Pilot's State of Mind

advertisement
CRASH OF THE POLISH GOVERNMENTAL AIRPLANE Tu-154M, FLIGHT 101
APRIL 10, 2010, SMOLENSK, RUSSIA
Smolensk Pattern
Threatens International Aviation
Maria Szonert Binienda, Esq.
Public Hearing in the European Parliament
Brussels, March 28, 2012
Danger to Aviation Safety and Security
 Cause of the Crash Predetermined
– Pilot Error –
 Undue Influence
 Investigation Standards Violated
 Wrong Conclusions
 Human Rights Violations
 Safety Recommendations Ineffective
The Cause of the Crash Predetermined
 The pilot error announced at the time of the crash.
 The Polish Government made a political decision not to
blame the Russian Federation for the Smolensk Crash.
 The pilot error scenario serves powerful interests:
 The Polish officials responsible in their official capacity for
the safety & security of State Flight 101 on April 10, 2010.
 The Russian Government.
 The investigative bodies consisting of people acting
in the position of conflict of interest.
Undue Influence Distorts Investigation
 Technical Malfunction Hypothesis Disregarded
 Technical condition of the Tu-154M not properly analyzed;
 Representatives of the designer, manufacturer and servicer of
Tu-154M acted as members of the investigation team.
 Terrorist Attack Hypothesis Disregarded
 Damage to the airplane contradicts the findings
 Analysis of the last stage of the flight wrong
 Relevant evidence not preserved or provided
 Suspicious activities disregarded
 Credible threats disregarded
Violations of Investigation Standards
 Destruction of Wreckage and Crash Scene
 No Records of Rescue Operation
 Inappropriate Treatment of the Bodies
 Inadequate Medical Examination
 Manipulation of Evidence
 Withholding of Evidence
Problems with Official Reports
 Contradictions
 Omissions
 Lack of Due Care
 Fabricated Statements
 Inadequate Safety Recommendations
“Immediate Cause” Conclusion Wrong
The Russian Report defines Immediate Cause (“IC”) as:
IC 1. The failure to proceed to an alternate airdrome;
IC 2. Descent without visual contact in order
to establish visual flight;
IC 3. No reaction to the TAWS warnings led to
controlled flight into terrain;
IC 4. The presence of the Commander-in-Chief
exposed psychological pressure on the PIC to
land at landing at any means.
IC 1. The failure of the crew to take a timely decision to
proceed to an alternate airdrome.
Transcript from the Air Traffic Control
One hour before the crash Colonel Krasnokutski states:
“A trial approach they will make without discussion.
To their minimum.”
15 minutes before the crash Col. Krasnokutski to CATC Plusnin:
“Paul, you will lead to 100 meters.
100 meters and no discussion.”
Col. Krasnokutski, an unauthorized person at the ATC tower,
exerted
pressure on the CATC to clear PL Flight No. 101 to 100
meters.
No safety recommendations for the ATC group were made.
IC 2. 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.
Transcript from the Cockpit Voice Recorder
8:40:51.7
N: “One hundred”
8:40:51.9 PIC: “Go around”
8:40:53.1 2P: “Go around”
IC 3. No reaction to the numerous TAWS warnings, which
led to controlled flight into terrain, aircraft destruction
and death of the crew & passengers.
Transcript from the Cockpit Voice Recorder
8:40:41,6
ATC:
“two, on course, on glide path”
8:40:42,3 1st TAWS: “terrain ahead”
8:40:51,9
PIC:
“go around”
•TAWS signal was expected because ‘Severny’
airdrome was not in the TAWS database.
•At 8:40:41,6 the aircraft was at about 115 m altitude and
outside the boundary of the glide path tolerance.
IC 4. The presence of the Commander-in-Chief of the
Polish Air Force in the cockpit until the collision
exposes 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.
A. The Commander-in-Chief NOT present in the cockpit
based on CVR expert reading
B. No evidence of psychological pressure on the pilot
based on CVR expert reading
C. CVR evidence contradicts “landing at any means.”
Pilot-in-Command anticipated a trial approach;
The command to “go around” was issued properly.
A. Commander-in-Chief of the Polish Air Force
General Andrzej Błasik NOT in the Cockpit
 The voice General Błasik not identified on the CVR.
 The body of General Błasik found with 12 other bodies
 The key statement: “One hundred meters” originally
assigned to General Błasik made by the Second Pilot.
 The above findings invalidate the following allegations:
 1) undue psychological pressure by Commander-in-Chief
 2) incorrect monitoring of the altitude by the pilots.
B. No Psychological Pressure on the Pilot
 No evidence of any psychological pressure from
the Commander-in-Chief of the Polish Air Force
 General Blasik was not in the cockpit and
did not talk with the pilots during the flight
 No evidence of any pressure from the President
 Statements “He will go crazy” were never made
 No psychological pressure from the superiors.
The CVR shows what is expected for the VIP flights.
C. No “Landing at any Means”
The only communication between the Pilot-in-Command and a
passenger regarding landing took place 15 minutes before the
crash with the Director of Protocol.
Pilot-in-Command:
Mr. Director, fog came out at this moment…
In these conditions that we have right now
we will not be able to land…
We’ll make one approach - but most likely nothing will come out of it.
So, please start thinking about a decision
what to do next.
Pilot Error Challenged
 Decision to request a trial approach to a
minimum descent altitude was legal and
appropriate.
 Decision to go around at a minimum
descent altitude timely and appropriate.
 The altitude reading was correct.
 No undue psychological pressure.
Safety and Security Recommendations
Deriving from Faulty Conclusion are Useless
Download