News Polish president dies in plane crash

[russ_watters]

Sad. I must admit I feel ashamed, it pushes us too far in the direction of some 3rd world country.

Don't. All it really proves is politicians in Poland are so arrogant that they think they are more powerful and important than the weather. I doubt anyone would be surprised to learn that Polish politicians are the same as politicians in other countries!

 

[arildno]

Don't. All it really proves is politicians in Poland are so arrogant that they think they are more powerful and important than the weather. I doubt anyone would be surprised to learn that Polish politicians are the same as politicians in other countries!

I'm not sure about that.
If true, it shows a worrying tendency of politically sub-ordinates to follow the irrational orders of their superior.

It is a reason why captains on ship and in planes are given supreme authority there:
Because they, and only they, know what is the safest way to complete the journey.

That the Polish pilots did NOT have that mentality ingrained IS worrying.

They should have criticized the politicos for interference in their jobs.
They did not.

 

[russ_watters]

That's easier said than done sometimes, arildno - whether the pilot is in charge or not, the politician still has the power to destroy their career.

 

[arildno]

That's easier said than done sometimes, arildno - whether the pilot is in charge or not, the politician still has the power to destroy their career.

In particular in countries with a strong authoritarian streak.

I may be mistaken, but I do think that Mr. Obama would have shut up in a similar situation, and let his pilots do the navigation&landing job.
Even if it meant he couldn't participate in a deeply symbolic remembrance act for his nation.

And, I think, Obama would have been shut down, if he showed himself as irrational&irresponsible as the Polis President seems to have been.Functional authoritarianism requires the ideological co-operation of both the superior and the inferior. Sadly, authoritarianism seems to function quite well in preserving itself as a cultural pattern...

 

[Andre]

I read the report and I understand your concerns, Borek, but it doesn't look good indeed.

A few thoughts,

It is not uncommon to practice trial approaches. Air Traffic control is not to prohibit that for safety concerns. They can however prohibit an aircraft to land, but this is only done normally if the runway is unsuitable to land, icing, aqua plaining etc etc. Weather is not a reason to prohibit such. I'm sorry, but I have to remark that I don't think that air traffic control could be blamed for anything.

The allegation that there would be no fuel for an approach at the destination followed by a diversion to the alternate is very strange. That is an elementary basic legal requirement for flight planning, which should also include extra fuel for delay in holding patterns.

The narrative about the events in the cockpit as of page 99 is hair raising, really. I could go into a lot of detail but the summary would be a total lack of airmanship.

The double standards of who is in command (the "main passenger", or the captain) is a classic. We had to explain our army generals all the time that the pilot could not be diciplined for not executing military orders, when safety is a concern and why that was stated explicitely in the flying laws rules and regulations.

 

[Andre]

That's easier said than done sometimes, arildno - whether the pilot is in charge or not, the politician still has the power to destroy their career.

Yes but leading politicians usually have not reached their positions by being dumb and rancorous. It's usually possible to explain them that there was no alternative. Good politicans are often good sports.

 

[Borek]

It is not uncommon to practice trial approaches. Air Traffic control is not to prohibit that for safety concerns. They can however prohibit an aircraft to land, but this is only done normally if the runway is unsuitable to land, icing, aqua plaining etc etc. Weather is not a reason to prohibit such. I'm sorry, but I have to remark that I don't think that air traffic control could be blamed for anything.

I don't know enough about details, so I am mostly repeating what was told by people that I usually find reasonable. There is some ambiguity and confusion here. There is some difference between military and civilian airports, and military and civilian flights. This is a military airport and from what I understand ATC had the option to close it (and if it was any Russian military flight they would be told to fly somewhere else), but he was afraid of doing it to avoid the scandal. He tried to contact his superiors calling them in Moscow, looking for help, but they never answered his calls.

Note that this confusion is part of the problem. Polish side asked for details about procedures that should be applied, as information our experts got from Russians was incomplete and they wanted to clarify the situation. Russians never gave them access to documents where these procedures are described. That's the simplest method of starting speculation that they are hiding something, even if they don't.

