MENASASI Middle East and North Africa Society of Air Safety Investigators

From Library: Organizing the MH17 Crash Investigation

The 2016 ISASI seminar theme was “Every Link Is Important.” In this paper, the Dutch Safety Board describes why and how the MH17 investigation was organized, the involved parties and agencies, and the cooperation with external institutions and experts. Aviation disasters shock the world. In today’s society, an incredible amount of information, including the circumstances, the possible causes, and who could be responsible, is shared immediately after a crash. An important objective of the investigation was to provide the international community and the victims’ relatives an accurate and truthful picture of the causes of the crash of Flight MH17 on July 17, 2014. Another objective of the Dutch Safety Board was to draw lessons for the future, based on the findings of this investigation.


From the start of the investigation, the Dutch Safety Board applied four principles: maintaining independence, achieving a high-quality investigation, focusing on determining the causes as accurately as possible to exclude other scenarios, and achieving as much international acknowledgment as possible for the investigation.


The investigation was carried out under exceptional circumstances. The Dutch Safety Board was not blind to the geopolitical implications of the crash but in the investigation deliberately kept its distance from international politics. The facts were leading in the investigation, and the views of parties were evaluated against those facts, a proven protocol that is used worldwide for aircraft accident investigations under the guidelines of the International Civil Aviation Organization (ICAO) Annex 13–Aircraft Accident and Incident Investigation.


The four different investigations were organized as four different projects, each project with its own project manager. For the investigations that were conducted in accordance with Annex 13, one investigator-in-charge was appointed who worked together with the project managers.


Investigation into the causes of the crash of MH17


The investigation into the causes of the crash of Flight MH17 was conducted in accordance with the provisions of Annex 13 of the Chicago Convention by an international investigation team in which, after the initial phase, the following states were represented by an accredited representative during progress meetings:

 

  • Netherlands - State conducting the investigation
  • Ukraine - State of occurrence
  • Malaysia - State of registry/operator
  • United Kingdom - State of design / manufacture (engines)
  • United States - State of design/manufacture (airplane)
  • Australia - State providing information (photos)
  • Russian Federation - State providing information (radar data) Six other states that suffered fatalities were invited to view the wreckage parts; of these, representatives from Belgium and Germany were present. An observer of ICAO was present during different phases of the investigation.

 

Investigation into the flight route of MH17


The fact that two judicial regimes apply, namely the Kingdom Act Dutch Safety Board and Annex 13 of the Chicago Convention, was especially noticeable in the investigation into how the decision-making related to the flight route of Flight MH17 was organized, and how decisions about flying over conflict areas are made in general. For the investigation into flying over conflict areas, the Dutch Safety Board approached various parties in and outside the Netherlands to request their cooperation in the investigation.

It was not always clear to these parties whether the Dutch Safety Board requested them to cooperate on the basis of Annex 13 of the Chicago Convention or on the basis of the Kingdom Act Dutch Safety Board. These parties, such as sister organizations and airlines, provided information to the Dutch Safety Board and cooperated with this part of the investigation anonymously and on a voluntary basis.
During the investigation, it became increasingly clear that parties all over the world attach great value to improving the safety of civil aviation regarding flying over conflict areas. This was demonstrated, for example, by a joint declaration (on July 29, 2014) from ICAO, the branches from air transport (IATA), airports (ACI), and air navigation service providers (CANSO).

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Following the crash, various international initiatives were undertaken to reduce the chance of an accident, such as that involving Flight MH17, from occurring in the future.

 

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In August 2014, ICAO set up a task force to advise on adapting roles and procedures focused on limiting risks that conflict areas pose to civil aviation. On Oct. 27, 2014, ICAO also adopted a resolution advocating for the investigation into the crash of Flight MH17 to be used to improve international standards and to share best practices for the safety of civil air traffic flying over conflict areas. The subject was also on the agenda of ICAO’s high-level safety conference in Montreal, Que., in February 2015. Flying over conflict areas and MH17’s flight above the eastern part of Ukraine were recurring themes in the news media, too.


