Polish Presidential Flight Crash Thread
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.
I therefore wonder why do you try to add an extra noise to the discussion?!? (and do not tell me about sarcasm, please).
According to some rumors, MAK's report should be published in January.
Probably another, separate report will be published by the Polish authorities. That question still remains unclear.
Arrakis
Probably another, separate report will be published by the Polish authorities. That question still remains unclear.
Arrakis
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1. This was a PRIVATE flight. Official one has been completed 2 weeks before.
2. The military airfield has been used very rare (almost no operations) for last 9 month.
2. The flight crew has been informed about the severe fog by military controller. This guy also suggested to divert to Moscow or Vitebsk.
3. Non-precision approach has been continued below minimum - classic crash..... they were cutting the trees even below RW theshold elevation.
4. ON TIME arrival was VERY VERY VERY important for the Mr. President...
2. The military airfield has been used very rare (almost no operations) for last 9 month.
2. The flight crew has been informed about the severe fog by military controller. This guy also suggested to divert to Moscow or Vitebsk.
3. Non-precision approach has been continued below minimum - classic crash..... they were cutting the trees even below RW theshold elevation.
4. ON TIME arrival was VERY VERY VERY important for the Mr. President...
So When do we see the FDR data?
Methinks the CVR and FDR data for the AA Jackson Hole overrun will be released to the public before the FDR for this crash
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The final report of the Technical Commission has been handed over to the to the Authorized representative of Republic Poland through Republic Poland Embassy in the Russian Federation. Watch the news evolve. Don't go away! Tu-154
The Technical Commission final report contains the Polish government comments as an integral part of the report and it will be handed over to the Interstate Aviation Commission (MAK).
The Technical Commission final report contains the Polish government comments as an integral part of the report and it will be handed over to the Interstate Aviation Commission (MAK).
Last edited by RegDep; 12th Jan 2011 at 07:56. Reason: Added detail
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Reuters say the crew were frightened of the consequences of what would happen if they didn't land.
"He'll (the Polish President) will get mad," one crew memebr said.
Sadly, the consequences of attempting to land were worse than that of a mad Polish President.
Edited to add an update hot off the trading screen.
MOSCOW, Jan 12 (Reuters) - Psychological pressure on the
crew of a plane carrying Polish President Lech Kaczynski to a
ceremony in Russia may have led to the April crash that killed
him and 95 others, Russian aviation officials said on Wednesday.
"He'll get mad," one of the plane's crew members said,
according to a flight recording excerpt aired during a press
conference by Russia's Interstate Aviation Committee (IAC) on
the probe into the crash that killed Kaczynski and 95 others.
The comment was in Polish and a Russian language translation
was provided by the IAC.
IAC head Tatiana Anodina said the decision to push ahead
with a landing in adverse weather conditions was the direct
cause of the crash that killed many of Poland's leading
political and military officials.
"On the one hand he (the pilot) knew the plane shouldn't be
landing in these conditions, on the other hand there was a
strong pressure on board to bring the plane to a landing," she
told a news briefing presenting the final report on the crash.
She said the presence of Kaczynski and other high-level
officials, including the Polish air force chief, inside the
cockpit influenced the pilot's decision not to abort the landing
and instead try to fly to an another airstrip.
"The expected negative reaction of the main passenger" to a
recommendation not to land "placed psychological pressure on
crew members and influenced the decision to continue the
landing," Anodina said, clearly referring to Kaczynski.
The crash, which took place in thick fog near Russia's
Smolensk airport on April 10, killed Kaczynski, his wife and
many other senior Polish government officials and lawmakers.
Poland, which received the IAC's report in December, said at
the time that it was dissatisfied with its findings, sparking
new tensions between Warsaw and Moscow.
"He'll (the Polish President) will get mad," one crew memebr said.
Sadly, the consequences of attempting to land were worse than that of a mad Polish President.
Edited to add an update hot off the trading screen.
MOSCOW, Jan 12 (Reuters) - Psychological pressure on the
crew of a plane carrying Polish President Lech Kaczynski to a
ceremony in Russia may have led to the April crash that killed
him and 95 others, Russian aviation officials said on Wednesday.
