroplane broke up. This sequence is of
importance because it can be inferred from this where the aeroplane started to break
up; this is related to the location where the aeroplane was hit from outside. The manner
in which the aeroplane broke up can also be derived from the locations on the ground
where the several wreckage pieces came down.

36

characteristics of certain weapon systems. With the help of these comparisons, certain
types of weapon systems were excluded because their expected damage pattern was not
consistent with the damage pattern found on the wreckage.
Other external causes that could have resulted in the crash of flight MH17, such as space
debris, a meteor or a lightning strike could be excluded as a result of the damage pattern
that was found on the wreckage.
Simulations
The combined analyses resulted in the conclusion about the type of warhead used, which
is carried on a particular type of missile. Simulations were performed by the Dutch
National Aerospace Laboratory (the NLR), the Netherlands Organisation for Applied
Scientifc Research (TNO) and the Kyiv Research Institute for Forensic Expertise of the
Ukrainian Ministry of Justice to investigate the location of the detonation. In these
simulations, the characteristics of the flight and the aeroplane as well as those of the
weapon were reconstructed. The results of the simulations were compared with the
actual damage pattern. The fndings from the analyses of the damage pattern on the
wreckage and from the simulations were consistent, which validated the conclusion with
regard to the weapon used.
Each of the simulations provided an estimated location of the detonation of the warhead.
The detonation locations calculated by the NLR, TNO and Ukraine differed but were
close together. The Dutch Safety Board took account of uncertainties in the models by
defning a volume of space enclosing the results of the different simulations instead of a
single point in space.
On behalf of the Russian Federation, the company Almaz-Antey performed similar
simulations and compared the results with their interpretation of the damage pattern,
which differed from the analysis of the Dutch Safety Board (more information on the
differences can be found in Appendix L of this report and Appendix V of the investigation
report about the crash). The detonation point which resulted from the calculations by
Almaz-Antey was not within the volume of space defned by the results of the simulations
by the NLR, TNO and Ukraine.
The volume of space where the warhead detonated was used by the NLR and Ukraine to
calculate possible missile trajectories. The NLR’s simulation model contained characteristics
of both the aeroplane and the missile. It took into account uncertainties about, for example,
the exact operation of the missile, the orientation angles on the ground and the missile’s
speed. The origins of the possible missile trajectories were visualised in an area on the
ground. The results of the simulations showed that missiles that could have carried the
type of warhead that caused the damage pattern found on the wreckage could not have
been launched outside this area. Ukraine performed similar calculations. The area
calculated by Ukraine is situated in the area identifed by the NLR’s calculations. In addition,
Almaz-Antey on behalf of the Russian Federation performed calculations using the same
volume of space as the Dutch Safety Board to simulate the possible trajectories of the
missile. The areas calculated by Almaz-Antey were consistent with the results of the
calculations by the NLR and Ukraine. The Russian Federation provided the results to the
Dutch Safety Board without confrming the type of warhead and missile used in the crash.

38

4 CRASH: FLIGHT ROUTE
4.1 Design of the investigation
After the crash of flight MH17, there was astonishment on international level at the fact
that Malaysia Airlines and other airlines were flying over the eastern part of Ukraine while
there was an armed conflict going on in that region. The airspace above the conflict area
was open to civil air traffc from a certain altitude. Because the Dutch Safety Board shared
in this amazement, on 18 July 2014 it decided to initiate an investigation into the decisionmaking related to flight routes over conflict areas. After the Dutch Safety Board had taken
charge of the international investigation from its sister organisation in Ukraine on 23 July
2014, the question of how and why it was decided that flight MH17 would fly this route
became more central in the investigation.
The purpose of the investigation into the flight route was to fnd out what Ukraine’s
considerations were regarding airspace management and why Malaysia Airlines used this
route to fly to Kuala Lumpur. The fndings of the investigation into the decision-making
related to flight routes over conflict areas were used to put the results of the investigation
into the specifc route followed by MH17 on 17 July 2014 into an internationally comparative
perspective.
The points for improvement that emerged from the investigation into the decisionmaking related to the route of MH17 also appeared to apply to the decision-making
related to flight routes over conflict areas. The recommendations for improving the
process of decision-making regarding flight routes which were formulated on the basis of
the investigation fndings therefore have a broad foundation. This is why the recommendations are addressed not only to the airline that operated this specifc flight, but also
extend to the international aviation sector as a whole.
The following questions were key in the investigation:

40

hindsight. HCSS consulted primary sources (such as public sector information and NOTAMs)
and secondary sources (such as media reports). These sources were categorised on the
basis of reliability. The Dutch Safety Board used the information provided by HCSS as
source material. Only the most reliable information was used for this.
The Dutch Safety Board also consulted non-public sources, whether or not classifed (see
Section 7.5). This mainly concerned sources from the Dutch diplomatic services in
Ukraine. Much of this information came from or was shared during closed briefngs, which
were used by - mostly Western - diplomats and military attachés to discuss the political
and military developments in and around the conflict area.
Other airlines overflying the eastern part of Ukraine
Immediately after the crash of flight MH17, it was reported in the media that some airlines
had already decided not to fly over the eastern part of Ukraine because of the threat in
the area. The Dutch Safety Board held interviews with EUROCONTROL and requested
data about flights operated in the airspace above the eastern part of Ukraine from
January 2014 to July 2014 (winter and summer flight schedules). From the information it
was deduced which airlines had flown over the area, although it should be noted that this
concerned the airlines under whose flight number the flight was registered and to whom
the route charges were billed.20 These are not necessarily the airlines that actually
operated the flights and chose the flight route.
To obtain information from multiple sources, various airlines in countries outside the
Netherlands were questioned about overflying the conflict area in the eastern part of
Ukraine. By means of a survey, participated in by nineteen airlines, they were asked to
indicate whether they had flown over the conflict area prior to the crash of flight MH17
and what the considerations were to fly or not fly there (any longer). The Dutch Safety
Board approached the airlines through its sister organisations in the relevant countries.
In addition, the Dutch Safety Board obtained background information on this subject
from three more airlines.
Role of the Netherlands in flight MH17
Soon after the crash of flight MH17, the question arose in the Netherlands whether the
Dutch government could have done anything to prevent Malaysia Airlines from flying over
the eastern part of Ukraine. Initially there was the idea, also with the Dutch Safety Board,
that the Dutch State had a role in the provision of information and advice as to the choice
for the route of flight MH17. It quickly became apparent from the investigation that, with
regard to this matter, the country of departure - in this case the Netherlands - bears no
responsibilities with regard to the foreign-based airline, Malaysia Airlines. Nevertheless,
the Dutch Safety Board wanted to further investigate the subject and to include it in the
investigation report, as it was conceivable that the Netherlands could have exerted some
influence.

20 Within Europe, EUROCONTROL on behalf of its member sates calculates the charges for using the airspace and
invoices them to the respective airlines that made use of that airspace.