In the investigation into the decision-making related to flight routes, the Dutch Safety Board attempted to do justice to these international developments and included them in its investigation where possible. The Dutch Safety Board involved representatives of sister organizations where possible and when necessary for the investigation. The investigation into the general decision-making related to flying over conflict areas made it possible to place the outcomes of the investigation into Flight MH17’s route in an international perspective and created the opportunity to learn deeper and broader lessons from this tragic accident.


Investigation of the occupants of MH17


According to Annex 13 of the Chicago Convention, the investigation should include the injuries suffered by the victims, medical and pathological information, and their chances of survival, depending on the circumstances of the accident. The Dutch Safety Board decided to conduct a more thorough investigation into the consequences of the crash for the occupants than is customary on the basis of Annex 13. Apart from the aspects listed there, the Dutch Safety Board attempted to answer the question as to what conditions the occupants were exposed to during the crash and what the influence of this was on their bodies, consciousness, and awareness. In addition, the Dutch Safety Board investigated how the human remains were handled following the crash. The investigation into these questions was conducted on the basis of the authority provided by the Kingdom Act Dutch Safety Board.


Investigation of the passenger information about MH17


The investigation into passenger information looked at the time needed to provide the relatives of the Dutch victims of Flight MH17 with official confirmation that their loved ones were on board the airplane. This investigation was conducted fully within the authority granted to the Dutch Safety Board by the Kingdom Act Dutch Safety Board. On the basis of this authority, the Dutch Safety Board can conduct an investigation into the way the Netherlands has managed the consequences of accidents abroad of which the impact extends to the territory of the Netherlands.

Conducting the investigations


The Dutch Safety Board conducts its investigations within the applicable legal framework respecting its core values: independent, professional, and transparent. In the following sections, the Dutch Safety Board explains how these terms in general are put into practice and what this meant for the investigation into the crash of Flight MH17.

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Independence


The Dutch Safety Board’s objective in conducting its investigations is to provide a definite answer about what happened and how, and to draw authoritative conclusions and lessons from this. From that objective, it is important that the Dutch Safety Board is able to formulate its own autonomous opinion about the facts and their interpretation. In this respect, the legal framework offers several guarantees.


In the context of an accident investigation, independence is not absolute. First, there is always a certain interdependency between the investigator and the subject of the investigation, because parties directly involved have knowledge of unique facts and circumstances that are necessary for understanding the accident. Although the Dutch Safety Board benefits from legal powers it can use to enforce cooperation with its investigation, that does not totally eliminate the type of dependency referred to above. Second, due to the scope of its field of work, the Dutch Safety Board will always depend on the expertise of others to effectively conduct its investigations. Third, in order to arrive at authoritative conclusions, it is important that the Dutch Safety Board also takes into account the views and interests of others.


The Dutch Safety Board therefore cannot and does not wish to wholly isolate itself in conducting its investigation. It is rather a matter of the Dutch Safety Board guarding its conclusions against the disproportionate influencing by other parties while ensuring observance of the aforementioned dependencies.

The Dutch Safety Board must at all times be able to formulate an autonomous and impartial perspective, fed by the perspectives of others.

The investigation into the crash of Flight MH17 took place in an extraordinary context. The large number of victims, the considerable news media attention and the public involvement in the crash, the simultaneous occurrence of an international criminal investigation, and the geopolitical interests involved made it even more important for the Dutch Safety Board to safeguard its independence.

Reflection meetings

From the very beginning of the investigation into the crash of Flight MH17, the Dutch Safety Board was aware that the risk of political influence could be higher than usual, given the tense international relations.

To effectively identify and manage this risk, the Dutch Safety Board held two reflection meetings with experts having extensive experience in conducting investigations in a political playing field. These meetings focused on obtaining advice about the right strategy for working and interacting with parties in this context. The meetings also aimed to explore what the Dutch Safety Board could do to ensure that the results and recommendations of the investigation optimally matched the expectations of the outside world.

