Crash of a Boeing 767-35DER in Warsaw

Date & Time: Nov 1, 2011 at 1439 LT
Type of aircraft:
Operator:
Registration:
SP-LPC
Survivors:
Yes
Schedule:
Newark - Warsaw
MSN:
28656/659
YOM:
1997
Flight number:
LOT016
Country:
Region:
Crew on board:
10
Crew fatalities:
Pax on board:
221
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
15980
Captain / Total hours on type:
13307.00
Copilot / Total flying hours:
9431
Copilot / Total hours on type:
1981
Aircraft flight hours:
85429
Aircraft flight cycles:
8002
Circumstances:
On November 1, 2011 a passenger LO 16 flight of B767-300ER airplane, registration marks SP-LPC, was scheduled from KEWR to EPWA. The Pre-Departure Check of the airplane was carried out by a ground engineer from a contracted service organization in accordance with Operator’s requirements. The ground engineer was responsible for conducting PRE-DEPARTURE CHECK and ETOPS CHECK. The above procedures did not include cockpit check. The ground engineer did not find any failures or irregularities and did not notice anything unusual. The flight crew arrived at Newark Liberty Airport at a time specified by Operator and in accordance with its operating procedures. When commencing the flight duty period the crew members were rested, refreshed, in a good psychophysical condition. They did not report overload by air operations. Upon arrival at the aircraft stand each flight crew member performed his duties as provided for in the operating procedures of the airline. CPT conducted Exterior Walk Around while FO conducted cockpit check. FO checked on-board equipment and the cockpit preparation for the flight. According to the flight crew statement no failures or irregularities were found. The crew deemed the airplane fully operational for the flight to Warsaw. The ground engineer from the contracted maintenance organization was not present in the cockpit during the flight crew preparation. During the flight CPT was PF and FO was PM. At 03:58:11 hrs the crew started the engines. The take-off took place at 04:19:08 hrs. After the take-off, during the retraction of landing gear and flaps the hydraulic fluid from the center hydraulic system (C system) flew out, which consequently led to pressure drop in this system. The pressure drop in the C system was signaled on the hydraulic panel – SYS PRESS and on EICAS - C HYD SYS PRESS and recorded by on-board flight data recorders. After completion HYDRAULIC SYSTEM PRESSURE (C only) procedure contained in QRH and consultation with the Operator's MCC, the flight crew decided to continue the flight to Warsaw. The flight proceeded without significant distortions. Landing in Warsaw was to be carried out with the alternate landing gear extension system. This situation was well known to pilots due to numerous exercises carried out in a flight simulator. Taking advantage of the available time, the CPT and FO developed a plan for landing in accordance with the procedure contained in QRH and discussed an anticipated sequence of events. At 12:17 hrs, during approach to landing on EPWA aerodrome the flight crew performed the procedure of the lading gear extension using the alternate landing gear extension system. However, after the anticipated time the landing gear was not extended. The crew checked the correctness of execution of the procedure against QRH and again attempted to extend the landing gear. After failure of the second attempt to extend the landing gear with the alternate system the approach to landing was abandoned. At 12:22 hrs the crew reported to ATC inability to extend the landing gear and requested the Operator’s MCC assistance. Around 12:25 hrs the flight crew declared EMERGENCY. The airplane was directed to a holding zone. The Operator’s Operations Centre enabled the crew to communicate with experts. FO executed expert recommendations and checked the alternate landing gear extension switch and circuit breakers on P-11 and P6-1 panels. After that FO reported to Operations Centre and to CPT that the circuit breakers had been checked. FO also cycled (pulled and reset) the ALT EXT MOTOR circuit breaker as indicated by an expert. However, the landing gear was not extended. In the meantime pilots of two F-16s of the Polish Air Force inspected SP-LPC from the air and informed the crew that the landing gear was still in the retracted position but the tail skid was extended. After that information the crew attempted to extend the landing gear in a gravitational way, but it also ended in failure. After a series of unsuccessful attempts to extend the landing gear and due to low fuel quantity, the crew decided to carry out an emergency gear up landing. CC1 was instructed by Captain to prepare the cabin and passengers for emergency landing. During the preparation the passengers were calm, they carried out the crew instructions, there was no panic. Prior to the landing firefighters distributed foam over RWY 33 at a distance of about 3000 m. External services arrived at the airport (PSP and emergency ambulances). The plane touched down on RWY 33 of EPWA aerodrome (Figure 7) at 13:39 hrs. At the time of touchdown about 1600 kg of fuel (1939 liters at a density of 0.825 kg/l) was in its tanks, the engines were running and their recorded speeds were N1ACTL = 57%, N1ACTR = 38%. The plane was moving on RWY 33 along its centre line and stopped 42 m after the intersection with RWY 29. When the aircraft was moving, sparks were coming out of the right engine, and they were suppressed by the applied foam; then the engine caught fire. When the airplane came to rest, the crew evacuated the passengers and LSP extinguished the fire. During the evacuation none of the passengers or crew suffered any injuries. During the landing the aircraft sustained substantial damage, which caused its withdrawal from service.
Probable cause:
Causes of the accident:
1. Failure of the hydraulic hose connecting the hydraulic system on the right leg of the main landing gear with the center hydraulic system, which initiated the occurrence.
2. Open C829 BAT BUS DISTR circuit breaker in the power supply circuit of the alternate landing gear extension system in the situation when the center hydraulic system was inoperative.
3. The crew’s failure to detect the open C829 circuit breaker during approach to landing, after detecting that the landing gear could not be extended with the alternate system.
Factors contributing to the occurrence were as follow:
1. Lack of guards protecting the circuit breakers on P6-1 panel against inadvertent mechanical opening; from 863 production line the guards have been mounted in the manufacturing process (SP-LPC was 659 production line).
2. C829 location on panel P6-1 (extremely low position), impeding observation of its setting and favoring its inadvertent mechanical opening.
3. Lack of effective procedures at the Operator’s Operations Centre, which impeded specialist support for the crew.
4. Operator’s failure to incorporate Service Bulletin 767-32-0162.
Final Report:

Ground collision of an ATR72-202 in Warsaw

Date & Time: Jul 14, 2011 at 2230 LT
Type of aircraft:
Operator:
Registration:
SP-LFH
Flight Phase:
Survivors:
Yes
Schedule:
Wrocław – Warsaw
MSN:
478
YOM:
1995
Flight number:
ELO3850
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
33
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On 14 July, 2011 ATR 72 flight crew after landing at EPWA aerodrome received the clearance for taxiing to parking stand 41 via taxiways: "S", "O" and "M". When the airplane was on taxiway "M2", "Mulag" type tractor was moving by the service road, passing perpendicularly to taxiway “M2”. The tractor driver did not give the right of way to ATR 72 and the tractor collided with the airplane. As a result, the airplane and the tractor sustained substantial damages. The flight crew stopped the airplane and shut down the engines. Airport Fire Brigade and an ambulance were called. The tractor operator suffered some injuries and was taken to hospital. the airplane passengers and the flight crew did not suffer any injuries. The impact caused a fuel leakage from the airplane of 200 m2 in area, which was removed along with other elements of the damaged aircraft by the Airport Fire Brigade. The airplane and the "Mulag" tractor were withdrawn from the further service. During the accident there were adverse weather conditions at the airport - heavy rain and lightning which caused reduction in visibility.
Probable cause:
Inadequate observation of the Ground Movement Area by the “Mulag” tractor operator.
Contributing factors:
1. Heavy rain and lightning.
2. Light reflections on the aerodrome surface which hindered observation from the tractor cab.
3. Construction of the "Mulag” tractor cab, left side of which could partially or completely obscure silhouette of the airplane.
4. Short distance between a service road and taxiway "O2".
Final Report:

Crash of a Tupolev TU-154M in Smolensk: 96 killed

Date & Time: Apr 10, 2010 at 1041 LT
Type of aircraft:
Operator:
Registration:
101
Flight Type:
Survivors:
No
Schedule:
Warsaw - Smolensk
MSN:
90A-837
YOM:
1990
Flight number:
PLF101
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
88
Pax fatalities:
Other fatalities:
Total fatalities:
96
Captain / Total flying hours:
3531
Captain / Total hours on type:
2906.00
Copilot / Total flying hours:
1909
Copilot / Total hours on type:
475
Aircraft flight hours:
5142
Aircraft flight cycles:
3907
Circumstances:
On approach to Smolensk Airport in poor weather conditions, crew was forced to make a go-around and approach was abandoned three times. On the fourth approach, at a speed of 260 km/h, aircraft went beyond the minimum safe altitude, hit tree tops, lost its left wing and crashed in a huge explosion. All 96 occupants were killed, among them the President of the Polish Republic Lech Kaczyński and his wife. He was flying to Smolensk to take part to the commemoration of the 70th anniversary of Katyn massacre when Soviet Army killed 20,000 Polish officers. Among the delegation were also members of the Polish Senate and Government; the ex President, the vice-president of low Chamber, the Senate vice-president, the president of the polish central bank, the chief of military staff, the chief of ground forces, the chief of the Air Force, the chief of special forces, the chief of Marines, the personal assistant of President, the chief of National Security, the vice-Minister of Defense and the vice-Minister of Foreign Affairs.
Probable cause:
The immediate cause of the accident was the descent below the minimum descent altitude at an excessive rate of descent in weather conditions which prevented visual contact with the ground, as well as a delayed execution of the go-around procedure. Those circumstances led to an impact on a terrain obstacle resulting in separation of a part of the left wing with aileron and consequently to the loss of aircraft control and eventual ground impact.
Circumstances Contributing to the Accident:
1) Failure to monitor altitude by means of a pressure altimeter during a non-precision approach;
2) failure by the crew to respond to the PULL UP warning generated by the TAWS;
3) attempt to execute the go-around maneuver under the control of ABSU (automatic go-around)
4) Approach Control confirming to the crew the correct position of the airplane in relation to the RWY threshold, glide slope, and course which might have affirmed the crew's belief that the approach was proceeding correctly although the airplane was actually outside the permissible deviation margin;
5) failure by LZC to inform the crew about descending below the glide slope and delayed issuance of the level-out command;
6) incorrect training of the Tu-154M flight crews in the 36 Regiment.
Conducive circumstances
1) incorrect coordination of the crew's work, which placed an excessive burden on the aircraft commander in the final phase of the flight;
2) insufficient flight preparation of the crew;
3) the crew‘s insufficient knowledge of the airplane's systems and their limitations;
4) inadequate cross-monitoring among the crew members and failure to respond to the mistakes committed;
5) crew composition inadequate for the task;
6) ineffective immediate supervision of the 36 Regiment's flight training process by the Air Force Command;
7) failure by the 36 Regiment to develop procedures governing the crew's actions in the event of:
a) failure to meet the established approach criteria;
b) using radio altimeter for establishing alarm altitude values for various types of approach;
c) distribution of duties in a multi-crew flight.
8) sporadic performance of flight support duties by LZC over the last 12 months, in particular under difficult WC, and lack of practical experience as LZC at the SMOLENSK NORTH airfield.
Final Report:

Crash of a McDonnell Douglas MD-83 in Istanbul

Date & Time: Oct 11, 2007 at 1929 LT
Type of aircraft:
Operator:
Registration:
SU-BOY
Survivors:
Yes
Schedule:
Hurghada - Warsaw
MSN:
53191/2151
YOM:
1996
Flight number:
AMV4270
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
156
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
En route from Hurghada to Warsaw, while cruising over Turkey, the crew contacted ATC and reported electrical and hydraulic problems. The crew was cleared to divert to Istanbul-Atatürk Airport for an emergency landing. After touchdown, the aircraft was unable to stop within the remaining distance. It overran and came to rest near the ILS antenna after both main gears collapsed. All 163 occupants evacuated safely and the aircraft was damaged beyond repair.

