Description

On 17 July 2014, a Boeing 777-200ER (9M-MRD) being operated by Malaysian Airlines on a scheduled passenger flight from Amsterdam to Kuala Lumpur as MH17 was in the cruise over eastern Ukraine at FL330 in day VMC when ATC unexpectedly lost contact with it. Wreckage of the aircraft was subsequently found over a wide area east of the last known position in territory not controlled by the State, indicating that an in-flight break up had occurred. All 298 occupants were killed and damage was found to have been caused to buildings and infrastructure by falling debris.

Investigation

An Investigation was commenced by the Ukrainian National Bureau of Air Accident Investigation (NBAAI) and subsequently delegated to the Dutch Safety Board (DSB). The FDR and CVR were recovered from the wreckage by "individuals unknown to the team" and, on 21 July were "handed over to a Malaysian official in Donetsk by representatives of the armed group controlling the area". They were passed to the DSB on 22 July and subsequently successfully downloaded by the UK AAIB. No evidence or indications of manipulation of the recorders was found and both had stopped recording simultaneously 7 seconds after the last transmission received from the crew who had acknowledged a routine instruction from ATC.

All relevant radar recordings were provided by Ukrainian ATC but such recordings were not forthcoming from the authorities in the nearby Russian Federation which had radars capable of monitoring the airspace of interest to the Investigation. The reason given to the Investigation for this was that "because the crash had occurred outside Russian Federation territory, no radar data was saved, nor was it required to be by national requirements". The Investigation noted that in this respect, the ICAO Annex 11 requirement for States to retain such data for 30 days (or beyond where relevant to accident investigation) did not distinguish between data within or beyond the boundaries of the State and that Russia had not filed a Difference with ICAO as required. Russia did provide screen shots and video film of radar displays seen by controllers to the Investigation but since this was not "raw data", its integrity could not be verified.

At the time contact was lost, it was established that the aircraft was flying in unrestricted controlled airspace on a designated route at a flight level which was 1000 feet above the upper limit of a Temporary Reserved Area (TRA) (TRA) notified as active in the form prevailing on the day of the investigated event from 14 July. This TRA was established due to hostilities between armed groups and Ukrainian armed forces and prior to 14 June had been active with a lower upper limit. The main wreckage site was located 4.6nm on a bearing of 080° from the last available radar position of the aircraft in flight. No distress messages were received from the aircraft but a signal was received from the ELT.

Due to the prevailing security situation, it was not possible to begin wreckage recovery until four months after the event and two further site visits for the same purpose followed in the spring of 2015. The recovered wreckage was found to have several hundred small holes and ricochet marks in the forward fuselage pieces and various embedded components not from the aircraft and of external origin were found in some of these wreckage pieces. No evidence of any flight crew or airworthiness factor which had any bearing on what was detemined to have happened was found. It was noted that whilst a few airlines had been avoiding the airway being used by MH17, most operators, not just MAS, had continued to do so.

After a very complex and detailed analysis, it was concluded that "the combination of the recorded pressure wave, the damage pattern found on the wreckage caused by blast and the impact of fragments, the bow-tie shaped fragments found in the cockpit and in the body of one of the crew members in the cockpit, the injuries sustained by three crew members in the cockpit, the analysis of the in-flight break-up, the analysis of the explosive residues and paint found, and the size and distinct, bow-tie, shape of some the fragments" showed that the aircraft had been struck by a 70 kg 9N314M warhead of the type carried by a 9M38-series missile and launched by a BUK surface-to-air missile system. The assembled evidence and rigorous simulations indicated that the detonation of this warhead had occurred about four metres above the tip of the nose of the aircraft to the left of the flight deck. There was no evidence of any conscious actions being performed by the occupants of the aircraft after the detonation of the missile and it was considered likely that they would have been "barely able to comprehend the situation in which they found themselves".

A total of 11 Safety Recommendations were made as a result of the Investigation in respect of three matters - Airspace management in conflict zones (1-3), Risk Assessment (4-9) and Operator accountability (10-11) as follows:

1. that the ICAO should 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, providing clear definitions of relevant terms, such as conflict zone and armed conflict.
2. that the ICAO should ask States dealing with an armed conflict for additional information if published aeronautical or other publications give cause to do so and offer assistance and consider issuing a State Letter if, in the opinion of ICAO, (such) States do not sufficiently fulfil their responsibility for the safety of the airspace for civil aviation.
3. that the ICAO should 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.
4. that ICAO Member States should ensure that States’ responsibilities related to the safety of their airspace are (strictly) defined in the Chicago Convention and the underlying Standards and Recommended Practices, so that it is clear in which cases airspace should be closed. (The publication of this Recommendation was accompanied by a Note which says that "the States most closely involved in the investigation into the crash of flight MH17 could initiate this".)
5. that the ICAO and the IATA should encourage States and Operators who have relevant information about threats within foreign airspace to make this available in a timely manner to others who have an interest in it in connection with aviation safety and ensure that the relevant paragraphs in the ICAO Annexes concerned are extended and made more strict.
6. that the ICAO should amend relevant Standards so that risk assessments also cover threats to civil aviation in the airspace at cruising level, especially when overflying conflict zones. Factors which increase risk and/or uncertainty need to be included in these risk assessments in accordance with the proposals made by the ICAO Working Group on Threat and Risk.
7. that the IATA should ensure that the (ICAO) Standards regarding risk assessment are also reflected in IATA Operational Safety Audits (IOSA).
8. that States (in their capacity as States of an Operator) should ensure that Operators are required through national regulations to make risk assessments of overflying conflict zones which include factors that increase risk and/or uncertainty in accordance with the proposals made by the ICAO Working Group on Threat and Risk.
9. that the ICAO and the IATA should, in addition to actions already taken, such as the website with notifications about conflict zones (ICAO Conflict Zone Information Repository), initiate a platform for exchanging experiences and good practices regarding assessing the risks related to the overflying of conflict zones.
10. that the IATA should ensure that their 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. that Operators should provide public accountability for flight routes chosen, at least once a year.

A Preliminary Report on the initial progress of the Investigation was published on 9 September 2014 and the Final Report was published on 13 October 2015 along with a series of Appendices (A-Z) which, if required, may be consulted using the links provided on the Dutch TSB website.

Related Articles

• State Safety Programme (SSP)
• Temporary Reserved Area (TRA)
• Loss of Control
• Security Management for Contingency

Further Reading

• ICAO Conflict Zone Information Repository
• EUROCONTROL Website for ATM Security
• Manual for National ATM Security Oversight, EUROCONTROL, Oct 2012