Voici les conclusions du rapport d’enquête : on the accident on 10 April 2010 « on Smolensk “Severny” airdrome, to the Tupolev Tu-154M ». Vous trouverez le rapport complet à l’adresse suivante : http://www.mak.ru/russian/investigations/2010/files/tu154m_101/finalreport_eng.pdf
Cet événement possède de nombreuses caractéristiques accidentogènes riches d’enseignements.
La pressionite
Un cocktail explosif
Toujours les mêmes pièges pour le pilote
The immediate cause of the accident was the failure of the crew to take a timely decision to proceed to an alternate airdrome although they were not once timely informed on the actual weather conditions at Smolensk “Severny” Airdrome that were significantly lower than the established airdrome minima; descent without visual contact with ground references to an altitude much lower than minimum descent altitude for go around (100 m) in order to establish visual flight as well as no reaction to the numerous TAWS warnings which led to controlled flight into terrain, aircraft destruction and death of the crew and passengers.
According to the conclusion made by the pilot-experts and aviation psychologists, the presence of the Commander-in-Chief of the Polish Air Forces 54 in the cockpit until the collision exposed psychological pressure on the PIC’s decision to continue descent in the conditions of unjustified risk with a dominating aim of landing at any means.
Contributing factors to the accident were:
– long discussion of the Tu-154M crew with the Protocol Director and crew of the Polish Yak-40 concerning the information on the actual weather that was lower than the established minima and impossibility (according to the Tu-154M crew opinion) to land at the destination airdrome which increased the psychological stress of the crew and made the PIC experience psychological clash of motives: on the one hand he realized that landing in such conditions was unsafe, on the other hand he faced strong motivation to land exactly at the destination airdrome. In case of proceeding to an alternate airdrome the PIC expected negative reaction from the Main Passenger;
– lack of compliance to the SOP and lack of CRM in the crew;
– a significant break in flights in complicated weather conditions (corresponding to his weather minima 60х800) that the PIC had had as well as his low experience in conducting non- precision approach;
– early transition by the navigator to the altitude callouts on the basis of the radio altimeter indications without considering the uneven terrain;
– conducting flight with engaged autopilot and autothrottle down to altitudes much lower than the minimum descent altitude which does not comply with the FCOM provisions;
– late start of final descent which resulted in increased vertical speed of descent the crew had to maintain.
The systematic causes of the accident involving the Tu-154M tail number 101 aircraft of the Republic of Poland were significant shortcomings in the organization of flight operations, flight crew preparation and arrangement of the VIP flight in the special air regiment.
Have a good flight