Crash of a Rockwell Grand Commander 690A in Warsaw

Date & Time: Nov 29, 1995 at 0220 LT
Registration:
EC-FFE
Survivors:
Yes
Site:
MSN:
690-11344
YOM:
1976
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Warsaw-Okecie Airport runway 33 by night, the pilot reported engine problems when the aircraft lost height and crashed in the district of Mysiadło, about six km short of runway threshold. All four occupants were injured and there were no victims on the ground. The aircraft was destroyed. It was reported that both engines lost power on approach, maybe after being taken over by frost. At the time of the accident, icing conditions were present in Warsaw.

Crash of an Airbus A320-211 in Warsaw: 2 killed

Date & Time: Sep 14, 1993 at 1643 LT
Type of aircraft:
Operator:
Registration:
D-AIPN
Survivors:
Yes
Schedule:
Frankfurt - Warsaw
MSN:
105
YOM:
1990
Flight number:
LH2904
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
64
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
12778
Captain / Total hours on type:
1440.00
Copilot / Total flying hours:
11361
Copilot / Total hours on type:
1595
Aircraft flight hours:
7546
Aircraft flight cycles:
6721
Circumstances:
Following an uneventful flight from Frankfurt, the crew started the descent to Warsaw-Okecie Airport in poor weather conditions with thunderstorm activity, wind shear, rain falls and CB's. After being cleared to land on runway 11, the wind component changed during the last seconds. The right main gear touched down 770 metres past the runway threshold (aircraft's speed was 170 knots). The left main gear touched down 9 seconds later, 1,525 metres past the runway threshold. On a wet runway, the crew started the braking procedure and activated the thrust reversers and spoilers but the remaining distance was insufficient. At a speed of 72 knots, the aircraft overran, went down an embankment, lost its left engine and came to rest 90 metres further, bursting into flames. A female passenger and the captain were killed while all other occupants were rescued, among them 51 were seriously injured. The aircraft was destroyed by a post crash fire.
Probable cause:
Cause of the accident were incorrect decisions and actions of the flight crew taken in situation when the information about windshear at the approach to the runway was received. Wind shear was produced by the front just passing the aerodrome; the front was accompanied by intensive variation of wind parameters as well as by heavy rain on the aerodrome itself. Actions of the flight crew were also affected by design features of the aircraft which limited the feasibility of applying available braking systems as well as by insufficient information in the aircraft operations manual (AOM) relating to the increase of the landing distance.
Final Report:

Crash of a Douglas DC-9-32 in Warsaw

Date & Time: Dec 17, 1991 at 1749 LT
Type of aircraft:
Operator:
Registration:
I-RIBN
Survivors:
Yes
Schedule:
Rome - Warsaw
MSN:
47339
YOM:
1969
Flight number:
AZ552
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
90
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
While descending to Warsaw-Okecie Airport, the crew encountered poor weather conditions with thunderstorm activity. On final approach, the copilot suggested the captain to abandon the landing procedure and to initiate a go-around maneuver. The captain dismissed the copilot's suggestion, disengaged the autopilot system and continued the approach when visual contact with the ground was established at an altitude of 400 feet. In a nose-down attitude and at an excessive speed of 155 knots (about 25-30 knots above the recommended speed), the aircraft struck the runway 33 surface nose gear first. The aircraft bounced then veered off runway to the left, rolled on soft ground for about 860 metres and lost its nose gear before coming to rest. All 96 occupants were evacuated, among them three passengers were slightly injured. The aircraft was damaged beyond repair.
Probable cause:
Wrong approach configuration on part of the flying crew who decided to continue the descent while the aircraft was unstable and misaligned with the runway. The following contributing factors were reported:
- Failure of the crew to initiate a go-around procedure,
- Unstabilized approach,
- Excessive approach speed,
- Touchdown completed in a nose-down attitude,
- Poor crew coordination,
- Poor weather conditions with thunderstorm activity.