The Dutch Safety Board used the results of these meetings in its decision-making processes throughout the investigation.

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Stakeholder analysis


To arrive at independent and authoritative conclusions in a complex array of forces, it is important that the investigative body has an effective understanding of these forces: what interests do the various parties have, how could they influence the course of the investigation, and how can the investigative body best deal with those forces? A stakeholder analysis was performed to systematically answer these questions.


International collaboration in aviation accident investigation


Annex 13 of the Chicago Convention provides for the participation of states having a special interest in the investigation into a civil aviation accident. Depending on the nature of their involvement in the occurrence, states can participate in the investigation through an accredited representative or an expert. The rationale behind involving various states in the investigation is that parties with potentially conflicting interests have the opportunity to take note of the facts firsthand and present their views in the investigation.


The fact that the interests of the states most involved in the investigation are represented in this manner enables the state that conducts the investigation to formulate autonomous conclusions based on the various views.


In international aviation accident investigation, it is customary for the state that is conducting the investigation to organize progress meetings with the participating states. The objective is to share relevant information within the team. Holding such meetings is not required, nor is the number of meetings or their frequency set. The investigator-in-charge invites the accredited representatives and their advisors. In the investigation into the causes of the crash of Flight MH17, this was done on three occasions.

 

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Guidance committee


To be able to form autonomous conclusions, the Dutch Safety Board obtained advice about the weighting of the findings drawn up by the investigation team. For this, it employed a guidance committee. A separate guidance committee was set up for each of the four different investigations regarding the accident of Flight MH17. For this organized critique, the Dutch Safety Board attempted to incorporate all the required expertise in the committees.


The members of the guidance committees have relevant expertise and are appointed in a personal capacity. Each committee convenes several times in the course of an investigation and advises the Dutch Safety Board on the focus and the findings of the investigation, the comments from the parties concerned on the draft final report, the conclusions to be formulated, and the recommendations, insofar as applicable. On occasion, guidance committees met jointly when this was helpful to the investigation.


Bringing the outside world inside


During the course of the investigation, the Dutch Safety Board consistently tried to keep an open eye to facts, information, investigations, suspicions, and theories presented by “outsiders” pertaining to the crash of Flight MH17. It did so with the conviction that the quality of its conclusions would be improved if all kinds of perspectives were incorporated into its formulation. The perspectives of parties other than the states and parties already involved and their experts can add great value to the process. In order to identify what statements were circulating about the causes of the accident and the flight route, the Dutch Safety Board asked Publistat, an organization that monitors media, to analyze the reports in international social media. This analysis served as the basis for the hypotheses that the Dutch Safety Board included in the investigation.


Regarding the results of investigations into the accident conducted by other parties, the Dutch Safety Board examined the sources that formed the basis of these investigations as much as possible. If the sources were accessible, the Dutch Safety Board assessed whether it was useful to incorporate the findings of the other parties in its investigation.


Composition of the investigation teams

The Dutch Safety Board strives to have all the necessary knowledge and skills among its own personnel and tries to realize this through recruitment, selection, and training. The investigation teams for each project are multidisciplinary and consist of investigators who possess the knowledge and skills required for the investigation at hand.

For the investigation into Flight MH17, the Dutch Safety Board called upon investigators having expertise on the subject of aviation, defense, health, crisis management, administrative processes, and risk management.

The investigation into Flight MH17 was an exceptionally large and complex project for the Dutch Safety Board. The project took up a great deal of the available resources: approximately three-quarters of the 72 staff members were at some point assigned to the investigation or to activities in support of it.

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Involving external investigators and support


The Dutch Safety Board is an organization with a broad scope of activity. Thus bringing in specific external expertise is unavoidable, especially for extensive investigations such as that into the crash of Flight MH17.


