I think everyone knows what happened here......

There are many reasons why a plane might crash into terrain, including bad weather, imprecise navigation and pilot error. In fact, pilot error is the single biggest factor leading to a CFIT incident.

The investigation team concludes that:

The immediate cause of the accident was the failure of the crew to take a timely decision to proceed to an alternate airdrome although they were not once timely informed on the actual weather conditions at Smolensk "Severny" Airdrome that were significantly lower than the established airdrome minima; descent without visual contact with ground references to an altitude much lower than minimum descent altitude for go around (100 m) in order to establish visual flight as well as no reaction to the numerous TAWS warnings which led to controlled flight into terrain, aircraft destruction and death of the crew and passengers.

According to the conclusion made by the pilot-experts and aviation psychologists, the presence of the Commander-in-Chief of the Polish Air Forces54 in the cockpit until the collision exposed psychological pressure on the PIC’s decision to continue descent in the conditions of unjustified risk with a dominating aim of landing at any means.

Contributing factors to the accident were:

- long discussion of the Tu-154M crew with the Protocol Director and crew of the Polish Yak-40 concerning the information on the actual weather that was lower than the established minima and impossibility (according to the Tu-154M crew opinion) to land at the destination airdrome which increased the psychological stress of the crew and made the PIC experience psychological clash of motives: on the one hand he realized that landing in such conditions was unsafe, on the other hand he faced strong motivation to land exactly at the destination airdrome. In case of proceeding to an alternate airdrome the PIC expected negative reaction from the Main Passenger;
- lack of compliance to the SOP and lack of CRM in the crew;
- a significant break in flights in complicated weather conditions (corresponding to his weather minima 60х800) that the PIC had had as well as his low experience in conducting non- precision approach;
- early transition by the navigator to the altitude callouts on the basis of the radio altimeter indications without considering the uneven terrain;
- conducting flight with engaged autopilot and autothrottle down to altitudes much lower than the minimum descent altitude which does not comply with the FCOM provisions;
- late start of final descent which resulted in increased vertical speed of descent the crew had to maintain.
The systematic causes of the accident involving the Tu-154M tail number 101 aircraft of the Republic of Poland were significant shortcomings in the organization of flight operations, flight crew preparation and arrangement of the VIP flight in the special air regiment.

3.2

Causes

Considering that:

The Tu-154M aircraft was serviceable before the departure from Warsaw. No evidence of aircraft, engine or system failures before the collision was revealed. There was no fire, explosion or in-flight destruction before the collision; There were serious shortcomings in the arranging of the VIP flight concerning the crew training, composition, monitoring of its preparation and selection of alternate airdromes; The departure was conducted without available actual and forecast weather and the actual aeronautical information for the destination aerodrome. According to available information the Polish side refused the leaderman (navigator) services;

In the course of the flight the crew of the Tu-154M not once was informed by the ATC of the Republic of Byelorussia and the Smolensk "Severny" airdrome as well as the crew of the Polish Yak-40 aircraft that had already landed on Smolensk "Severny" airdrome on the incompliance of the actual weather conditions at the destination airdrome to the established minima. Despite that, the crew did not take a decision to proceed to the alternate airdrome which can be considered as the beginning of the chain of events which led to the accident;

On contacting the ATC group of Smolensk "Severny" airdrome the crew did not report the selected approach system to them which deviated from the Russian AIP requirements. Further the crew continued approach using the on-board equipment without utilizing ground navigation aids;

The crew requested conducting a "trial" approach in the actual weather conditions below the established minima for landing. In compliance with the Russian AIP (Russian AIP AD 1.1-1 Para.1 c) Pilots-in-command of foreign aircraft operating in Russia, shall make a decision on the possibility of taking-off from an aerodrome, and of landing at destination aerodrome on their own, assuming full responsibility for the decision taken) the controller cleared the crew for the "trial" approach provided they should descend not lower than 100 m and go around from that altitude. The crew confirmed they received that instruction;

Before the final turn the crew of the Yak-40 warned the crew of the Tu-154M that the visibility was 200 m. This warning did not affect the decision of the Tu-154 crew who continued the approach; The PIC had a break of over 5 months in approaches in complicated meteorological conditions (corresponding to his weather minima 60х800) on Tu-154M. The PIC had not
had enough training on approaches in manual steering mode using non precision type of
approaches.

The approach was made using the autopilot in pitch and roll channels as well as the autothrottle. This type of approach is not provided by the Tu-154M FCOM and the weather minima and SOP for this type of approach are not described there;

The crew did not receive the clearance to land from CATC;

The crew interaction and the PIC’s CRM were unsatisfactory;

Despite the established procedure, from 300 m the navigator started altitude callouts on the basis of the radio altimeter indications;

The crew did not terminate descent at the established minimum descent altitude of 100 m, but continued descent with a vertical speed two times higher than the estimated without establishing visual contact with the ground references;

Despite the numerous TAWS (TERRAIN AHEAD and PULL UP) alerts, the triggering of the radio altimeter decision height alert at 60 m and the ATC instruction, the crew continued descent which can be an evidence of their attempt to establish visual flight before passing the middle marker in order to conduct a visual landing;

The operation of the ground based navigation and lighting equipment did not affect the accident;

The presence of high-ranked persons in the cockpit including the Commander-in-Chief of the Polish Air Forces and the Protocol Director, and negative reaction of the Main Passenger expected by the PIC exposed psychological pressure on the crew members and influenced the decision to continue approach in the conditions of unjustified risk.