Crash investigators of the Dutch Safety Board (DSB) in its final report today confirm a Russian-built Buk ground-to-air missile downed MH17. The DSB released its findings at 1:45 pm local Dutch time, 7:45 am ET on the causes of the Boeing 777-200 crash in war-torn Hrabove, Ukraine on July 17, 2014, in which 283 passengers and 15 crew members died on board Malaysia Airlines flight MH17’s Boeing 777-200 en route from Amsterdam, The Netherlands to Kuala Lumpur.
Today’s MH17 crash final report by the DSB of The Netherlands, headed by Chairman Tjibbe Joustra, follows a previously released preliminary MH17 investigation report on September 9, 2014, sketching out the causes of the aviation disaster that has impacted Malaysia Airlines Berhad (MAB).
Video Credit: about the Dutch Safety Board’s investigation into the causes of the crash of flight MH17 on July 17, 2014 in the eastern part of Ukraine and the Board’s investigation into flying over conflict zones. The video was based on the Dutch Safety Board’s investigation reports, which were published on October 12, 2015.
DSB chairman Joustra said the warhead that downed MH17 fits the profile of a Russian-built automatic computerized Buk ground-to-air missile. However, Russian officials who participated in the investigation said “it was not possible to confirm the warhead or type of system,” according to Joustra (via CNN).
The new air carrier has been operational, since September 1, 2015, with a new RM6 billion (or US$1.9 billion) business model and management team, led by Christoph Mueller, CEO of Malaysia Airlines Systems and CEO-Designate of the new “value-based” airline, aiming for profitability estimated by 2018 (which is briefly reviewed at the end of this piece).
Photo Credit: Taken on July 28, 2013, at Shanghai Pudong Airport, by Steven Richardson, aviation analyst at FlyersPulse.com, of Malaysia Airlines Boeing 777-200, Registration Number 9M-MRD, which is reported by Malaysia Airlines as the crashed aircraft of Flight 17.
A total of 193 Dutch nationals and 38 Australian nationals were on board Flight MH17. Besides 44 Malaysians, nationals from the Netherlands, Australia, Indonesia, the United Kingdom, Germany, Belgium, the Philippines, Canada and New Zealand were among the 283 passengers and 15 Malaysia Airlines crew on board MH17.
Our thoughts, prayers, and sympathies still remain with the families, friends, and loved ones of those 298 persons lost, as they continue to wait in deep anguish for the most complete closure to their lingering questions in search of the most definitive answers and justice surrounding the MH17 aviation disaster.
After more than 15 months of searching and waiting for those answers, this history-making aviation safety and security breach is still raising even more questions, as to why this MH17 aviation disaster happened on the morning of July 17, 2014 to this particular Southeast Asia air carrier in the wake of a little over four months after the stunning disappearance of the Boeing 777-200ER airliner that frames the ongoing mystery of the MH370 aviation tragedy on the morning of March 8, 2014.
Scope of Dutch Safety Board (DSB) MH17 Crash Investigation.
The DSB investigation is operated in accordance with the standards and recommended practices in the International Civil Aviation Organization (ICAO) Annex 13.
The largest number of 193 passengers on board flight MH17 were Dutch. As a result of international protocols and norms in aviation crash events, involving safety and security breaches, The Netherlands has taken the international lead in the overall safety investigation and findings report of the crash of Malaysia Airlines flight MH17.
The nation-state (Ukraine) in which the Boeing 777-200 airliner safety breach occurred has delegated the investigation to the Dutch Safety Board, which is leading the investigation and coordinating the international team of investigators. The group of international investigators consists of aviation safety and security representatives of The Netherlands, Malaysia, Australia, United States, Russia, and Ukraine.
This MH17 causal report contains the complete circumstances surrounding the aircraft hull “high-energy” foreign object impact and explosion, a comprehensive technical analysis of the airliners’ flight data recorders (or “black-boxes”), an investigation into the decision-making process with regard to flight routes over war-torn Hrabove, Ukraine on July 17, 2014, and a scientific forensic analysis of the remains of the 283 passengers and 15 Malaysia Airlines crew members.