42

The investigation focused on the structure of the decision-making process related to the
safety of flight routes in different states, the role of the national authorities and the
airlines and the ways both parties interact. For this part of the investigation the Dutch
Safety Board was assisted by sister organisations in six countries. In all of the countries
taking part, the sister organisations on behalf of the Dutch Safety Board held interviews
with airlines and, in some countries, with the national authorities as well.
With some airlines, participant observations were conducted with the objective of
acquiring a realistic picture of the practice. This meant that the investigators observed
the decision-making related to flight routes from behind the scenes in order to get an
inside view. This investigation focused on how processes of gathering and sharing
information, analyses of threats, risk assessment and decision-making are carried out in
practice, what mechanisms and considerations play a role in the decision-making
regarding the safety of flight routes and how these processes deal with statistically
improbable scenarios.
For the interviews and participant observations, the sister organisations used an
investigation protocol set up by the Dutch Safety Board. They recorded their fndings in
a report that was made available to the Dutch Safety Board for use as source material.
The airlines and authorities cooperated in this part of the investigation on a voluntary
basis and in anonymity. The results were incorporated into the investigation report
anonymously (untraceable to the specifc airline). The Dutch Safety Board chose to use
this approach in order to increase the willingness of parties to take part in the
investigation, with the objective of reaching as many safety benefts as possible.
4.3 Analysis and assessment
The Dutch Safety Board considered it relevant to analyse the actions of parties from the
context in which those actions occurred. To that end a comparison was made, where
possible, of what other parties did in the same situation or similar situations. The decision
by Ukraine to keep the airspace open to civil air traffc above a certain altitude, was put
into perspective by comparing it to the airspace management in other areas of armed
conflict. The decision by Malaysia Airlines to fly over the eastern part of Ukraine was
compared to the choices that other airlines and states made pertaining to this issue. The
decision-making related to the route of flight MH17 was also compared to the common
practice of decision-making in the aviation sector (processes and patterns) with regard to
overflying conflict areas.
The Dutch Safety Board sought to explain the decisions that parties made with regard to
the airspace and the route of flight MH17 from several perspectives. For each of these
decisions, the investigators mapped as many arguments ‘for’ and ‘against’ as possible.
This helped the investigators to form a picture as objective as possible of the
considerations on which the decisions were based, disregarding today’s knowledge. The
objective was to prevent fndings from being assessed with hindsight bias or with
prejudice.

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5 CRASH: THE OCCUPANTS
5.1 Design of the investigation
After the crash of flight MH17, some relatives wanted to know what the occupants of the
aeroplane consciously may have experienced during the crash. This question and
thoughts about it became even more poignant in the (social) media after the speech by
the Dutch Minister of Foreign Affairs in the Security Council of the United Nations on
19 September 2014.
For the investigation into the causes of the crash, the Dutch Safety Board had already
considered the victims’ injuries, medical and pathological information and survival
aspects, as required by the Appendix of Annex 13 to the Chicago Convention. On the
basis of consultations with several technical specialists and experts in the feld of
psychological trauma and grief counselling the Dutch Safety Board concluded that a
further investigation could be meaningful.
After the Dutch Safety Board had decided to investigate the experience of the occupants,
a separate investigation team was compiled. This investigation team consisted of (medical)
experts who were especially recruited by the Dutch Safety Board for this investigation.
At the advice of specialists and experts in the feld of psychological trauma and grief
counselling, an objective was added to the investigation: describing the way in which the
recovery and transfer of the human remains to the Netherlands took place. The experts
advised the Dutch Safety Board to include this topic in the investigation because of the
different reports circulating about how the human remains of the victims in Ukraine were
handled shortly after the crash. The Dutch Safety Board followed this advice.
The following questions were key in the investigation:

Reporting
The Dutch Safety Board incorporated the conclusions of the investigation into the occupants’
conscious awareness and the handling of the human remains in the investigation report
about the crash. Extensive research was necessary to draw conclusions related to the
occupants’ awareness, because little information was available on the subject. However, the
fnal conclusions that could be made were too limited to include the fndings in a separate
report.

