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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 Casa C-295M in Mirosławiec: 20 killed

Date & Time: Jan 23, 2008 at 1907 LT
Type of aircraft:
Operator:
Registration:
019
Flight Type:
Survivors:
No
Schedule:
Warsaw– Powidz – Poznań-Krzesiny – Mirosławiec – Świdwin – Krakow
MSN:
S-043
YOM:
2007
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
16
Pax fatalities:
Other fatalities:
Total fatalities:
20
Aircraft flight hours:
300
Circumstances:
The aircraft departed Warsaw at 1651LT on a flight to Krakow with intermediate stops in Powidz, Poznań-Krzesiny, Mirosławiec and Świdwin, carrying 36 passengers and a crew of four. They were returning to their base after intending the 50th Annual Aviation Safety Conference held in Warsaw. Nine passengers deplaned at Powidz and 11 others at Poznań-Krzesiny AFB. On approach to Mirosławiec by night, the crew encountered poor weather conditions with a ceiling at 300 feet, visibility 2 sm and mist. On short final, the aircraft was unstable. With a rate of descent of 6,000 feet per minute and at a speed of 148 knots, the aircraft impacted trees and crashed in a wooded area located 1,300 metres short of runway threshold, bursting into flames. The aircraft was totally destroyed and all 20 occupants were killed.
Crew:
Maj Jarosław Haładus,
Adj Robert Kuźma,
Adj Michał Smyczyński,
Sgt Janusz Adamczyk.
Passengers:
Gen Brig Andrzej Andrzejewski,
Col Dariusz Maciąg,
Col Jerzy Piłat,
Lt Col Wojciech Maniewski,
Lt Col Zbigniew Książek,
Lt Col Dariusz Pawlak,
Lt Col Zdzisław Cieślik,
Maj Robert Maj,
Maj Mirosław Wilczyński,
Maj Grzegorz Jułga,
Maj Piotr Firlingier,
Maj Krzysztof Smołucha,
Cpt Karol Szmigiel,
Cpt Paweł Zdunek,
Cpt Leszek Ziemski,
Cpt Grzegorz Stepaniuk,

Probable cause:
Inadvertent loss of spatial and situational awareness by the aircraft crew during final stages of PAR approach, which, within 12 seconds period before crash, resulted in the aircraft’s bank increasing unmonitored and accompanying altitude loss, while the flight crew apparently was trying to establish visual contact with runway and approach lights.

Among the secondary causes the Board listed:
- Improper flight crew selection for the flight:
- The PIC did not have any previous experience on this version of CASA C-295 aircraft, which was additionally equipped with 2 IRS/GPS LN-100G units instead of 2 TOPSTAR 100-2 GPS receivers, and, ironically, with EGPWS Mk. V - unfortunately lack of cryptographic modules in GPS receivers, which made IRS/GPS LN-100G system almost useless (IRS alone with no GPS enhancement) caused flight crew to use handheld GPS receivers (Garmin GPSMAP 196),
- The SIC was not rated in CASA C-295 aircraft for night/IMC operations,
- Poor flight crew coordination and cooperation (poor MCC & CRM):
- improper altimeter setting procedures,
- probably both pilots were looking for visual cues and nobody was observing flight instruments in the very last seconds before they crash),
- Poor weather conditions in vicinity of Miroslawiec AB; ceiling 300 feet, visibility 2 sm, in mist. Icing was excluded as a factor.
- Spatial disorientation of the flight crew,
- EGPWS Audio warning was inhibited (the flight crew missed EGPWS test before departure from Warsaw, even though it was a checklist item, and never corrected the problem - the PIC was not familiar with the system - he has never flown before CASA C-295M equipped with EGPWS) - in result no audio warning of excessive bank angle, high terrain closure rate and high sink rate was available to the flight crew, as well as no automatic height above ground callouts were given,
- The flight crew failed to monitor radio-altimeter indication during both approaches,
- Both pilots concentrated their attention outside of the cockpit during final seconds before crash and did not scan flight instruments.
- The military PAR controller did a poor job during the approach, he let for the non-stabilized approach, he was not compensating properly for left crosswind of 20 kts and allowed the aircraft to stay high above glide slope during both PAR approaches, he also was not fully aware of altimeter setting (QNH or QFE) and altitude reports by flight crew– improper values QNH/QFE were used by the flight crew during first approach, additionally PIC has set his altimeter to QFE, while SIC to QNH. During the approach the controller’s instructions were hesitant and inconsistent, probably making the flight crew to believe their approach was going well.
- The military PAR controller was giving improper suggestions to the flight crew - he was questioning them during final stage of approach whether they see approach or runway lights or not, instead of continuous talking them down to the runway threshold,
- Altimeter indications were improperly interpreted by the flight crew,
- Improperly performed search for visual contact by the flight crew during final stage of approach,
- Improper, lacking weather situation analysis performed by the PIC before the flight,
- The flight crew did not properly set DH/MDA (they did the same error on previous two legs before crash).

Contributing factors were:
- The SIC was not rated in CASA C-295 aircraft for night/IMC operations (the SIC total flight time was 800 hours including 100 hours in CASA C-295M),
- The PIC has no previous experience on the accident version of CASA C-295 aircraft, (although he logged 800+ hours in another version of CASA C-295M aircraft used by Polish AF and his total flight time was 2500 hours),
- Because of lack of GPS enhancement to IRS, the flight crew used Garmin GPSMAP 196 handheld GPS receiver,
- The PIC had no previous experience in PAR approaches in IMC, close to minimums, which in Miroslawiec AB were reported to be aprox. ceiling 270 feet and visibility of 3300 feet,
- The military PAR controller had no previous experience in conducting PAR approaches of aircraft other than Sukhoi Su-22,
- The aircraft was improperly vectored to final approach by military APP controller (the same person performing PAR controller duties) which resulted in rushed, non-stabilized first approach, because the aircraft started descent on final approach segment being twice as high as glide slope,
- Lack of instrument approach procedures meeting ICAO standards at Polish military airports, including Miroslawiec AB, published in Aeronautical Information Publication (AIP),
- Use of different units by pilots and controller (the aircraft’s altimeters were scaled in feet and hPa, while the controller was using meters and millimeters of Hg, there was also misunderstanding regarding use of QNH and QFE),
- Even though the aircraft was equipped with ILS receiver, the ILS equipment at Miroslawiec AB was inoperative (it was installed in 2001, but since then has never worked properly, and therefore was not used, despite several repair attempts - now, 2 months after the crash, it is reported to work properly - the crew had available only military PAR (unable to meet ICAO standards), assisted with 2 military NDBs located 4 km and 1 km from the threshold of runway 30),
- The information on minimum weather conditions and available navaids in Miroslawiec AB were improperly disseminated (dispatch personnel had no information the ILS in Miroslawiec AB was inoperative).

Crash of a PZL-Mielec AN-2P in Przełęcz Koscierska

Date & Time: Sep 12, 2005
Type of aircraft:
Operator:
Registration:
1464
Flight Phase:
Flight Type:
Survivors:
Yes
Site:
MSN:
1G114-64
YOM:
1970
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine aircraft suffered an engine failure and crashed in a wooded area located near Przełęcz Koscierska, about 55 km southwest of Krakow. All 11 occupants were slightly injured while the aircraft was destroyed.
Probable cause:
Engine failure for unknown reasons.