The final report also contains factual information obtained from safety investigative teams having accessible evidence of the MH17 crash site, including on-board flight records and radar stations, MH17 black-box flight data, as well as, satellite imaging and other visual sources.
The following areas of interest substantiate the wealth of factual information and recommendations (quoted in the Appendix Section of this piece) inside the massive final report regarding:
- detailed analyses of data, including black-box flight data recorders and other sources, recorded on-board the Boeing 777-200 airliner;
- detailed analyses of recorder air traffic control surveillance data and radio communication;
- detailed analyses of the meteorological circumstances;
- forensic examination of wreckage, if recovered and possible foreign objects, if found;
- results of the pathological investigation;
- analyses of the in-flight break up sequence;
- assessment of Malaysia Airlines operator’s and State of Occurrence’s management of flight safety over a region of conflict or high security risk;
- detailed analysis of eleven (11) aviation safety and security recommendations to the International Civil Aviation Organization (ICAO) and International Air Transportation Association (IATA);
- any other areas that are identified during the ongoing MH17 crash investigation.
The MH17 crash findings released today builds the most complete picture of how the Boeing 777-200 airliner, Registration Number 9M-MRD, was brought down on the morning of July 17, 2014 over war-torn Hrabove, Ukraine.
The DSB’s main objective is to establish the causes of the MH17 crash and to offer recommendations for safety of international commercial passenger flights.
In addition, DSB stresses inside its preliminary and final reports that the safety council does not have any authority to “apportion blame” and to “place blame, liability or responsibility for the tragedy” on any nation or specific group or persons. The Board further adds such issues must remain within the scope of the Dutch prosecutorial authorities.
What happened exactly? Why was Malaysia Airlines’ Boeing 777-200 airliner performing its flight MH17 precisely across the much-troubled war-torn Harbove, Ukraine region, where an armed conflict was being fought? What extent the occupants of flight MH17 consciously experienced the crash?
Transport Minister Datuk Seri Liow Tiong Lai has said Malaysia would continue with its own safety investigation and criminal probe into the MH17 aviation disaster through the Malaysian Department of Civil Aviation (DCA), alongside the Dutch team of safety investigators, including further assessments into the preliminary and final reports of the Dutch Safety Board.
“We hope the final report can help in obtaining sound evidence to bring the criminals to the international court,” Lai has said.
Main Conclusion – Preliminary findings of “high-energy objects” now concluded by DSB as a Buk ground-to-air missile downing MH17.
Based on the preliminary findings to data, no indications of any technical or operational issues were found with the aircraft or crew prior to the ending of the black-box flight data recording of MH17 at 13.20:03 hours UTC.
The damage observed in the forward section of the Boeing 777-200 airliner appears to indicate that the aircraft was penetrated by a large number of high-energy objects from outside the aircraft. It is likely that this damage resulted in a loss of structural integrity of the aircraft, leading to an in-flight break up.
“High-energy objects,” as suggested in the preliminary findings of the DSB on September 9, 2014, penetrated the aircraft as it flew over war-torn Hrabove, Ukraine.
It has been determined by the DSB in their preliminary report that a Boeing 777-200, operated by Malaysia Airlines as flight MH17, broke up in the air, as the result of structural damage caused by a large number of “high-energy” objects that penetrated the airliner’s fuselage from outside. The Board found no indications that the MH17 crash was caused by “a technical fault or by actions of the crew.”
“The cockpit voice recorder, the flight data recorder and data from air traffic control all suggest that flight MH17 proceeded as normal until 13:20:03 (UTC) after which it ended abruptly. A full listening of the communications among the crew members in the cockpit recorded on the cockpit voice recorder revealed no signs of any technical faults or an emergency situation. Neither were any warning tones heard in the cockpit that might have pointed to technical problems. The flight data recorder registered no aircraft system warnings, and aircraft engine parameters were consistent with normal operation during the flight. The radio communications with Ukrainian air traffic control confirm that no emergency call was made by the cockpit crew. The final calls by Ukrainian air traffic control made between 13.20:00 and 13.22:02 (UTC) remained unanswered,” the DSB preliminary report concluded.
The Dutch preliminary report added: “The pattern of wreckage on the ground suggests that the aircraft split into pieces during flight (an in-flight break up). Based on the available maintenance history the airplane was airworthy, when it took off from Amsterdam, and there were no known technical problems. The aircraft was manned by a qualified and experienced crew.”
The DSB went on to summarize the findings of the crash site debris field: “The pattern of damage observed in the forward fuselage and cockpit section of the aircraft was consistent with the damage that would be expected from a large number of high-energy objects that penetrated the aircraft from outside” … “The fact that there were many pieces of aircraft structure distributed over a large area indicated that the aircraft broke up in the air.”
Photo Credit: Dutch Safety Board (DSB), The warhead, points 1-3 mark the parts of the warhead recovered on the crash site.
Nearly a year later on August 11, 2015, the DSB took possession of parts recovered from the MH17 crash site in Hrabove, Ukraine, that the DSB preliminarily determined could possibly have originated from an advanced computerized BUK ground-to-air missile. Upon further investigation by the DSB to determine the cause of the crash, and by the Joint Investigation Team (JIT), which conducted the criminal investigation, the final MH17 causal report definitively links the discovered parts to an advanced computerized Buk warhead ground-to-air missile. The MH17 final report further concludes that the discovered parts of the Russian-built Buk ground-to-air missile was indeed the “high-energy” impact which caused the downing of Malaysia Airlines flight MH17 on July 17, 2014.
Extent of Flight MH17 Boeing 777-200 Hull Damage on the 298 Passengers and Crew.
Damage observed on the forward fuselage and cockpit section of the Boeing 777-200 airliner appears to indicated that there were impacts from a large number of high-energy objects, now concluded by the DSB as originating from a Russian-built Buk ground-to-air missile, from outside the aircraft.
The pattern of damage observed in the forward fuselage and cockpit section of the aircraft was not consistent with the damage that would be expected from any known failure mode of the Boeing 777-200 airliner, its engines or systems.
The fact that there were many pieces of aircraft structure distributed over a large area, indicated that the aircraft broke up in the air.
The DSB concluded that “pre-formed fragments” or “high-energy objects” from the warhead explosion at the forward fuselage and cockpit section killed three crew members instantly. In the aft section of the Boeing 777-200 airliner no such damage was placed upon the other occupants in the cabin section.
“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,” the report said.
“The Dutch Safety Board did not find any indications of conscious actions performed by the occupants after the missile’s detonation. It is likely that the occupants were barely able to comprehend the situation in which they found themselves.”
Brief summary of the Dutch Safety Board Preliminary and MH17 Crash Final Report findings are quoted below for reader convenience in the Appendix and on the Safety Board’s website.
Malaysia Airlines Berhad (MAB) sheds staff, routes and planes in US$1.9 billion restructuring and recovery to profitability by 2018.
Brief Summary of the Dutch Safety Board MH17 Crash Final Report Findings
Aircraft Type and Registration: Boeing 777-2H6ER, 9M-MRD
Number and Type of Engines: 2 x Rolls-Royce Trent 892B
Location: Near Hrabove, Ukraine
Date and Time (UTC) 17 July 2014 at 13.20 hours
Type of Flight: Scheduled passenger flight
Persons on Board: Crew = 15 (4 flight deck crew, 11 cabin crew); Passengers = 283
Injuries: Crew = 15 (fatal); Passengers = 283 (fatal)
Nature of Damage: Aircraft destroyed
According to the information received form Malaysia Airlines the crew was properly licensed and had valid medical certifications to conduct the flight.
According to the documents, the aircraft was in an airworthy condition at departure from Amsterdam Airport Schiphol, there were no known technical malfunctions.
No evidence or indications of manipulation of the recorders were found.
No aural alerts or warnings of aircraft system malfunctions were heard on the Cockpit Voice Recorders. The communication between the flight crew members gave no indication of any malfunction or emergency prior to the occurrence.
The engine parameters were consistent with normal operation, during the flight. No engine or aircraft system warnings or cautions were detected.
No technical malfunctions or warnings in relation to the event flight were found on the Black-Box Flight Data Recorder data.
Air Traffic Control and Airspace
At the time of the occurrence, flight MH17 was flying at a flight level of 33,000 feet in unrestricted airspace of Dnipropetrovs’k in the eastern part of Ukraine. The aircraft flew on a constant heading, speed and altitude, when the Flight Data Recording ended. Ukraine air traffic control, then immediately, issued an emergency that restricted all access to the airspace below flight levels of 32,000 feet.
The last radio transmission made by the crew began at 13.19:56 hours and ended at 13.19:59 hours UTC.
(Note: Ukraine local time – Central European (Summer) Daylight Saving Time – was 2 hours ahead of UTC, that is UTC+2).
- At 13.19:53 hours, radar data showed that the aircraft was 3.6 nautical miles north of centerline of airway L980, having deviated left of track, when Dnipro Control directed the crew to alter their route directly to waypoint RND due to other traffic. The crew acknowledged at 13.19:56 hours. At 13.20:00 hours UTC, Dnipro Control transmitted an onward air traffic control clearance to proceed directly […], no acknowledgement was received.
The last radio transmissions made by Dnipropetrovs’k air traffic control center to flight MH17 began at 13.20:00 hours UTC and ended at 13.22:02 hours UTC. The crew did not respond to these transmissions.
No distress messages were received by the Dutch air traffic control.
According to the radar data, three commercial aircraft were in the same Control Area as flight MH17 at the time of the safety breach occurrence. All were under control of Dnipro Radat. At 13.20 hours UTC the distance between the closest aircraft and MH17 was approximately 30 kilometers.
Causes of MH17 Crash
“On July 17, 2014, at 13.20 (15.20 CET) a Boeing 777-200 with the Malaysia Airlines nationality and registration mark 9M-MRD disappeared to the west of the TAMAK air navigation waypoint in Ukraine. A notification containing this information was sent by the Ukrainian National Bureau of Air Accident Investigation (NBAAI) on July 18, 2014, at approximately 06.00 (08.00 CET).
(Note: Ukraine local time – Central European (Summer) Daylight Saving Time (CET) – was 2 hours ahead of UTC, that is UTC+2).
The NBAAI was notified by the Ukrainian State Air Traffic Service Enterprise (UkSATSE) that communication with flight MH17 had been lost.
A signal from the aeroplane ́s Emergency Locator Transmitter had been received and its approximate position had been determined.
The aeroplane impacted the ground in the eastern part of Ukraine. The wreckage was spread over several sites near the villages of Hrabove, Rozsypne and Petropavlivka. Six wreckage sites were identified, spread over about 50 kilometers.
Most of the wreckage was located in three of these sites to the south-west of the village of Hrabove. This is about 8.5 km east of the last known position of the aeroplane in flight. At two sites, post-impact fires had occurred.
All 298 persons on board lost their lives.
The in-flight disintegration of the aeroplane near the Ukrainian/Russian border was the result of the detonation of a warhead.
The detonation occurred above the left hand side of the cockpit. The weapon used was a 9N314M-model warhead carried on the 9M38-series of missiles, as installed on the Buk surface-to-air missile system.
Other scenarios that could have led to the disintegration of the aeroplane were considered, analyzed and excluded based on the evidence available.