46

trauma was gathered. For this part of the investigation, use was made of the expertise of
the Military Mental Health Research Centre (Onderzoekscentrum Militaire Geestelijke
Gezondheidszorg), the Arq Psychological Trauma Expert Group (Arq Psychotrauma
Expert Groep) and the department of Clinical and Health Psychology (Klinische en
Gezondheidspsychologie) of Utrecht University. They also made use of scientifc research
into physiological and psychological reactions to the exposure factors that may occur in
a crash such as this one.
Interviews about the recovery of the human remains
For the investigation into the recovery of the human remains, interviews were conducted
with professionals who had played a role in the recovery and transport of the human
remains from Ukraine to the Netherlands. Due to circumstances it proved impossible to
speak with those involved locally about the recovery of human remains and the transport
of human remains to the Netherlands (State Emergency Services, local emergency
services and the mortuary in Donetsk). The Dutch Safety Board did speak with those
involved from the International Red Cross in Ukraine. It also spoke with Dutch citizens
who worked side by side with the local people. The Dutch Safety Board also made use of
the knowledge of its own staff members who were stationed in Ukraine.
5.3 Analysis and assessment
It was not possible to be certain as to what exactly happened on board the aeroplane.
Nor was it possible to know exactly where the individual passengers were in the cabin
during the crash: people could have been walking around, they could sit on exchanged
seats or been visiting the lavatory. The analyses that led to the answering of the
investigation questions are explained below.
What circumstances were the occupants exposed to during the crash and what was the
influence on the body, the conscious awareness and perception?
For analysing the effect on the body, the expertise of a pathologist,24 two trauma
surgeons (Erasmus University Medical Center Rotterdam and University Medical Center
Groningen) and a specialist in cardiovascular physiology was called upon (Academic
Medical Center in Amsterdam). They looked at the nature of the injury patterns in
combination with the various factors to which the occupants were exposed.
In order to gain insight into the consequences for the awareness and the perception, in
their analysis experts combined the information about the exposure factors with the
gathered scientifc knowledge about physiological and psychological reactions to acute
stress. The fndings from this analysis were submitted to a wider circle of experts for
further interpretation. With the aid of their comments, a conclusion was drawn with
regard to what the occupants may have experienced of the crash. The literature consulted
is included in the report.

24 This person, who had been involved in the past in the investigation of aviation accidents from within the NFI,
contributed to the investigation in a private capacity.

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6 PASSENGER INFORMATION
6.1 Design of the investigation
After the crash of flight MH17, it became apparent that not all the information needed to
provide the relatives of the Dutch passengers with confrmation of the presence of their
loved ones on board the aeroplane was immediately available. The 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 appeared not to be the case. It took two to four days before
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 available immediately prompted the
Dutch Safety Board to conduct an investigation into how passenger information was
collected and verifed to formally confrm the presence of Dutch passengers on board
flight MH17. In deciding to launch an investigation into this matter, the Dutch Safety
Board included bottlenecks encountered earlier pertaining to the availability of passenger
information, such as after the crash of a Turkish Airlines aeroplane in Haarlemmermeer in
2009.
The investigation into the availability of passenger information concerned the situation in
the Netherlands in the days following the crash. This, however, does not exclude other
countries from learning from the results of this investigation. As a matter of fact, all
relatives of victims of aviation accidents want to know as quickly as possible whether
their loved ones were on board the aeroplane. Experience shows that, in many aviation
accidents, a complete and reliable passenger list is not available immediately after the
accident. The results of the investigation into passenger information can help authorities
of other countries to assess, and, where necessary, improve their preparations for
informing relatives about the fate of their loved ones. The report also shows the common
international interest in expanding the information in passenger lists.
In the investigation into the passenger information of flight MH17 the following questions
were key:

50

Registration of passenger information prior to the flight
In order to catalogue the compilation of the passenger list of flight MH17 and the
influence this process had on the availability of passenger information after the crash, the
Dutch Safety Board used various methods to gather information about the information
flows from booking to departure.
The Dutch Safety Board requested and examined internal documents from parties
involved, such as Malaysia Airlines and Amsterdam Airport Schiphol. In addition, the
Dutch Safety Board conducted interviews with staff members of relevant parties including
Malaysia Airlines (both in the Netherlands and in Malaysia), a travel agency, a tour operator,
an online travel agency, a Dutch travel association, a ground handling agent, other airlines
and authorities involved (such as the Royal Netherlands Marechaussee). Written questions
were submitted to a developer and administrator of the computer systems that are used
for reservation, preparation and handling of the flight. Finally, the Dutch Safety Board
made working visits to airlines to see how passenger data is registered in practice.
In order to increase the willingness of the parties who were not involved with flight MH17
to cooperate with the investigation, the fndings of the investigation were processed in
the report anonymously. In this way, they cannot be traced back to the parties with whom
the Dutch Safety Board spoke in the context of the investigation. The Dutch Safety Board
opted to do so in this case for the purpose of achieving maximum safety gains.
Gathering and verifying passenger information after the crash
The Dutch Safety Board investigated what actions parties undertook after the crash in
order to confrm to the relatives of the victims of flight MH17 that their loved ones were
on the aeroplane and to what extent these parties were prepared for this. The Dutch
Safety Board requested and examined internal documents from the parties involved
(such as log books and minutes of meetings, manuals and crisis and emergency plans,
whether or not in draft form), namely the Ministry of Security and Justice (the National
Crisis Centre), the Ministry of Foreign Affairs, the Ministry of Defence (Royal Netherlands
Marechaussee), the Kennemerland Safety Region, the Municipality of Haarlemmermeer
and Malaysia Airlines.
The Dutch Safety Board conducted interviews with staff members of parties involved,
including the Municipality of Haarlemmermeer, the Kennemerland Safety Region, the
Ministry of Security and Justice, the Ministry of Foreign Affairs, the Ministry of Defence
(Royal Netherlands Marechaussee) and the National Police (LTFO). The Dutch Safety
Board also spoke with staff members of the Eurocross emergency centre, of embassies
and of Malaysia Airlines (in the Netherlands and Malaysia).
During the investigation it proved impossible to examine all of the communication of all
parties involved. Many parties shared information and made agreements with one another
and discussed matters, using various means of communication (for example, telephone,
e-mail or WhatsApp). Not all of these communications were recorded or requested.
However, the information available to the Dutch Safety Board provided a clear picture of
the parties who were in contact with each other, whether, how and when they shared
information or made agreements, what information or agreements it concerned and when
this all took place. This picture was confrmed in interviews with various parties involved

52

7 EXCEPTIONAL CIRCUMSTANCES
This chapter discusses the circumstances that made the investigation into the crash of flight
MH17 exceptional. It concerns matters that require further explanation. This chapter has
been written from the Dutch Safety Board’s perspective and focuses on the Dutch Safety
Board’s investigation and therefore does not describe activities by other parties involved.
7.1 Visiting the wreckage area and recovery of the wreckage
7.1.1 The frst weeks after the crash
When a civil aviation accident occurs, the aviation investigators usually visit the wreckage
area as quickly as possible. During the frst few days after the crash, the National Bureau
of Air Accidents Investigation of Ukraine (NBAAI) was in charge of the investigation. The
formal delegation of the investigation to the Dutch Safety Board took place on 23 July.
Many efforts made during the initial period following the delegation focused on enabling
the Dutch investigators in Ukraine to visit the crash site, so that they could examine the
wreckage at the scene. There was no guarantee that it would be possible to safely
conduct a (comprehensive) examination of the wreckage area in the short or long term
due to the unstable safety situation. As long as the wreckage sites in the area could not
be accessed in safety, the investigators worked on collecting and analysing as much
other evidence as possible.
The safety situation in the wreckage area
Although Ukrainian aviation accident investigators (19-21 July), Malaysian investigators
(22-24 July) and observers from the OSCE briefly accessed the wreckage area and took
photographs, it was not possible to carry out an extensive investigation at the scene of
the crash during the initial period after the crash of flight MH17.
Visiting the wreckage area was risky because there was regular fghting in and around the
area. The Dutch Safety Board as an investigative body is not equipped for investigation in
conflict areas and was dependent on the support of other parties for the investigators’
safety on site. New developments were closely followed and information about the local
situation was obtained. A Dutch Safety Board delegation was stationed at the Dutch
embassy in Kyiv. At the embassy, information from the NCTV, the OSCE, the embassy and
the Dutch Intelligence Services was assessed at least once a day to see whether the
situation was safe enough for the investigators to visit the site. The NCTV ultimately
decided whether the situation was safe enough. The investigation bodies of other involved
states made their own decisions about the way in which they would operate and how to
manage their safety.
Investigators of the Dutch Safety Board joined a large-scale mission to transfer the human
remains and personal belongings of the victims to the Netherlands. As soon as the
wreckage area could be visited, the recovery of human remains and personal belongings

