andrasz

I believe we had this discussion before on the original accident thread. You are very lucky to have had your career in an environment where professionalism was the norm, and issues were decided based on sound reasoning rather than who has more stars. We who grew up in the old system, and experienced firsthand the operating and thought environments of the old Warsaw Pact militaries, can recognise all the symptoms instantly. I see several nodding heads when I'm saying, the extra occupants in the cockpit did have a significant influence on the final outcome. Emphasis on the presence, the 0.6 alcohol level is totally insignificant.

I will make this last comment and then shut up, as really the bone is starting to have no scraps left. The Russian report sums up very nicely the causes for the accident, which are on three levels.

1) Direct cause - poor airmanship from the side of the flight crew, who through a series of inappropriate actions or ommissions directly caused a CFIT. The responsibility for this, as several have pointed out, rests primarily with the PIC.

2) Influencing cause - real and perceived pressure from the 'Main passenger' and the PAF Chief to 'land whatever it takes'. Knowing the history of the Tbilisi flight, this pressure wery clear, even if it remained unsaid. The presence of the PAF Chief in the cockpit reinforced and aggravated this pressure. Some of the mistakes made by the crew are probably due to this pressure - it is a well established fact that under stress and anxiety individual performance drops. In this respect, any person who made such pressure is directly responsible for the accident, at least to the same extent as the PIC.

3) Systemic cause - the apallingly low operating standards exhibited by the PAF, demonstrated extensively in the report. This resulted in having an inexperienced and ill-trained crew operate this flight with inadequate flight preparation, in conditions far exceeding their abilities. These same low standards have already caused another CFIT accident that had chilling similarities to this one. The 'accountable manager' whose responsibility was to oversee operations was sitting there in the cockpit...

The ommission of the report in analising any deeper whether the flight should have been permitted at all relates to systemic causes arising from the Russian ATC procedures, and how they were applied to this flight. However no failure or ommission from the Russian ATC could be considered a direct or indirect cause. They might have influenced the final outcome, but that would not negate any of the above interrelated findings.

Really it all boils down to one thing. The 'Main passenger' created an environment around him where no one dared (or bothered) to put up any arguments or counter-proposals. Not even the Russian government, and that's saying something... He paid the ultimate price.

ATC Watcher

andrasz : :
And may the Polish Air Force learn the lessons this time.

BOAC

I think andrasz's summary is the one I go for, although I do think the BAC of 0.6 was relevant as it may have clouded judgement. Perhaps sober he may have realised that what was happening was not sensible.

Regarding cause 2), ANY VIP flight with a need to 'land' at a particular airfield at a particular time will ALWAYS create a pressure that 'normal' pilots do not understand and which requires a particularly strong discipline to resist. For historic reasons this Captain's 'strength' was affected. As I said way, back, a tragic and unnecessary loss of life - but then, are they all not?.

SmaugHR

Guys, no offense, but I think you're a little too much fixated on the fact that it was specifically PAF airplane in the Russian airspace. I suggest you check the 1996 air crash in Croatia, Dubrovnik, when USAF CT-43 carrying VIPs crashed in IMC into the mountain near the airport. The accident is classified as CFIT (http://flightsafety.org/fsd/fsd_jul-aug96.pdf), the same thing as in this case.

There are many similiarites among these accidents:

- delay of departure
- military crew carrying civilian VIPS (and resulting pressure on pilots)
- bad airmanship
- IMC preventing use of the destination airport
- botched non precision approach
- disregard to SOP
- unfamiliar airport

The low down can also be found here (1996 Croatia USAF CT-43 crash - Wikipedia, the free encyclopedia).

My point is - VIPs + military personel, procedures and aircraft = recipe for tragedy.

Military aviation has FAR lower safety standards than GA, and in the same time those guys that don't have problem with evading rebel's shoulder launched missiles on the approach to Kabul, have great problem putting VIPs
in their place.