The airworthy aeroplane was under control of Ukrainian air traffic control and was operated by a licensed and qualified flight crew.”
“Flight MH17 was shot down over the eastern part of Ukraine, where an armed conflict broke out in April 2014. At first this conflict took place mainly on the ground, but as from the end of April 2014 it expanded into the airspace over the conflict zone: Ukrainian armed forces’ helicopters, transport aeroplanes and fighters were downed.
On July 14, the Ukrainian authorities reported that a military aeroplane, an Antonov An-26, had been shot down above the eastern part of Ukraine. On 17 July, the authorities announced that a Sukhoi Su-25 had been shot down over the area on 16 July.
According to the authorities, both aircraft were shot down at an altitude that could only have been reached by powerful weapon systems. The weapon systems cited by the authorities, a medium-range surface-to-air missile or an air-to-air missile, could reach the cruising altitude of civil aeroplanes. Consequently they pose a threat to civil aviation.
Although (Western) intelligence services, politicians and diplomats established the intensification of fighting in the eastern part of Ukraine, on the ground as well as in the air, it was not recognised that as a result there was an increased risk to civil aeroplanes flying over the conflict zone at cruising altitude. The focus was mainly on military activities, and the geopolitical consequences of the conflict.”
Ukraine’s airspace management
“With regard to airspace management Ukraine is responsible for the safety of aeroplanes in that airspace. On 6 June 2014, the airspace above the eastern part of Ukraine was restricted to civil aviation from the ground up to an altitude of 26,000 feet (FL260).
This enabled military aeroplanes to fly at an altitude that was considered safe from attacks from the ground and eliminated the risk that they would encounter civil aeroplanes, which flew above FL260. The authorities automatically assumed that aeroplanes flying at a higher altitude than that considered safe for military aeroplanes, were also safe.
On July 14, 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 July 14, 2014 and July 17, 2014, related to the military aeroplanes being shot down, mentioned the use of weapon systems that can reach the cruising altitude of civil aeroplanes.
In the judgment of the Dutch Safety Board, these statements provided sufficient reason for closing the airspace over the conflict zone as a precaution.”
Choice of flight route by Malaysia Airlines and other airlines
“Malaysia Airlines assumed that the unrestricted airspace over Ukraine was safe. Thesituation 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.
Not only Malaysia Airlines, but almost all airlines that used routes over the conflict zone continued to do so during the period in which the armed conflict was expanding into the airspace. On the day of the crash alone, 160 flights were conducted above the eastern part of Ukraine until the airspace was closed.”
Other states and the state of departure (the Netherlands)
“The Chicago Convention provides states with the option of imposing a flight prohibition or restrictions on airlines and issuing recommendations related to the use of foreign airspace.
Some states, such as the United States, the United Kingdom, France and Germany, use this option with regard to their resident airlines.
Although flight MH17 took off from Dutch soil the Netherlands did not bear any formal responsibility for the flight, because it concerned a non-Dutch airline. The fact that Malaysia Airlines was operating the flight as KLM’s code share partner did not provide any legal authority either.
During the period in which the conflict in the eastern part of Ukraine expanded into the airspace over the conflict zone, from the end of April 2014 up to the crash of flight MH17, not a single state or international organization explicitly warned of any risks to civil aviation and not a single state prohibited its airlines or airmen from using the airspace over the area or imposed other restrictions.
At the Dutch Safety Board’s request, the Dutch Review Committee for the Intelligence and Security Services (CTIVD) examined whether the Dutch intelligence and security services possessed any information that could have been important for the safety of flight MH17.
The services had no indication that the warring factions intended to shoot down civil aeroplanes. The services did not have any information that the groups that were fighting against the Ukrainian government in the eastern part of Ukraine possessed medium or long-range surface-to-air missiles.”
Possibilities for improvement
“The crash of MH17 demonstrates than an unrestricted airspace is not, by definition, safe if the state managing that airspace is dealing with an armed conflict. The reality is that states involved in an armed conflict rarely close their airspace. This means that the principle of sovereignty related to airspace management can give rise to vulnerability.
In the Board’s opinion, states involved in armed conflicts should give more consideration to closing their airspace as a precaution. More effective incentives are needed to encourage them to do so.
Airline operators may not assume in advance that an unrestricted airspace above a conflict zone is safe. The fundamental principle currently adopted by operators is that they use the airspace, unless doing so is demonstrably unsafe. In their risk analyses, operators should take greater account of uncertainties and risk-increasing factors, such as when a conflict expands into the airspace. The current regulations do not stipulate that operators shall assess the risks involved in overflying conflict areas.
Operators themselves should gather more information to be able to perform an adequate risk assessment. This information can largely be acquired by consulting open sources, but in the case of conflict zones operators also need confidential information from states with intelligence capabilities.
Vital in this respect is the sharing of information between states, between states and operators and between operators. Not only the gathering of information, but also combining information in the fields of safety and security, as well as on developments on the ground and in the air proves important. In this regard, international regulations (the Chicago Convention) are currently too divided across these different fields. It was established that there are gaps between the various responsibilities, for which a solution should be found.”
Summary of MH17 Crash Final Report Recommendations
Level 1: Airspace management in conflict zones
1. “Incorporate in Standards that states dealing with an armed conflict in their territory shall at an early stage publish information that is as specific as possible regarding the nature and extent of threats of that conflict and its consequences for civil aviation. Provide clear definitions of relevant terms, such as conflict zone and armed conflict.
2. “Ask states dealing with an armed conflict for additional information if published aeronautical or other publications give cause to do so; offer assistance and consider issuing a State Letter if, in the opinion of ICAO, states do not sufficiently fulfil their responsibility for the safety of the airspace for civil aviation.
3. “Update Standards and Recommended Practices related to the consequences of armed conflicts for civil aviation, and convert the relevant Recommended Practices into Standards as much as possible so that states will be able to take unambiguous measures if the safety of civil aviation may be at issue.
To ICAO Member States:
4. “Ensure that states’ responsibilities related to the safety of their airspace are stricter defined in the Chicago Convention and the underlying Standards and Recommended Practices, so that it is clear in which cases the airspace should be closed. The states most closely involved in the investigation into the crash of flight MH17 could initiate this.
Level 2: Risk assessment
To ICAO and IATA:
5. “Encourage states and operators who have relevant information about threats within a foreign airspace to make this available in a timely manner to others who have an interest in it in connection with aviation safety. Ensure that the relevant paragraphs in the ICAO Annexes concerned are extended and made more strict.
6. “Amend relevant Standards so that risk assessments shall also cover threats to civil aviation in the airspace at cruising level, especially when overflying conflict zones. Risk increasing and uncertain factors need to be included in these risk assessments in accordance with the proposals made by the ICAO Working Group on Threat and Risk.
7. “Ensure that the Standards regarding risk assessments are also reflected in the IATA.
Operational Safety Audits (IOSA)
To states (State of Operator):
8. “Ensure that airline operators are required through national regulations to make risk assessments of overflying conflict zones. Risk increasing and uncertain factors need to be included in these assessments in accordance with the proposals made by the ICAO Working Group on Threat and Risk.
To ICAO and IATA:
9. “In addition to actions already taken, such as the website (ICAO Conflict Zone Information Repository) with notifications about conflict zones, a platform for exchanging experiences and good practices regarding assessing the risks related to the overflying of conflict zones is to be initiated.
Level 3: Operator accountability
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.
11. “Provide public accountability for flight routes chosen, at least once a year.”
More extensive detailed summary findings of the massive DSB’s MH17 final report may be seen at Aviation Herald.
Photo Credits: Malaysia Airlines Boeing 777-200, Registration Number 9M-MRD, which is reported by Malaysia Airlines as the crashed aircraft of Flight 17.
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