54

In order to facilitate the recovery mission, the Dutch Safety Board conducted consultations
with a representative of the Ministry of Emergency Services from the Donetsk Region
Administration to ensure that the investigators could perform their work at the wreckage
area without obstruction. It was agreed that this representative would hand over the
pieces of wreckage to the Dutch Safety Board, being the leader of the internationally
authorised investigation team. It was also agreed that all states represented in the
investigation team would be enabled to participate in the investigation into the wreckage
in the Netherlands (see Appendix G). The formalisation of the agreements took place
through the mediation by the OSCE, which did justice to the Dutch opinions in this matter.
Efforts were also made to build mutual trust at local level so that the work at the crash
site could be performed in relative safety. To this end a special request was issued (see
Appendix H). The Dutch Safety Board’s investigators were afforded the protection of the
Dutch Ministry of Defence. The Dutch Safety Board received help from the OSCE, the
SES (State Emergency Services of Ukraine) and other local authorities. The local police
provided escorts for the visits to the wreckage area.
Even though a lot of relevant information that could be used to investigate the causes of
the crash (such as photographs, flight recorders), had already been collected during the
period prior to the recovery missions, the wreckage was of great value to the investigation.
It was necessary to examine the wreckage to be able to draw solidly supported conclusions
about the causes of the crash. After recovering the pieces of wreckage, all the international
parties involved could view and study these for themselves and together discuss the
fndings undisturbed (in progress meetings). The substantive contribution of the wreckage
pieces to the investigation is described in Chapter 3. Finally, the wreckage pieces were
needed to explain clearly to the outside world what happened to flight MH17.
Choices made at the wreckage sites
The safety situation was still unstable when the investigators obtained access to the
wreckage area. The people taking part in the recovery mission performed their work
very close to the area where fghting still was going on. During the frst recovery mission
(November 2014), the front line ran through the north-western part of the wreckage area
and therefore the Dutch Safety Board was unable to access this part during this frst
mission (later, in the spring of 2015, they were able to do so). Other supplemental safety
measures were also necessary: it was required to wear bulletproof vests and travelling
and working was restricted to daylight hours. There was the risk that the activities could
be called off at any time. These circumstances had an impact on the choices that were
made on site. The situation created the pressure of transporting important pieces of
wreckage that had been recovered to a safe place as quickly as possible.
Normally, in the event of an accident investigation, the initial investigation is carried out
at the crash site before the wreckage and components are confscated by the
investigators. This often involves mapping out the situation at the crash site by, for
instance, taking photographs. Given the unstable safety situation when visiting the
wreckage area in the eastern part of Ukraine, the priority was to recover the most relevant
pieces of wreckage. Extensive investigation activities at the site would have been of
limited added value because the pieces of wreckage had been lying unguarded in the
intermediate period. The situation no longer resembled that of shortly after the crash.

56

to excavate the area, which the Dutch Safety Board joined. During this period, the pieces
of wreckage from the second mission already stored in Kharkiv were transported to the
Netherlands. More pieces of wreckage were recovered in the region and brought to
Kharkiv by truck. Lastly, during the third mission, house visits were made in the villages
surrounding the wreckage site to collect more pieces of wreckage.
While the recovery mission in November 2014 focused mainly on recovering as many
relevant pieces as quickly as possible and securing them, the missions in spring focused
on recovering everything the investigators could lay their hands on. During the fnal
mission, the north-western part of the wreckage area was also accessible. The Dutch
Safety Board hoped to fnd the upper section of the cockpit there. Photos and satellite
images had shown earlier that it was located in this area but, upon arrival in the area, it
appeared it was no longer there. Eight more containers of wreckage were recovered
during the second and third recovery missions in spring. The containers held various
parts of the outside of the aeroplane, parts of the inside of the aeroplane and a large
quantity of mostly small, burnt parts. The eight containers were transported to the
Netherlands at the end of the third mission.
After the recovery activities had fnished, the Dutch Safety Board had suffcient aeroplane
wreckage at its disposal to be able to reliably establish the causes of the crash and to
perform a physical reconstruction of a relevant part of the aeroplane.
Cooperation with other authorities
During the recovery missions the Dutch Safety Board worked in close cooperation with
other Dutch authorities. This was done for security reasons and because the missions for
recovering human remains, personal belongings and wreckage pieces were combined. That
is why the Dutch Safety Board joined the operational meetings concerning the missions for
as long as deemed necessary to carry out the recovery work. These meetings were
organised by the Dutch Ministry of Defence and were attended by the Dutch authorities
that took part in the recovery missions, namely the Ministry of Defence, the Royal
Netherlands Marechaussee, the National Police, the Ministry of Foreign Affairs, the MIVD,
the AIVD and the NCTV. For the purpose of coordinating the activities there were also
bilateral consultations between the Dutch Safety Board and the involved public bodies.
7.1.3 Reliability of the material at the wreckage area
Wreckage pieces
The material that was found at the wreckage sites was not unscathed. The wreckage had
been lying at the wreckage sites unguarded for several months and was prone to being
damaged, altered or removed. The wreckage was partially affected by weather and by
the handling that was necessary during the frst few weeks to recover the human remains
and personal belongings. The latter in some cases required moving pieces of wreckage.
Furthermore, there had been repeated fghting in the area, which could also have had
repercussions on the state of the wreckage when it was recovered.
The wreckage was still valuable to the investigation, even though it had been exposed to
the conditions mentioned above. It was possible to verify the reliability of the wreckage
for the investigation and the damage to the wreckage caused by the crash using