The most relevant selection criteria when involving external staff are relevant expertise, proven quality, and impartiality of the external employee. The Dutch Safety Board prefers to use its own network in the sector related to an investigation, including contacts in sister organizations and independent knowledge institutions such as universities, when recruiting external investigators.


Transparency


The Dutch Safety Board attaches great value to conducting its investigation in a way that is comprehensible to others so that in turn they can form their own opinion on the investigation’s validity and reliability. Moreover, it is important that the Dutch Safety Board informs the different stakeholders (relatives, other parties involved, the general public) about the investigation and its findings in such a way and at such times that they are not unnecessarily obstructed from coming to terms with their grief or drawing lessons from the event.

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The extent to which the Dutch Safety Board can practice transparency is limited due to the legal obligation to protect its sources. Other than the information in the final report, the Dutch Safety Board does not release any underlying source information related to the investigation, except in exceptional cases. The purpose of this source protection is to enable those involved in an accident to give the Dutch Safety Board full disclosure without fearing any disciplinary measures or criminal prosecution. This means that the Dutch Safety Board is in an optimal position for discovering the true causes of an accident and for drawing lessons from it.


The following part of this section describes how the Dutch Safety Board, taking into account the limitations mentioned earlier, achieved transparency in the investigation into the crash of Flight MH17.


Preliminary report

Given the scope of the accident and its impact on Dutch society and on other nations that suffered fatalities in the accident, the Dutch Safety Board chose to publish the preliminary report after a consultation period. In publishing the preliminary report, the Dutch Safety Board aimed to provide the relatives of the victims, while the investigation was still in progress, with factual information about the crash and the findings up until that time.


Dutch relatives received the preliminary report an hour before it was published on Sept. 9, 2014, under embargo via the family liaison officers deployed by the national police. This allowed the relatives to become acquainted with the report’s content before it was released by the news media.


Consultation and review


Both Annex 13 of the Chicago Convention and the Kingdom Act Dutch Safety Board include provisions concerning to which parties and in what manner the draft final report must be presented for consultation, as well as the way in which the resulting comments are to be processed. The objective of these provisions is to ensure that the final report does not contain any factual inaccuracies and to be informed of interested parties’ views on the findings and conclusions that the Dutch Safety Board has drawn on the basis of the facts investigated.
Communication policy


The needs, expectations, and perceptions in the outside world have influenced the choices the Dutch Safety Board made concerning the type and scope of its reporting. During the investigation, the Dutch Safety Board publicized information about the investigation process more than had previously been customary. The Dutch Safety Board also published a number of relevant documents on its website to provide clarity about some of the agreements that were made. This concerns the agreements between the Dutch Safety Board and other parties with regard to taking charge of the investigation into the crash of Flight MH17 and with regard to the recovery of the wreckage.


The press and news reports published by the Dutch Safety Board were not shared with other parties in advance, with some exceptions. In certain cases, the Dutch Safety Board believed it was necessary to supply parties with the information that it was going to publish prior to the moment of publication. In particular, in cases where information was directly related to a (joint) mission carried out by (or with) another party, the content of the news report was shared in advance with the party concerned.

 

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Informing the relatives


The Dutch Safety Board wanted to keep the relatives of the victims informed of the progress of the investigation as effectively as possible. Never before did the Dutch Safety Board have to deal with such a large group of relatives originating from so many different countries during an investigation. The Dutch central government organized information meetings for the relatives, and the Dutch Safety Board attended these meetings to provide information about the process of the investigation and to answer the questions of relatives.


During the investigation, the Dutch Safety Board maintained contact with the MH17 Aviation Disaster Foundation (Stichting Vliegramp MH17), Victim Support the Netherlands (Slachtofferhulp Nederland), and the family liaison officers and sought their advice prior to having meetings, publicizing reports, or undertaking other kinds of communications.

The relatives of the victims received information via a special forum before it was shared with the news media. Where possible, questions asked of the Dutch Safety Board by relatives via a dedicated forum, family liaison officers, or via Victim Support the Netherlands were answered immediately.