"He'll get mad," one of the plane's crew members said,
according to a flight recording excerpt aired during a press
conference by Russia's Interstate Aviation Committee (IAC) on
the probe into the crash that killed Kaczynski and 95 others.
The comment was in Polish and a Russian language translation
was provided by the IAC.
IAC head Tatiana Anodina said the decision to push ahead
with a landing in adverse weather conditions was the direct
cause of the crash that killed many of Poland's leading
political and military officials.
"On the one hand he (the pilot) knew the plane shouldn't be
landing in these conditions, on the other hand there was a
strong pressure on board to bring the plane to a landing," she
told a news briefing presenting the final report on the crash.
She said the presence of Kaczynski and other high-level
officials, including the Polish air force chief, inside the
cockpit influenced the pilot's decision not to abort the landing
and instead try to fly to an another airstrip.
"The expected negative reaction of the main passenger" to a
recommendation not to land "placed psychological pressure on
crew members and influenced the decision to continue the
landing," Anodina said, clearly referring to Kaczynski.
The crash, which took place in thick fog near Russia's
Smolensk airport on April 10, killed Kaczynski, his wife and
many other senior Polish government officials and lawmakers.
Poland, which received the IAC's report in December, said at
the time that it was dissatisfied with its findings, sparking
new tensions between Warsaw and Moscow.
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Der Spiegel (German news magazine, probably the best in the country and serious) reports on the final report here. In German only.
Synopsis: the slightly drunk (0.6 part per thousand) Commander of the Polish Air Force Andrzej Blasik was in the cockpit and forced the pilots to land. Also in the cockpit was the Polish Chief of Protocol, adding to the pressure on the pilots.
Synopsis: the slightly drunk (0.6 part per thousand) Commander of the Polish Air Force Andrzej Blasik was in the cockpit and forced the pilots to land. Also in the cockpit was the Polish Chief of Protocol, adding to the pressure on the pilots.
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Maybe pressure, but why and how did it lead to CFIT? What made them think that they were higher than they were? That's what we want to know.
Edit to say that the full report is now available at ÌÀÊ .
On investigation of accident of plane Tu-154M board number 101 of Republic Poland,
Occurred on April, 10th, 2010 around airdrome Smolensk "Northern"
The Final Report (in Russian)
The Final Report (in English) http://www.mak.ru/russian/investigat...report_eng.pdf
The expert judgement under the analysis of actions of group of a management of flights of airdrome Smolensk "Northern" on April, 10th, 2010
Comments the Polish party to the Definitive Report (in the Polish language)
Flight estimation of actions of crew
Mediko-psychological examination of actions of crew
The report on training experiment
Estimation of psychoemotional condition КВС
The report of transfer of copy МСРП and Mars
Recommendations to the commander 36 спецполка
The decision of the Technical commission
The expert judgement on finding possibility in пилотской to a cabin of the extraneous person
The expert judgement № 1050 Open Companies Foreneks
(Sorry for the bad translation)
Edit to say that the full report is now available at ÌÀÊ .
On investigation of accident of plane Tu-154M board number 101 of Republic Poland,
Occurred on April, 10th, 2010 around airdrome Smolensk "Northern"
The Final Report (in Russian)
The Final Report (in English) http://www.mak.ru/russian/investigat...report_eng.pdf
The expert judgement under the analysis of actions of group of a management of flights of airdrome Smolensk "Northern" on April, 10th, 2010
Comments the Polish party to the Definitive Report (in the Polish language)
Flight estimation of actions of crew
Mediko-psychological examination of actions of crew
The report on training experiment
Estimation of psychoemotional condition КВС
The report of transfer of copy МСРП and Mars
Recommendations to the commander 36 спецполка
The decision of the Technical commission
The expert judgement on finding possibility in пилотской to a cabin of the extraneous person
The expert judgement № 1050 Open Companies Foreneks
(Sorry for the bad translation)
Last edited by RegDep; 12th Jan 2011 at 10:24. Reason: Details
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From the Final Report (English version, pages 182 - 3):
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.
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.
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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.
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.
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