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:
Thirty minutes after departure from Newark, crew informed their base in Warsaw that the central hydraulic system failed (hydraulic system C). On approach to Warsaw, crew completed the landing checklist but was unable to lower the gear. At 3,000 feet on approach, captain decided to abandon the descent and made a go around . During an 80 minutes holding circuit over Warsaw, a fighter pilot confirmed that all gear were not deployed and despite several troubleshooting, crew was unable to lower the gear. Eventually, it was decided to make a belly landing on runway 33. Following an uneventful approach, aircraft landed smoothly and skidded on runway, creating several sparks before coming to rest at 1439LT. All 231 occupants were evacuated safely and the company decided later that the aircraft was not repairable.
Probable cause:
The cause of the hydraulic leak and resulting failure was caused by the fracture of a flexible hydraulic hose connecting the brakes system of the right main gear with hydraulic system C. The fracture occurred in the area of a metal band around the tip of the hose. The nature of the crack suggests there was a stress relaxation resulting in material creep. The inner Kevlar lining of the pressure sleeve had signs of abrasions which according to the manufacturer suggests the hose had been repeatedly flexing as result of pressure changes, so that the manufacturer suspects the hose was not installed completely straight.
The hydraulic fluid was found to meet required specifications.
Following comparison of the alternate landing gear system with another aircraft with the circuit breaker C829 in both off and on positions, it was found that the alternate landing gear sequence would extend the gear with the circuit breaker in the on position, however, would not operate if the circuit breaker was in the off position.
The actuator was found operative.
The C829 circuit breaker was confirmed to not be indicated on the engine indications and crew alerting system (EICAS) and was not recorded by the black boxes.
Documentation (checklists) would turn attention towards that circuit breaker only if systems protected by the circuit breaker needed to be activated.
The checklist for loss of pressure in the central hydraulic system did not refer to the circuit breaker C829 leaving the crew without guidance if the first item to activate the alternate gear extension switch did not illuminate the "gear down" lights. The checklist did not include the possibility of the alternate gear extension failing at all.
The checklist for gear disagree also did not include the possibility of a failed alternate gear extension.
There was no checklist available at all in case of both primary and alternate gear extension had failed, e.g. a all gear up landing checklist.
Based on current technical evidence the investigation thus may conclude that the cause of the belly landing was the circuit breaker C829 in the off position. A separate issue will be to find out why the circuit breaker was off.

Source: AvHerald
Final Report:

Ground collision with 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:
Wroclaw - 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:
Following an uneventful flight and landing from Wroclaw, aircraft evacuated the runway and was taxiing on apron to rich its parking place. While manoeuvring, aircraft was hit by a vehicle pulling baggage carts. The vehicle impacted the right engine, causing three blades to separate. They hit the fuselage and the wing, causing several damage. While all 37 occupants were uninjured, the vehicle driver was seriously injured. The aircraft was later considered as damaged beyond repair.
Probable cause:
Ground collision with a baggage vehicle.

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: