Polish AF Casa 295 crashes

[SAR_ Zipperhead]

Originally Posted by bitter man

Oh, interesting comment.......based on what evidence? What a crass remark you muppet!

LOL - muppet!

Originally Posted by some more bitter man comments

It's pretty obvious that you know little or **** all about approaches into Polish Airports, or come to think about it - any airports. Did you ever fly an airplane in IMC?

Look what you've done to my font and text colour - for that insult alone I shall shun you for the next 48 hours.

Do you really think I would post something to which I had absolutely no clue? I have flown SAR in IMC - something to which should never be done - 300' AGL in IMC in a 45k Lbs aircraft.

PAR is an approach which every NATO pilot is skilled at - we all know that the PAR controller keeps talking until the wheel actually touch down on the runway. I have told the controller "Thanks RADAR, we have the runway" He kept talking all the way down - they don't care what we say, the have rules and regs to follow just like us bus drivers.

Frick - I'm still laughing over your "muppet" comment - can I use that?

[ARRAKIS]

Data from flight recorder downloaded. The bits and pieces are in a hangar. Now, the tough work.
The rest is just pure speculation.

Arrakis

[Stuck_in_an_ATR]

Now, the tough work.

Yep... The question is whether the investigation board concentrates on finding the truth, or saving some faces...

[ARRAKIS]

Taking into account the situation, in my opinion the truth.
The remaining 9 machines are grounded and will be until further notice. 6 are in Poland, 1 in A'stan, 1 in Lebanon and 1 in Spain.


Arrakis

[GfaRm]

I wonder if they have the PAR controller - aircrew comunication recordings? If so, they should already have some clues what really happened during that fatal approach without the need of downloading any data from the FDR...

I still cannot believe that PAR controller let them descend so low that they end up in the trees!

[Ptkay]

I still cannot believe that PAR controller let them descend so low that they end up in the trees

Still icing is the main suspect.

[green granite]

I still cannot believe that PAR controller let them descend so low that they end up in the trees!

The vulcan pilot at Heathrow probably thought that as well.

[criss]

According to the spokesman for the Polish Air Force, only the first approach was made using PAR. The minima for PAR at EPMI are (reportedly, I don't have any papers for this) 80m ceiling and 1000 metres visibility, and the weather was 90m/3000m, so above minima. Anyway, the approach was aborted, but the runway was in sight, and the pilots decided to make a tight visual circuit. So the second approach was not conducted with PAR, nor any other instrument approach system.

[ARRAKIS]

Yes, it's 80 m. Confirmed in a press interview by PAF.
From what I know, above the woods next to the airbase the clouds were locally even lower.
Two birds allowed to fly home.


Arrakis

[POLISH_EDDIE]

According to Polish Minister of Defense, the a/c didn't have any glitches. Meanwhile, all the remaining CASAs have returned to a normal service. It's currently also rumored that pilot's error might have been a cause of this horrible accident but icing theory is still quite possible even though it was not picked up by the media.

[kkania]

A little something for my fav forum.

http://wiadomosci.onet.pl/1721107,11,item.html

CASA crash report - all procedures were broken

A report regarding the carsh of a CASA military airplane in Poland has been revealed by the TV station TVN24. It concludes that all flight procedures were broken. According to TVN24, the procedures were broken by the pilots, ground crews and commanders. The report has been forwarded to the ministry of defense on monday morning.

The ministry of defense is planning a conference on Wednesday at 10.00 AM CET.

TVN24 reports that on the feral day of 23 January, the machine should have not lifted off the airport at all due to insufficient weather conditions. A clearance should not have been given by the ground crew. However, according to TVN24, the primary fault has been assigned to the breaking of landing procedures by the pilot.

At the time of landing the ILS equipment on Miroslawiec military airport was inoperative. After the first go-around, the pilot decided to attempt to land with help from the ATC - reports TVN24. The pilot was not following his instruments, but rather concentrated on looking for the runway landing lights visually. Due to bad weather conditions, he misjudged his current altitude. He tried supplying more power, but it was not enough. The plane was too low and crashed.

The plane disintegrated on impact into two parts - the main fuselage and the tail section. Seven bodies were hurled outside during the crash, while the rest of the passengers and crew died in the fiery wreckage.

One of the biggest accidents in Polish aviation history

On January 23rd 2008 at 19.07 one of the biggest accidents in Polish aviation history took place. A military CASA c-295 airplane crashed just outside the Miroslawiec military airport with 20 people on board, of which none survived. Amongst the passengers were high-ranking Polish air force officials.