Other reports


Part of the transparency policy of the Dutch Safety Board is to include information about how the investigation is conducted. Normally one appendix in the final report contains this information. For the MH17 investigations, the Dutch Safety Board dedicated a separate report to this purpose.


The Dutch Safety Board is obliged to publish the comments from the consultation phase of the investigation that were not adopted with counter arguments. The parties concerned are informed of this procedure during the consultation. These comments are presented in a table that is appended to the final report.


The Dutch Safety Board also published a book with the stories behind the investigations into the crash of Flight MH17 (see Figure 6). For this purpose, an investigative journalist and writer was commissioned to record these stories from inside—from the perspective of the board members and some of the investigators—to disclose the manner in which the investigation was conducted, the choices that were made, and how the investigation was experienced, both as an organization and as human beings. This book is an “answer” to the long amount of time the investigation was going on without releasing information to the families of the victims.


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 organized by the Dutch Ministry of Defense and were attended by the Dutch authorities that took part in the recovery missions, namely the Ministry of Defense, the Royal Netherlands Marechaussee, the national police, the Ministry of Foreign Affairs, and the Dutch Intelligence and Secret Services—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.


Concurrence with the criminal investigation


Following the crash of Flight MH17, an international criminal investigation started on Aug. 7, 2014. This investigation was conducted by a joint investigation team, in which police and judicial authorities from the Netherlands, Australia, Malaysia, Belgium, and Ukraine cooperated. The Netherlands coordinated the investigation. The objective of the criminal investigation differed from that of the investigation conducted by the Dutch Safety Board. The Dutch Safety Board focused on the question of what happened and what could be learned, and not on the question of who was to blame. The joint investigation team, on the other hand, focused on the causes of the crash in response to the question of whether punishable offenses had been committed and who could be held responsible in terms of criminal law.


Since both investigations considered the same events, they partly relied on the same evidence, each from their own perspective. This situation required coordination between the crash investigation and the criminal investigation to prevent both investigations, each responding to a legitimate social need, from frustrating each other. This necessary alignment was achieved through agreements between the Dutch Safety Board, being the accident investigation authority, and the Dutch Public Prosecution Service as coordinator of the joint investigation team.


The agreements constitute a detailed elaboration of the existing Dutch Safety Board–Dutch Public Prosecution Service Coordination Protocol (Afstemmingsprotocol Onderzoeksraad voor Veiligheid–Openbaar Ministerie). This protocol regulates the coordination between both organizations in a general sense if a criminal investigation and an investigation by the Dutch Safety Board into an occurrence are conducted simultaneously. Additional agreements were required given the complexity of both investigations, their concurrence, and the international context in which these investigations took place. These agreements related to the reciprocal exchange of investigative information, the seizure of physical evidence and documents, the examination of the pieces of wreckage, and the fragments and periodical coordination consultation.


Sharing information related to investigations


In order to determine the causes of an accident or crash, it is of great importance that those involved can speak freely and are able to provide the Dutch Safety Board with information without having to fear prosecution under criminal law. Both Annex 13 of the Chicago Convention and the Kingdom Act Dutch Safety Board include various provisions on the subject of maintaining the confidentiality of information related to the investigation.


Insofar as these provisions offered this possibility, information that was also needed for the success of the international criminal investigation was shared with the Dutch Public Prosecution Service. The idea was not to withhold information if that would hinder the progress of the criminal investigation. Thus the Dutch Safety Board continually considered whether sharing information could in any way be detrimental to its own investigation. Vice versa, the Dutch Public Prosecution Service also shared information proactively if it was relevant to the accident investigation.


Examination of the wreckage


The Dutch Safety Board was responsible for recovering the wreckage pieces and their transport to the Netherlands. The recovered material was inspected and sorted at Gilze-Rijen Air Base in the presence of the Dutch Public Prosecution Service, which indicated which pieces could be relevant to the criminal investigation. These pieces were marked. After this, the material became available for examination to both parties simultaneously. Destructive examination (i.e., an examination of an irreversible nature) could only take place once both parties had investigated the relevant material for damage patterns and traces, and after both parties consented.

