SLFinAZ

I am very familiar with command responsibility Nigel, and am also very capable of passing judgement accordingly. The aircraft commander has final responsibility for all souls in his care. This is not a case of all the holes lining up but a profound lapse in judgement. Take out all the garbage and questionable decisions and boil it down to a simple reality. He chose to bust his minimums....

Semaphore Sam

It seems, the idiot President, the idiot Head of the Air Force, the idiot Protocol Officer, and the PIC deserved their Fate...and were duly HUNTED. Sympathies to the PIC, but, if you take the job of PIC, you take the consequences of having Idiots for Bosses. Being PIC REQUIRES you to...do your job, with all that implies. Sam

MountainBear

That may be the simple reality but it's also a simplistic analysis.

The question is why did he chose to bust his minimums. To pretend that there was no context to his decision making process is either deliberately ingenuous or naive.

There's a reason why, for example, there is a sterile cockpit rule. Because context matters. Environmental factors influence decision making. That's always the case. The purpose of the sterile cockpit rule is to create an environment where pilots can make better decisions.

To what extent those environmental factors influenced this particular crash I'll let others decide. But to say that those factors are not even open for discussion is an act of intellectual blindness.

ARRAKIS

Pure B.S. based probably on some press "facts". He was waiting for a promotion. The Tbilisi flight story never get to the court.

Arrakis

ATC Watcher

What I found extremely "sad" ( in absense of a better word) is that The polish Air Force , once one of the best, has fallen so low in Safety standards and most importantly never learns apparently.

The very similar crash of one of their Casa C295s in January 2008 should have started to rings bells. What it did was the dismissal of a few guys, and continue business as usual. see here ( despite the misleading title ) :
Boeing 747 and Airbus A380 Aircraft News from Flightglobal
Blame individuals to hide systemic failures . As old as the world. Not learning from past experiences and they will resurface and bite you.

The "ironic " bit of that C295 accident is that the Top Polish Air Force brass on board was going to attend a "Safety conference " . I guess the conference was cancelled and never took place again.

andrasz

Before going into this futile debate, please read the full report! I find it reasonably well written, and evidently great care is taken to substantiate every statement and finding with factual information. The only part which I find a little apologetic is the part on the actions of the airport controller, who could have waived off the aircraft when he saw it was way below glideslope (a firm order to immediately abandon approach would probably have been followed by the crew who all had a military mindset), but only gave rather feeble warnings in a wording that probably was not fully comprehended.

The key findings:

The Tbilisi incident (witnessed by both the PIC and the co-pilot) was treated quite extensively in the report (complete section 1.17.1), and the comment of the navigator two (!) minutes before the accident well sums up what must have been on the minds of the crew:

Yes, it was the PIC who actually flew the a/c into the ground, and presented apallingly low standards of airmanship throughout the approach. It was not only his failure to go around at DA that was the immediate cause, but several other actions (or lack of) as well. An interesting overlooked comment in the report is that had the aircraft not hit the large tree causing the wing separation, the PIC's last moment terrain avoidance actions would have led to an unrecoverable stall just a few seconds later.

In my reading the principal causes of this accident were:
- Pressure from the "Main passenger" and the PAF Chief to land at all cost (they paid the price, unfortunately taking the lives of 95 others as well).
- The chain of systemic failures within the PAF that allowed an untrained and unprepared crew to pilot this flight in conditions that were beyond their abilities

I know, the findings will result in many red faces in Poland, but it is time to look away from the last five minutes of the flight, and look for the causes in the weeks and months that preceded it. Anyone contesting the principal findings on grounds of national pride presents the same attitude and arrogance that caused the accident in the first place. Maybe, just maybe a few lessons can be learned...

ATC Watcher

Andrasz :I do not know if this would have changed anything and this is accepted in Poland Air force (*) . In many Countries (my own ,and I suspect valid for rest of NATO Countries) a TWR controller cannot order a go around for visibilty reasons. It is always the PIC who has responsibility and decides to break approach, not the controllers. Going below "glideslope" is also not unusually a go-around factor in the military,( especially in airfields where there is no ILS !)
Incidentally this airfield had a PAR but a PAR APP was not requested ( page 116 of report.)

