Pages 181-2:
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.