 

[arildno]

It might well be that inflexibility on the Russian side was part of the problem.
That should not be swept under the carpet, if true.

 

[Andre]

I don't know enough about details, so I am mostly repeating what was told by people that I usually find reasonable. There is some ambiguity and confusion here. There is some difference between military and civilian airports, and military and civilian flights. This is a military airport and from what I understand ATC had the option to close it (and if it was any Russian military flight they would be told to fly somewhere else), but he was afraid of doing it to avoid the scandal. He tried to contact his superiors calling them in Moscow, looking for help, but they never answered his calls.

Note that this confusion is part of the problem. Polish side asked for details about procedures that should be applied, as information our experts got from Russians was incomplete and they wanted to clarify the situation. Russians never gave them access to documents where these procedures are described. That's the simplest method of starting speculation that they are hiding something, even if they don't.

Yes I understand the complications and I'm aware about different rules in Eastern countries. Nevertheless "state" flights get some priority and are not necessarily subject to routine procedures. And also flight safety is the ultimate responsibility of the pilot in command.

Maybe I should elaborate a little about the chain of events. Final approaches in instrument flying conditions (clouds) can be done with precision and non precision approach type. Due to limitations the latter had to be executed. This means that there is no glidepath information and required height in the descent must be correlated with distance to go.

The report mentions that the descent was started too late which resulted in a too steep descent, which brought the aircraft in a position in which a "go around" became impossible, after the crew had ignored all signs of problems, like ground proximity warning and descending below "altitude of airdrome minima". However this terminology is ambiguous for the following reasons:

To a precision approach is tied the "decision height", at which the decision must be made to continue to land or to 'go around'. This means that in the process of going around the aircraft will descend slightly below the DH before the engines pick up and the climb is initiated. But this was a non precision approach and to a non-precision approach is tied the Minimum Descent Altitude to which an aircraft may descent. Hence it should have leveled off there when the runway was not in sight. Then it is allowed to continue level flight, ultimately until the "missed approach point", and resume descending when the runway gets in sight and a safe landing can still be made from that position.

Hence in this mishap, the critical error was descending below minimum descent altitude before the runway was in sight. That should never ever have happened regardless of anybody doing this or that, guilt this or that.

 

[Borek]

http://www.mswia.gov.pl/portal/pl/2/9282/Raport_koncowy_w_sprawie_ustalenia_okolicznosci_i_przyczyn_katastrofy_samolotu_T.html

Final report of the Committee for Investigation of National Aviation Accidents into the causes and circumstances of the Tu-154M plane crash (tail number 101) in Smoleńsk

On 29 July 2011 the Committee for Investigation of National Aviation Accidents presented the final report into the causes and circumstances of the Tu-154M plane crash (tail number 101) in Smoleńsk.

It is not the Committee's responsibility to find anyone guilty or hold anyone responsible for the plane crash. The aim of the Committee was to determinate the circumstances and causes of the plane crash, draft recommendations and draw conclusions on how to avoid such accidents in the future.

Final report of the Polish Commitee

Annexes to the report

Summary:

On the basis of the studies and analysis performed, the Committee established that 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 landing zone controller (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.

3.2.3. 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:
   • failure to meet the established approach criteria;
   • using radio altimeter for establishing alarm altitude values for various types of approach;
   • 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 Weather Conditions, and lack of practical experience as LZC at the SMOLENSK NORTH airfield.

I haven't read the report yet, I plan to at least skim it (time permitting). Summary was taken from some other document (also published on the Ministry of the Interior and Administration page).

 

[Andre]

Sorry for ressurecting this old one. It appears that we never finalized it.
The essential mistake was almost certainly a very old mistake, a wrong altimeter setting.

From the report (p 14):

...A moment later, CC set his WBE-SWS altimeter to the standard pressure of 1013 hPa. It caused TAWS to receive wrong data and, in effect, the system inhibited generation of warnings, assuming that the aircraft was higher up than in reality.

So as altimeters are working on local barometric pressure, it has to 'know' the ground pressure. There is a dial to put that in. However there are three different settings QFE, pressure for field elevation, giving 0 at ground level, which is hardly used anymore (in the west), QNH, pressure Nautical Height, (sea level) giving the field elevation on the ground, which is used for low altitude parts of the flight, and standard altimeter setting (1013.25 hPa or 29.92 inches) which is used above a certain altitude (transition height), obviously to ensure altitude separation between flights, all being on the same setting.

In the log you can read that the altimeter was indeed changed both in the climb to standard setting and later in the descend to local QFE(?), which was much lower at the time.

p: 213:

At 0628:47, at an altitude of 2,176 m, the aircraft commander‘s VBE-SVS altimeter was switched from standard pressure to another setting (judging by the discussion between crew members, to 993 hPa, which was the barometric pressure at airfield level, and from that point barometric altimeters read altitudes in reference to the runway)

But then suddenly:

At 0640:14.5 at an RA altitude of 366 m (297m above airfield level, at a distance of 4,768 m from RWY 26 threshold), at a speed of 309 km/h, the VBE-SVS altimeter of the aircraft commander was switched to standard pressure of 1,013 hPa.

Immediately afterwards, at 0640:15 – at RA altitude of 366 m, 295 m above airfield level, at 4,724 m from RWY 26 threshold, TAWS stopped generating the TERRAIN AHEAD message.

And that caused the accident almost certainly. Obviously the person who made that mistake was under great stress. He checked the altimeter setting, did not mentally process the indicated value maybe and changed it maybe to a setting that was familiar to him. A 20 hPA error equals 540 feet/ (165 meter) 28 ft per milibar, the wrong way. Obviously that was enough to make the accident unavoidable.

 

[Czcibor]

That's easier said than done sometimes, arildno - whether the pilot is in charge or not, the politician still has the power to destroy their career.

The pilot who lead this tragic flight was the second pilot in the flight to Tbilisi. One of presidents men (Gosiewski) actually tried to prosecute the first pilot for cowardice and refusal to perform presidential order.

Our prime minister (yes, Tusk is a more sensible person with rather unfriendly attitude towards Kaczyński brothers) actually awarded the pilot for this refusal. However, from perspective of long term job security of pilots... that still wasn't tempting.

Keep in mind that Poland is now full of conspiracy theories, and Jarosław Kaczyński is actually trying to win next election by implying some kind of plot.

 

[Andre]

The pilot who lead this tragic flight was the second pilot in the flight to Tbilisi. One of presidents men (Gosiewski) actually tried to prosecute the first pilot for cowardice and refusal to perform presidential order.

This is a very common dillemma. When I was asked to rewrite our air force rules book, this was by far the biggest [STRIKE]PITA[/STRIKE] bleeb. Army generals want to order the aircraft captain to go where they want to go. One of the rules that is written in blood (of many and counting) is that the captain of the aircraft decides what is safe and what is not safe and nobody shall ever challenge that. Not even your favorite local god.

There should have been no stress on this captain for his carreer for whatever he was going to decide.

And remember: a superior pilot uses his superior judgement to avoid situations that require his superior skills.

 

[dlgoff]

The essential mistake was almost certainly a very old mistake, a wrong altimeter setting.

I don't understand why, even in small planes, you wouldn't go the cost for a Radar Altimeter.

 

[Borek]

They had the radar altimeter, but they were not aware of the way the land is formed on the approach. There is a wide and shallow valley there. So while the terrain around the airfield is generally flat, when you are approaching it raises much faster than expected. That means barometric altimeter was giving better information.

I don't remember report details now and I don't plan on rereading it, but this slope was one of their problems - I think the second pilot was reading indications of the radar altimeter, which gave them feeling of false safety, as they thought they were tens of meters higher than they were in reality. Once the land raised they got very low very fast and the situation got critical immediately.

 

[dlgoff]

I guess I was somehow thinking the RA values in the report was from a ground based measurement.

 

[Borek]

In Poland today National Geographic is going to air "Death of the President" for the first time. This is part of their Mayday series.

But I won't be able to see it.