(*) the YAK 40 which landed earlier was apparenttly told by ATC to go around, " but the crew ignored the instruction and landed." (page 114 or report)

andrasz

I have carefully chosen the wording "could have". The report goes to great lenghts to explain why the controller was not required to do so. However the report also explains that under Russian military procedures, the controller actually has this authority. The controller received explicit training sometime before the accident that the PAF flight will operate under civilian rules, and the PIC has final decision authority.

I can well envision the scenario, where the controller was thinking "this a..h.le is going to fly into the ground", but he had instructions not to interfere. While spending pages on the evolving psychological state of the pilots, this likely mental conflict from the side of the controller is not addressed. The report simply sums up that the actions of the controller were both legal and appropriate under the applicable regulations, circumventing that a more assertive controller could perhaps* have saved the day.

(*) Perhaps is the right word, in light of the actions of the Yak-40 crew. I'm not saying that the controller's actions directly contributed, rather that his confused mindset removed yet another layer of swiss cheese, which the report fails to acknowledge. This does not detract from the overall transparency and quality, which I find to be far beyond what we expected from the Russian investigation team.

NigelOnDraft

SLFinAZ May I ask you 2 questions:

1. Have you actually read the report
2. Since you choose to stick to the "P1 is sole person responsible", presume you agree with my
   Quote:

   if you say the PIC is the only person to blame, you are effectively saying that now he is dead and buried, we can ignore the rest of the findings - we have removed the entire problem and so there will no no repetition

Have you actually thought through the "Terrain Warning(s)"? Whilst a reaction to them would have prevented this accident, so would the P2's attempted GA, a diversion or whatever. But it is my reading of the system and report that the warning was actually "spurious"... / a side effect of the inappropriate system with that airfield / approach. In short, to land at that airfield, on a correctly flown approach, in VMC or IMC, they would have had to ignore the "Pull Up", or devise (as we do in my company) a very strange way of flying QFE approaches (where we convert everything ATC say to QNH - hardly ideal) and inhibit the TAWS.

We will obviously disagree, but in my book, the day of just blaming a dead pilot and congratulating everybody else (and our own selves) on not being so arrogant / stupid / unprofessional does little to advance flight safety, and fortunately most of the world has moved on. A fairly good read of that report, and I would think most people could see how the holes lined up, and combined with certain human failings (from which we will all suffer at times) a tragic outcome resulted. One needs to design a "system" where such human failings will get trapped - which we have come a fair way to in modern western airline culture. This culture is still not perfect however, and I am unfamiliar with other cultures, but we can see aspects of them in accidents such as this.

NoD

ATC Watcher

N.O.D. :very true and well said !

andrasz : You're correct, I edited my post accordingly. This is the Polish Military who migh not accept this "go around" order ( like most western military would not either) the action of the previous YAK crew, as you correctly point out could have led the controller to think that, "what the heck" those Poles are doing what they want anyway " or something similar.
And kept open a large hole on the cheese.

Could the controller had been more pro-cative and offered the PAR guidance ? probably yes on hinsight. And there under PAR (GCA) guidance , a break approach instruction is mandatory everywhere on the planet.

But on an attempt ( a try ) to make a visual approach ( which is basically what they were doing : waiting to see the ground to decide ) a controller can do little, as the controller mostly is not aware of the minimas of the aircraft and the crew.

But it is not only the Poles military that do not trust RVRs reports and want to see for themselves and would try APPs anyway even under the worst visibility conditions. "Let's try APPs" have killed many in the 70-80s" where "minimas" were more flexibly interpreted. A better understanding of the respective work of each other (ATC and PIC) and a global fixed set of rules for everyone would help closing holes in the cheese and preventing similar accidents in the future.

Ptkay

Don't forget, that Smolensk accident PIC was F/O on the Georgaia flight.

He was witness to the conversation you quoted above...

Ptkay

This was even more ironic, than you think.
They were returning form the conference...

Kulverstukas

There is very interesting part of conversation between ATCs quoted in report after Yak-40 landed: "May be they have SOME equipment..."

Ptkay

According to the ATC tower tapes (to be published by Polish side next week)
not only was he sure, that Polish pilots have superior skills, but he,
and other people in the tower believed, that Polish government AC
are equipped with some special devices allowing them to do
such precise manoeuvres under such VIS conditions.

When they have seen on youtube some films of the NATO cruise missiles hitting
the door of a hangar in IMC using GPS, they could have easily believed,
you can hit the runway touch-down zone, which is slightly bigger...

SadPole

The only good thing that may come out of this mess is increased understanding that you don’t want, ever, to have a "nice guy" (called a conformist in MAK/IAC report) as PIC. It's really good that this issue is dealt with in the report see 1.16.10 Assessment of the PIC's Psychoemotional Status.

In the aftermath of the Tbilisi incident, it was re-confirmed that (even in Poland) the PIC makes final call on anything that goes on at the aircraft and that nobody has a right to order the PIC around. And, in spite of that, the nonsense with the politicians crowding the cockpit and making a final call about landing in fog still happens. Why?! Because the PIC got selected precisely because he was a "nice guy" who would make the "main passenger" happy by not interfering with his egomania. At the same time, the competent PIC who knew how to perform his duties in all circumstances as demonstrated in Tbilisi incident is relieved of duty and does not fly the VIPs anymore. While he was at the end given a medal by politicians opposed to the "main-passenger", he nevertheless did go through hell.

Another "nice guy" on board was that (allegedly drunk) Air-Force General on board who was found to have been a major surviving culprit in the CASA crash but who got to keep his job thanks to personal intervention by Kaczynski (aka the main-passenger).

So there it is. You don’t want to have a "nice guy" as PIC. You want a guy who is able to grab a hunk of pipe and throw the bums out of the cockpit if they screw around with him. If you don't follow that rule, all you get is a bunch of headstones with "He was such a NICE guy" written on them.

NigelOnDraft

ATC posts above are interesting... but again, do we really know what (if any?) SOPs were in place for ATC / the crew for this type of approach? They would no doubt differ from what UK civvy ATCOs remember (from a long time ago) and UK Mil ones, which in turn differed.

e.g. "Not cleared to land". My understanding, I think, from the report, was that landing clearance would be issued when they called visual?

e.g. "Did not go around when ordered" (the Yak). This was, I believe ordered by the PAR controller. Do we know the SOP in this case if the Yak had become visual by that stage? Was a PAR GA call mandatory?

I also understood it that the Russian ATC SOPs / authority differed when handling foreign / VIP flights to Russian Mil flights? i.e. a Russian Mil flgiht could be ordered to divert (effectively "Approach Ban") whereas this was not the case for the Polish Tu-154.

SadPole - some good points. The 2 previous incidents show that unless things were seriously addressed, a further incident/accident was likely, as unfortunately happened here

NoD

Kulverstukas

Ptkay

So was poor PIC who tried to land with cruise control engaged

ARRAKIS

Russian Federatian AIP requires for such flights like the one of the "101" to XUBS the presence of a Russian navigator on board of the aircraft.

On what basis that rule was ignored?

Arrakis

SadPole

There is one issue that I wish the report addressed a little more. (I could not find it there).

Blasik (the Air-Force General) comes to cockpit and starts participating in some pre-landing checks. This already creates confusion in everyone's mind. Who is in command here?! By the book, Protasiuk is still the PIC, but Blasik is the big boss (also a pilot), so he may be playing some supervisory role.

And so, they start the approach. I think Protasiuk (clearly opposed to landing at the beginning but going along) is expecting Blasik to order Go Around so that everyone is happy, but in Blasik's mind there suddenly is this feeling, "difficult situation – I should not interfere". And so, neither Protasiuk nor Blasik do anything because they expect the other to make the call. Had any of the two of them been less of a "nice guy", he would have asked – "what the **** are we doing?!"

Then the 2'd Pilot (by transcript a little more assertive/competent than the other two) tries to break the impasse and orders Go Around, but still nothing happens because, most likely, Protasiuk expects Blasik to confirm Go Around and Blasik vice-versa.

There is absolutely NOTHING WORSE than a critical situation where it isn't crystal clear who is in charge.

As to that whole mess with what the ATC could and could not have done, and the status of the flight (International Rules/Russian Military Rules) – they are just making complete fools of themselves by admitting that they never knew/clarified under what rules they were allowed to fly to Smolensk.

Kulverstukas

Arrakis, I read the report in russian. I can confirm that it is slightly biased toward russian side - like "some equipment was broken but". The part about "leading" or requirement of russan nav on board is unclear. There was request for it in FIRST letter from polish side, but in the mess which was in this THREE requests with different planes, mixed bort numbers and types, AND request for Tusk visit sent AFTER Kachinsky request BUT for EARLIER flight it's not strange that this goes out of control.

From "Smolensk forum" I remember that there was blame from Polish AF representative that polish diplomats doesn't process their request for leading nav.