I really don't see any comercial pilot who wouldn't in a blink of an eye divert to alternate.

criss

ATCWatcher - in my previous post I referred to "M" or "S" designator in the flightplan - "M" standing for State/Military. Of course, most of the flight (EPWA TWR and APP, Polish, Belarussian and Russian ACC) was conducted as a GAT flight. Controllers in Smolensk were not certified according to ICAO requirements, so we could treat it as OAT. But as was stressed many times before the release of the report, and was reiterated in it, it doesn't really matter - according to Russian rules, they can issue "commands" only to Russian a/c on domestic flight or military. So just because PLF was military/state, and was flying according to OAT rules it didn't mean ATC could "command" it to go around or divert. And add to it the fact that as the report states, Yak's crew disregarded instructions from ATC, and it seems Tupolevs crew were doing the same.

I highly doubt that unfortunately. Politicians on both sides are preoccupied with how to slander the Russian report, most of them without even reading it. Minister of Defence, who should be directly responsible for how things are run in military, during the TV interview first said "yes, they shouldn't have tried the approach, but that's NOT what caused the crash" - and then quoted some unimportant mistakes from the report. Then he produced some papers saying that his subordinates assured him after Casa's crash that NOW everything would be ok and it wouldn't happen again... That's how things are run here, and level of debate is pathetically low. Sorry for this excursion, but I think it's somewhat relevant to the case. I hope we don't have another similar topic soon (remember, apart from Casa and Tu, we had smaller Antonov 28 and Mi 8 helicopter crashes in last 3 years due to similar reasons).

dvv

BOAC, just making sure about the BAC: 0.6‰ as reported by MAK (0.06% as we call it here in the Great Commonwealth of Virginia), while certainly is over the 0.04% max level for a flight crew, is still legal for driving a car here. And I'm almost sure that Błasik could not be considered to be the PIC or a crew at all by any of the rules. And, as MAK reports, he wasn't even occupying any of the seats in the cockpit. So frankly, my humble opinion is that his BAC is a red herring and out of place in the report.

Kulverstukas

RetiredF4

LNAV and VNAV was engaged at 9:28 MSK ie 6:28 UTC, 1 minutes after takeoff and NEVER swithed off. (Pict. 22 page 76 of MAK Report).

The reason for trying to land in autopilot is unclear for me but it seems that crew was completely relying on FMS, which will guide them directly to the treshold of landing stripe +/- 10m.

BOAC

- open to opinion, of course, but a small amount of alcohol could cloud one's judgement and perhaps 'embolden' and thus in my opinion relevant.

dvv

BOAC, from the CVR transcript, the video reconstruction and the report itself, I don't remember Błasik's doing anything except standing there in the cockpit watching the crew work. I'm pretty sure he would've been doing the same even if he had been completely sober. It was his presence that was mighty distracting, not the level of his inebriation.

BOAC

dvv - you have missed the point - I am saying that it is possible that he might have called a halt to the approach in different circumstances.

RegDep

dvv:

I believe the situation is such that the Polish party has not contributed to the interpretation of the numerous "unintelligible" parts of the CVR towards the end of the flight (Report page 63). The Polish would be the ones who best could try to identify what was said and by whom in the cockpit. So we do not know if General Blasnik spoke or not, and if he did, what he said.

I stand to be corrected.

dvv

BOAC, he might've or he might've not — that's as open to interpretation as anything. We don't even know if he was around when the captain was explaining the situation to the protocol dude. And when he was in the cockpit for sure, he was busy explaining the mechanics of the aircraft to some other person, and not mentally flying the aircraft. So my guess is that even in the case of his being completely sober, his chances to fully assess the situation and call a halt were only marginally better than a direct intervention from Virgin Mary.

Ptkay

Could anybody comment on the fig. 24, page 69 of the report.

The pressure altitude readings are very erratic and end at a constant 188m
for 20 sec. It also seems constantly overestimating.

Is this normal, or this instrument was rubbish and there was no other
way to fly, as by the RA ??

It looks really scary to me.

Or is it just showing all the time the STD value?