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7.2 Reconstruction of the aeroplane
Only in rare cases aeroplanes are reconstructed following a crash or accident. Such a
process is labour-intensive and time-consuming. Nevertheless, on 20 January 2015, the
Dutch Safety Board decided to reconstruct the part of the aeroplane that was the most
relevant to ascertain the causes of the crash. The objective of the reconstruction was to
further verify the conclusions drawn in the investigation report about the causes of the
crash and to demonstrate the consequences for the aeroplane.
First the outline of the aeroplane was drawn on the floor of the hangar in Gilze-Rijen. The
pieces of wreckage that were relevant to the investigation were placed inside the outline
at their original position in the aeroplane. Then a set up of the pieces of wreckage with
high-energy object damage was produced for the analysis. Based on the pattern found
on the wreckage, the direction from which the high energy objects approached the
aeroplane was roughly ascertained, using stringing (see paragraph 3.3).
Once the relatives of the victims had had the opportunity to view the wreckage, the
forward part of the aeroplane, consisting of the skin of the cockpit, business class and a
small section of economy class, was reconstructed. It was decided to only reconstruct
the forward part of the aeroplane as this was suffcient to be able to investigate the
causes of the crash. In order to reconstruct this part of the aeroplane true to fact, only
pieces of wreckage that the Dutch Safety Board had actually retrieved from the crash site
were used. The missing pieces were not reproduced. The reconstruction of the forward
part of the aeroplane underpinned the conclusion that the aeroplane was impacted by
high-energy objects originating from a missile.
Prior to the three-dimensional reconstruction, the Dutch Safety Board studied the
reconstruction of TWA flight 800 in the United States and parts of the reconstruction of the
aeroplane of the Pan Am flight 103 in Scotland.26 On the basis of these studies, the Dutch
Safety Board decided to use a steel structure, which was best suited to a reconstruction
that had to be realised in a short time. In the reconstruction, the Dutch Safety Board used
the exact dimensions of the aeroplane. These dimensions were requested from Boeing. The
remaining sizes were determined, based on a scan made by the police of a similar Boeing
777-200. The steel frame was designed and constructed using these dimensions. Upon
delivery of the frame in May 2015 the pieces of wreckage were ftted on the frame. Because
the pieces of wreckage risked being damaged when they were being attached to the frame
the reconstruction only began after all pieces of wreckage had been thoroughly examined.
The reconstruction was completed mid July 2015.

26 An explosion occurred in the Trans World Airlines aeroplane that crashed near New York in 1996, as a result of fuel
vapours igniting in the central fuel tank. The fuel vapours probably ignited as a result of a spark caused by a shortcircuit in poor wiring. In 1988, the Pan Am aircraft fell apart above Lockerbie as the result of a bomb attack.