Crash of an Antonov AN-24B in Łańcut: 1 killed

Date & Time: Nov 2, 1988 at 1028 LT
Type of aircraft:
Operator:
Registration:
SP-LTD
Survivors:
Yes
Schedule:
Warsaw - Rzeszów
MSN:
67302209
YOM:
1976
Flight number:
LO703
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
25
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
While descending to Rzeszów-Jasionka Airport, one of the engine failed. Unable to maintain a safe altitude, the captain decided to attempt an emergency landing in a field located in Łańcut, about 14 km southeast of Rzeszów Airport. After landing, the aircraft slid for few dozen meters then came to rest, bursting into flames. Five occupants were injured while 23 others escaped uninjured. A passenger aged 69 was killed. The aircraft was totally destroyed by a post crash fire.
Probable cause:
It was determined that the crew failed to activate the engine deicing systems.

Crash of an Ilyushin II-62 in Warsaw: 183 killed

Date & Time: May 9, 1987 at 1112 LT
Type of aircraft:
Operator:
Registration:
SP-LBG
Survivors:
No
Schedule:
Warsaw - New York
MSN:
3344942
YOM:
1973
Flight number:
LO5055
Country:
Region:
Crew on board:
11
Crew fatalities:
Pax on board:
172
Pax fatalities:
Other fatalities:
Total fatalities:
183
Captain / Total flying hours:
19745
Captain / Total hours on type:
5546.00
Copilot / Total flying hours:
10957
Copilot / Total hours on type:
1966
Aircraft flight hours:
6972
Aircraft flight cycles:
1752
Circumstances:
At 10:18 flight LO5055 took off from Warsaw runway 33 for a flight to New York-JFK. The aircraft headed for the GRU VOR, which it passed at FL265, climbing to FL310. Two minutes later (at 10:41) the n°2 engine Low Pressure turbine shaft broke loose, followed by the failure of the turbine disc. Debris punctured the aft fuselage, causing a fire in the cargo hold. The elevator control system was severed and the n°1 engine had to be shut down. The flight crew immediately started an emergency descent to 4,000 metres. After shutting down both n°1 and n°2 engine the crew mistakenly thought the fire was extinguished. They had decided to land at Modlin airport, but still unaware of the fire, changed to Warsaw-Okecie runway 33 because of better rescue equipment there. The flight started a left turn for runway 33 at 11:09 at an altitude of 1,450 metres and an airspeed of 480 km/h. The crew lost control during the turn and the Il-62 crashed into a forest, 6 km from the runway at an airspeed of 465 km/h and an 11° left bank and 12° nosedown. The aircraft disintegrated on impact and all 183 occupants were killed.
Probable cause:
The cause of the accident was the destruction of engine no.2 resulting in disconnection of the longitudinal control system from the control column, cabin depressurisation, damage to the electric system and fire. At the end stage of flight the fire caused the loss of the aircraft longitudinal control and the impact with the ground after 31 minutes as counted from the beginning of the emergency situation. The destruction of engine no.2 occurred without any signal from the warning/testing system. Under the circumstances the crew members were not able to stop the engine in good time, consequently an emergency situation was created on board the aircraft.

Crash of a PZL-Mielec AN-2P in Pilisszentlélek: 2 killed

Date & Time: Mar 31, 1987
Type of aircraft:
Operator:
Registration:
SP-DNM
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Budapest - Warsaw
MSN:
1G107-60
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The single engine airplane departed Budapest-Ferihegy on a ferry flight to Warsaw. En route, the crew encountered icing conditions and poor weather. He was cleared to return to Budapest and was instructed to maintain 4,000 feet minimum altitude. Few minutes later, the aircraft lost height and crashed on the slope of a hill located near Pilisszentlélek. Both occupants were killed.
Probable cause:
It is believed that the crew lost control of the airplane following an excessive accumulation of ice on fuselage, wings and tail.