[translation by me, pardon for errors]

[oleczek]

Partial translation of the document posted on the Polish Ministry of Defense website.

http://www.wp.mil.pl/pl/artykul/4582

I have translated part that starts with the bolded text about halfway down the page. I used the following conventions:

[v] ... [v] - translated verbatim as I do not know appropriate english words/terms
[*] ... [*] - almost certain of the translation

[?] ... [?] - not translated, not familiar with the term/word neither in polish nor english

All errors are mine .

Olek


CAUSE

Direct cause of the accident was unintended excessive banking of the airplane,
causing in the final stage of the flight, rapid descent with loss of
direction and impact with the ground.

FACTORS HAVING DIRECT EFFECT ON THE CAUSE OF THE ACCIDENT

• incorrect selection of the crew for the mission; inadequate crew teamwork in the cockpit

• existence in the area of the airfield MIROSLAWIEC of unfavorable weather conditions

• spatial disorientation of the crew caused by inappropriate [v] attention division [v] during the flight without ground visibility

• switching off EGPWS audible warning, denying the crew information about dangerous approach to the ground, excessive banking, and passing through [v]successive altitude thresholds [v] during descent (during both landing attempts)

• failure to observe radio altimeter readings, during first as well as second landing approach

• failure to observe instruments during the final phase of the second landing approach

• inept guidance of the aircraft for the landing by [?] krl [?] PAR

• inappropriate radio commands by [?] krl [?] PAR, suggesting to the crew, in the last phase of the flight, diverting their attention to the outside of the aircraft.

• incorrect interpretation of the radio altimeter reading by the crew

• attempt to establish visual contact with ground objects during the flight without ground visibility which is against established procedures

• incorrect analysis of meteorological conditions before the flight; failure to set decision height (minimum descent altitude)

CONTRIBUTING FACTORS

• lack of training of the second pilot on CASA C-295M aircraft during night IMC

• lack of experience of the crew commander on this type of an aircraft

• use of additional,ad hoc navigational tools by the crew because of incomplete equipment of the aircraft

• lack of experience of the crew commander in utilizing [?] RSL [?] during minimal weather conditions
  

• lack of experience of [?] krl [?] PAR at MIROSLAWIEC in guiding aircrafts other than Su-22

• inept guidance of the aircraft to [?] MATZ [?] zone by [?] krl [?] APP

• lack of appropriate landing procedures in [v] obligatory normative documents [v]

• use of different units of measures by the crew and controllers

• navigational landing system ILS, installed on the aircraft, could not be utilized because system was not functioning at the MIROSLAWIEC airfield

• erroneous determination and dissemination of information about minimum landing conditions of CASA C-295M aircraft to the concerned parties

[Wojtus]

"krl" means ATCO.

RSL is a SRA (Surveillance Radar Approach). It was PAR in this case.

[Ptkay]

Perfect lining up of holes in the Swiss cheese...

Horror.

In the meantime the detailed report is published:

http://www.mon.gov.pl/pliki/File/Protokol.pdf

Among others.

The GPS signal encrypting module for IRS/GPS type LN-100G
was not installed hence GPS INOP, pilots usig GARMIN 196...


Pilots turned off GPWS, no bank or GP warnings heard.
PF MFD set to QFE, C/P MFD set to QNH.

Ceiling 60-90m, PAR approach. Both pilots looking out for the runway,
ecpecting to see it because ATCO told them "on slope",
while they were 120 m above,
nobody looked on the instruments after turning of A/P.

Increasing, uncontrolled bank to 19 then 67 deg, not corrected,
8 sec before impact stall, nose down 21 deg.

Spatial disorientation, bank, stall, crash.

RIP

[ARRAKIS]

Yes,
SD leading to CFIT.
What the report didn't mention is that the crew started their duty early in the morning around 3:00. The crash was at 19:00 which means a total of 16h. They had a break in the middle (a few hours at Warsaw) but, anyway, it's still 16h on duty.


Arrakis

[Ptkay]

Until crash they made on that day:

EPKR-EPSN-EPMI-EPKS-EPPW-EPWA-EPPW-EPKS-....

...they never made it to EPMI again.

Eight (8) T/O & seven (7) LDG.

[Ptkay]

SAR_ Zipperhead wrote:

"Sounds like the PAR controller screwed the pooch on this approach"

You were absolutely right.

He kept confirming "on slope", while the A/C was gradually 80, 100, 120 m over...

Two (2) sec before impact, when the A/C was 84 deg and 320m off course,
the controller confirmed "three zero four and on slope" (runway is 304 deg MAG)

[Ptkay]

Detailed translation of the report conclusions here:

http://aviation-safety.net/database/...?id=20080123-0