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The Warsaw Voice » Politics » April 16, 2008
Air Disaster
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Catalogue of Errors
April 16, 2008 By W.Ż.    
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Bad weather, mistakes by an inexperienced flight crew and a string of poor decisions by ground controllers caused the death of 20 people in Poland's worst military aviation disaster earlier this year, a special commission investigating the crash reported April 3.

A day after the commission's findings were made public, defense minister Bogdan Klich announced he was firing five military staff for their part in contributing to the tragedy. Four crew and 16 high-ranking officers-ironically returning from a conference on flight safety-were killed when a Polish air force CASA C-295M transport plane crashed Jan. 23 near a military airfield in Mirosławiec in West Pomerania province.

The disclosed part of the report of the Commission for Investigation of Aviation Accidents shows that the crash was caused by factors such as poor organization of flights and flight training, an insufficiently experienced crew and bad weather. Col. Zbigniew Drozdowski, the commission's chairman, said that the direct reason for the crash was "the crew inadvertently causing the plane to tilt excessively... causing progressively decreasing aerodynamic lift, which in the final phase of the flight led to a sudden loss of altitude with loss of direction and causing the plane to crash into the ground."

Investigators found that during two landing attempts the plane was flying too high for the planned path of descent. Additionally, a strong wind pushed the plane off to the right of the landing strip. In addition, the EGPWS (Enhanced Ground Proximity Warning System) was switched off, meaning that the crew was not warned that the CASA was dangerously close to the ground, and that the plane was tilting too much. The commission ruled out system failures during the flight. Rumors that the crew and passengers had been drinking or taking drugs were also ruled out by tests on the bodies of the victims conducted at the Medical University in Szczecin. On April 4, a day after part of the report was made public, Klich said he was dismissing five military staff over the disaster.

Klich fired the commander of the 13th transport flight squadron in Cracow, Lt. Col. Leszek Leśniak, for poor organization of training and mistakes in task organization. The first pilot assigned by Leśniak to the doomed flight had never previously flown that model of the plane.

Lt. Adam Bonikowski, approach and precision landing controller at the Mirosławiec airfield, was dismissed for mistakes made when directing the plane as it was about to land.

Klich also fired airport flight controller Capt. Andrzej Koniarz for allowing a dangerous situation to arise and for the lack of a decisive reaction to deteriorating weather-for not deciding to send the plane to another airfield.

The minister also fired the airfield's commander Major Jędrzej Wójcicki for poor management of staff. Lt. Col. Marek Sołowianiuk, commander on duty at the Air Operations Center, was dismissed for poor work organization and shortcomings in the supervision of the flight-for not passing on information about the deteriorating weather.

In an unprecedented move, Klich announced that the report into the crash, over 700 pages long, would be declassified. So far just four pages have been made public. "To cut short any speculation, I have decided to declassify the report," the minister said, referring to media rumors that one of the passengers on board, an officer, had tried to land the CASA plane. "Recordings of communication between the crew and the control towers in Powidz, Krzesiny and Mirosławiec show there were no unauthorized persons in the cockpit, and even that the cockpit was bolted from the inside during landing in Mirosławiec... I want to emphasize that there are no other recorded voices beside those of the flight control officer and the pilots trying to land," Klich said.
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