“For Russia, the situation is now clear: the final report on the disaster is a drunken commander of Poland’s Air Force.  He allegedly forced the pilot to land.”  “Also in the cockpit was the Polish Chief of Protocol, adding to the pressure on the pilots.”

“Andrzej Blasik Commander of the Polish Air Force, had 0.6 part per thousand alcohol blood level, despite warnings from the Russian flight control forced the pilots to land. Blasik was in the cockpit. The tower at the airport in the western Russian Smolensk was due to bad weather, clearly offered an alternate landing site.”

Source:  Der Spiegel Tipsy Air Force Chief Caused Kaczynski Crash (English Translation)

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 Forces 54 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.

Source:  Final Report (English Version, Pages 182/3)

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.

Source:  Final Report (English Version, Pages 181/2)

Pilot error cause of Smolensk crash, say Russian investigators

Polskie Radio

Tatyana Anodina, head of the Russian investigative team into the Smolensk air disaster (Interstate Aviation Committee – MAK) has blamed pilot error in the resubmission of the report into the death of President Kaczynski and 95 others in Smolensk last April.

Anodina presented the conclusions of the report in Moscow, Wednesday morning.

The main conclusions to the revised, 210 page report – after Prime Minister Donald Tusk asked for clarifications and corrections to the original document handed over to Poland last October – are that:

* the crew failed to take the decision to land at another airport, as suggested by air traffic control  despite information of unfavourable weather conditions.

* a dangerous drop in altitude despite poor visibility [heavy fog] and despite warnings from the control tower.

* a lack of correct reactions from the pilot despite warnings issued by the automatic Terrain Awareness and Warning System

* the crew repeatedly received information that meteorological conditions did not meet minimum requirements for landing.

* the crew did not make the decision to fly to a reserve airport – that is when the extraordinary circumstances ensued

* the crew attempted to land despite conditions below minimum requirements, thus taking on full responsibility for the consequences.

* using the autopilot while landing was not stipulated in aviation rules for landing in such conditions.

* the crew decreased altitude with speed exceeding the safe rate twofold

* the presence of the head of Poland’s Air Force in the cockpit and the predicted negative reaction of the main passenger {President Kaczynski] exerted pressure on the crew to land.

* collaboration between the crew was less than satisfactory.

* the deficiencies of the airport’s infrastructure and its equipment were not the reason behind the catastrophe.

* it was an international flight, where the main pilot had the right to decide independently on the landing or leaving the airport.

The ‘second Katyn’

The report is being released in its entirety on the internet this morning in English and Russian and is sure to cause controversy in Poland among those who suspect a cover up by the Russian investigators as to the real causes of the disaster.

The original report was sent back by PM Tusk in December, saying some of the conclusions and methodology were “unacceptable” and not in keeping with the Chicago Convention on international aviation disaster investigations.

Suspicions as to the motives behind Russian conclusions as to the cause of the crash in western Russia – as President Kaczynski, First Lady Maria and 94 top politicians and military were on their way to an anniversary ceremony of the 1940 Katyn massacre – emerged almost immediately after the fatal crash on 10 April last year.

Artur Gorski from the Law and Justice party said three days after the crash that Russians have “come up with some dubious reasons” as to the cause of the disaster because they feared President Lech Kaczynski’s presence would overshadow a similar event hosted by Prime Minister Vladimir Putin, and attended by Prime Minister Tusk a few days before.

That theme has continued ever since. Twin brother of the late president and leader of the Law and Justice party Jaroslaw Kaczynski has said that negligence and collusion between governments in Warsaw and Moscow has assured the real truth has not come out.

Read full report (English version)(PDF)(108 Pages)

Related stories:

Don’t blame Poland for Smolensk crash, says Kaczynski, thenews.pl, 12 Jan

Russian Smolensk report – fact or fiction?thenews.pl, 12 Jan

PM stays on holiday as Smolensk Russian report released, thenews.pl, 12 Jan

PM suddenly breaks off holiday after Smolensk reportthenews.pl, 12 Jan

Related Links:

MAK (RU): Tu-154 04.10.2010 № 101

Polish Commision Commentary to the Report (PDF)(148 PAGES)(Polish)

Annex 13 To the Convention on International Civil Aviation (PDF)(43 PAGES)

Kommersant (RU): The disaster has returned to Russia

Terrain Awareness Warning System (TAWS) Lessons Learned Paper (PDF)(31 PAGES)

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