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
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 goaround);
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.
I've read the report (Russian version), obviously quite rapidly, without any re-reading. First impressions.
- There's a world of difference between the tone of the document with Polish objections to MAK, and this report. Obviously there was a lot more time to make it neutral and less emotional. It reads even and professional, and surpasses the MAK report on these qualities.
- The analysis is extremely thorough. The 350 or so page document goes into details as minute as taxiing of the airplane in Warsaw
- There's little new information about the flight itself other than the supporting activities around it. However, there's a lot of new info about the past activities of the (now disbanded) 36th special transport regiment. Not a pretty picture. (I say "little new" assuming that one has read the ATC transcripts, which were not the focus of the MAK report)
- I cannot argue with the conclusions. As the authors of the report said, nobody involved is going to like it. They could not possibly find more errors in the actions of the pilots. The "systematic" causes in the organization of VIP flights in Poland are also many. I think they are a little too harsh on the head controller (while of course most of the blame on the Russian side goes to Landing Zone Controller). The report again discusses the "should have closed the airport" aspect but I don't believe it's in the conclusions.
- Report's recommendations are focused internally to various Polish officials. I am surprised they offer only one minor recommendations to the Russian side.
Obviously, the fallout from this is going to be mostly in Poland. We already saw 3 big things: resignation of Defense Minister, resulting firings of Air Force generals and appointment of LOT to fly the VIPs. There's an upcoming election in October, but we have to wait and see for results--as far as I have heard most of the Poles accept the conclusions.
What is going to be interesting to see is the impact on the Russian-Polish relations. At least if the present government stays in power in Warsaw, it should be positive. (of course in the ideal world a "technical" report should have no bearing on politics, but we do not live in such world)
HaveBlue From United States of America, joined Jan 2004, 2160 posts, RR: 1
Reply 4, posted (4 years 2 months 1 week 9 hours ago) and read 9764 times:
Quoting ChicagoFlyer (Reply 3): There's little new information about the flight itself other than the supporting activities around it. However, there's a lot of new info about the past activities of the (now disbanded) 36th special transport regiment. Not a pretty picture. (I say "little new" assuming that one has read the ATC transcripts, which were not the focus of the MAK report)
ChicagoFlyer thanks for posting the link to the ATC transcripts, that was most interesting. The Cheif Controller repeatedly and strongly didn't want him landing there... a desire that was tragically ignored.