Alice025

Even a sip of champaign "emboldens" a person. (for example when one has to do an injection to one's dog ;o, when prescribed by the vet)(otherwise both dog and owner are too scared ;o)

Seriously, General could have put a stop to the attempt to approach, provided he could evaluate the situation, what I mean is what is his own flight experience with TU-s or flight time overall? If any one read his own record? He may have been very experienced. Could be not.
I can't stop thinking how here, in Russia, for example, at one nice day early in his career our president appointed a former civillian and a furniture company maker :o))))))) - as a head of the Defense Ministry. The army simply flopped down collapsed ;o)) in amazement. Imagine HIS advice, on board of, say, any thing ;o), come eh, whatever.

andrasz

I promised no more comments, but...

Lt. General Blasik's CV:

400 Bad Request
(The link is live if you click on it, I don't know why the 400 code comes up as title...)

Will let everyone draw their own conclusions...

BOAC

- yes, I've drawn mine

dvv

Ptkay, you're looking at the data from the flight data recorder, and my guess would be that the quantization of the barometric altimeter data is rather crude there. Also, it is a pressure altitude reading (look it up). As of the RA, its data are right there (see the red line which is annotated "Alt.r: Radio altitude"). And it might've been exactly what they were doing — flying by the RA (this hypothesis has been discussed here to death).

RetiredF4

It is a standard military agenda, nothing special, nothing out of order.
Even the hours mostly flown in a combat jet with average flight time of one hour ist nothing to quarrel about. Those hours are meassured wheels off ground, to wheels on ground. The career type officers dont fly that much, and his flying expierience has no weight in this accident.


I still dont get the point concerning all this talking

- he ordered it
- he should have prohibited it
- he influenced the crew
- they would have decided otherwise if he wouldnīt have been there.....

Those are all assumptions based on the tragic outcome. Further on, it founds on the conclusion, that the flight and approach itself was illegal already from the beginning and nobody stopped it.

Again, the aircraft did not crash due to the flight itself or due to the weather or due to a general on board, it crashed because of simple human errors or neglects, which showed too late. The report and the CVR show none of the previously assumed scud-run. It shows no clear and proven intention to bust the minimums from beginning, it shows no direct influence of General Blasik in the final moments. And only those final moments caused the tragic outcome.

Why did they not go around in time and bust the minimums? Because the used altitude information (from ATC and from the Navigator) had been wrong and in their minds the time to go around lay ahead in the future, when they already had passed it. When everybody caught up with the reality, it ws too late.

Be honest, the "General Blasikīs" are present in any operation of commercial and military aviation. The personal presence is not necessary. Any diversion has to be explained, any denial of flight has to have itīs sound reason. Any delay in departure or arrival is questioned and so on. And the consequences of decisions leading to those unwanted items can go as far as loosing the job.

Same with the approach. Approaches below minimum WX, with too much crosswind, with lots of water on the runway and so on occur daily around the world, being planned or unplanned. Most end up ok, some dont. Flights are heading to airfields with none or minimal or out of order nav-aids, nothing special there either.

So forget about the cargo (VIPīs), the type of flight (Mil/OAT or GAT), the airfield filed to (MIL or GAT), the ATC available, and follw through the flight.

Then you end up with a CFIT due to Pilot / Crew error. The role of ATC is in question concerning the given incorrect glidepath information, but as it was only information the blame falls short.

That the flight carried on till impact with automatics on is another point to think about, but it is discussed in several other threads already.

franzl

criss

Was it? Information from ATC was correct (within limits), and navigator was reading information from RA, which was giving correct readouts. If you were correct, why would F/o call out a go around when he did?

RetiredF4

Let me rephrase that.

Although the informations of ATC had been given on radar information within allowed limits, the actual flightpath was initially above the recommended glidepath, leading to a nearly double higher descent rate than recommended, leading later on to a drop way below glidepath.

Although the Navigator was reading the correct readouts of the radar altimeter (like he was supposed to do during his duties on YAK40), the PF was expecting the figures to be barometric height (as stated in the report).

My point is, the PIC with his limited expierience (only 6 NDB approaches total on TU-154, all of them in good weather), could assume to be on a well established final approach using those two inaccurate altitude informations alone. The failure being, that he relied totally on those informations disregarding descent-rates and other necessary crosschecks. And he was not helped out by his (inexpierienced) crew either.

The FO caught up with the developping problem, but way too late. I wonder what kind of duty he had during this approach.

But again, my oppinion, im not god and might be wrong.

franzl