All pieces of wreckage, parts, or secured evidence were only to leave the hangar in Gilze-Rijen for investigation after the Dutch Safety Board and the Dutch Public Prosecution Service had agreed. This applied, for example, to material analyses that were performed by external agencies.


Examination of the human remains

The Dutch Public Prosecution Service seized the human remains when they arrived in the Netherlands, after which the injuries and the fragments that were found in the bodies were forensically examined. The Dutch Safety Board was informed of the results of these examinations and used these for its own investigation. The Dutch Safety Board did not perform its own examination of the human remains.


Recorders from MH17


During the investigation, the Dutch Safety Board provided the Dutch Public Prosecution Service with the data files from the flight data recorder and some of the data from the cockpit voice recorder. The Dutch Safety Board was very cautious about providing the recordings in order to guarantee the cockpit crew’s privacy.


In the presence of the Dutch Safety Board and the Public Prosecution Service, specialized staff listened to the sound recordings on the Dutch Safety Board’s premises, with the objective of determining what information could be essential to the criminal investigation. The entire 30-minute recording was found not to be relevant in that respect, with the exception of the final milliseconds, the moment when the airplane was hit. After consultation with the Dutch Public Prosecution Service, it was decided, for the above-mentioned reasons, to hand over only the recording of this short period of time. The data carriers themselves were not handed over. These remained in the hands of the Dutch Safety Board.


Examination of the fragments

 

Both the Dutch Public Prosecution Service and the Dutch Safety Board arranged for the fragments found in and on victims’ bodies and in and on the pieces of wreckage to be analyzed.
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Both parties outsourced this process separately to external agencies but jointly coordinated this process since the outcomes constituted a substantial source of information for both the criminal investigation and the Dutch Safety Board’s investigation.

With regard to the fragments found in the victims’ bodies, a selection of human remains was made of which scans revealed that they contained “foreign” fragments. The selection included the human remains of the crew in the cockpit. The fragments were removed from the bodies by forensic investigators commissioned by the Dutch Public Prosecution Service.

The fragments were removed from the wreckage pieces by the Dutch Safety Board and the Dutch Public Prosecution Service. The Dutch Public Prosecution Service and the Dutch Safety Board shared the results of the different analyses that they had arranged.

Other evidence


In addition to the aforementioned information, the Dutch Safety Board provided the Dutch Public Prosecution Service with the following information: photographs of the wreckage area, lists of the parts of the airplane that had been seized, and information about the damage patterns on the wreckage pieces. Statements from individuals as well as medical and private information collected by the Dutch Safety Board were not shared with the Dutch Public Prosecution Service. In addition to the results of the forensic analyses of the fragments, the Dutch Public Prosecution Service shared other information with the Dutch Safety Board, such as the autopsy and inspection reports of the victims, photographic and video material, and the results of the analyses concerning the found objects that probably originated from a missile.

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Periodic consultation


Throughout the investigation, frequent consultations took place between the Dutch Public Prosecution Service and the Dutch Safety Board, during which they discussed the progress of the investigation activities and matters related to this.


Classified information


All the Dutch Safety Board’s investigation material is of a confidential nature. However, in the investigation into the crash of Flight MH17, confidential information was used that the Dutch authorities had categorized as “classified” and that the Dutch Safety Board was not able to access at all times or could not include in its reports. The central government of the Netherlands adopts different levels of classification, from “departmentally confidential” to “top state secret.” It is unusual for the Dutch Safety Board to work with this type of material and to not have all the source material in its possession.


This is why additional explanation of the working methods concerning classified information is given in the report.


The Kingdom Act Dutch Safety Board stipulates that the minister of the Interior and Kingdom Relations, the minister of Defense, and the minister of Security and Justice, or persons under their jurisdiction, may provide confidential information to the Dutch Safety Board. How to handle classified information in the investigation into Flight MH17 was determined in consultation with the organizations that were owners of the information. The central question in this consideration was whether use of this information could endanger the security of the Netherlands. An additional consideration was the extent to which the information was necessary for arriving at a conclusion or whether the information could also be used in a supporting capacity.


In the investigation into the crash of Flight MH17, classified information was used in several ways:

  • There were classified documents that the Dutch Safety Board had requested in the context of the investigation and that it kept copies of at its The Hague office.
  • There was classified information that was available to the Dutch Safety Board for inspection only. The Dutch Safety Board was able to see relevant classified information regarding Flight MH17 that was in the possession of the MIVD and the AIVD.


The findings of the Dutch Safety Board as described in the report about the crash of Flight MH17 agree with this classified information. Because of national security reasons, this classified information could not be publicized.


Since it is unusual for the Dutch Safety Board to make use of classified military information, an agreement was concluded between the Dutch Safety Board and the MIVD for this specific investigation. This agreement stipulates that both organizations may provide the other with the information it needs to perform its legal tasks. The Dutch Safety Board was allowed to discuss classified
information under strict confidentiality. Consultation of the secret information was limited to board members and a small number of Dutch Safety Board employees who had undergone an extensive security screening for handling secret information.


 

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Lastly, classified information was included in the investigation that the Dutch Safety Board neither had access to nor was able to see. This concerned information from the Dutch Intelligence and Security Services (AIVD and MIVD) related to the armed conflict in the eastern part of Ukraine. At the Dutch Safety Board’s request, the minister of the Interior and Kingdom Relations and the minister of Defense asked the Dutch Review Committee on the Intelligence and Security Services (CTIVD) in a letter dated Nov. 21, 2014, to examine this information.


The ministers asked the CTIVD to report the findings directly to the board members of the Dutch Safety Board. The letter also mentioned the agreement that the Dutch Safety Board would first submit the CTIVD report to both ministers to check it for any state secrets prior to the Dutch Safety Board making it public.

Before finalizing its report, the CTIVD submitted it with references to underlying classified sources to the AIVD and the MIVD for verification of the facts. Both intelligence services made only a few minor comments, and on April 10, 2015, the CTIVD handed over the still-classified report to the Dutch Safety Board members without any references to classified sources. In conformity with the letter of Nov. 21, 2014, the Dutch Safety Board subsequently submitted the report to both ministers to have it checked for potentially classified information. The ministers did not find any state secrets in the report, which was then declassified.


Reprinted with permission of ISASI Forum July - September 2017 issue.

About the Author

Kas E. Beumkes, born in 1964 in the Netherlands, has been involved in aviation safety investigation since 1990. He started as an aircraft accident investigator for the Netherlands Aviation Safety Board and became chief investigator in 1998.

After the board merged into the multimodal Dutch Transport Safety Board, he became the secretary of the Aviation Commission in 2001.

When this board merged into the multisectoral Dutch Safety Board in 2005, he became senior secretary of aviation. Since 2008, Beumkes has served the board as senior investigator/project manager.

Beumkes has two Bachelor of Science degrees, one in aeronautical engineering (1986) and the other in industrial engineering (1988). He attended the Cranfield Aircraft Accident Investigation Long Course in 1991, the SCSI HFAI in 1999, and the AAAI in 2000.

In 2006, he obtained a master’s degree in management of safety, health, and environment at the Technical University Delft, the Netherlands.


Adapted with permission from the author’s technical paper entitled Organizing the MH17 Crash Investigation presented during ISASI 2016, in Reykjavik, Iceland. The full presentation with references can be found on the ISASI website at www. isasi.org in the Library tab under Technical Presentations.-Editor


Photos: Courtesy of the Dutch Safety Board

 

Written by: Kas E. Beumkes, Senior Investigator/Project Manager
Dutch Safety Board.

Published in the Investigator Magazine Volume 1 Issue 9 December 2017