Crash of the Polish Governmental Plane PFL 101 in Smolensk on April 10, 2010 [1]

Independent Investigation Status Report, November 10, 2011 [2]

TABLE OF CONTENT

Introduction

The Republic of Poland, acting as the State of the Operator and the State of Registry pursuant to Article 6.3 of Annex 13 to the 1944 Convention on International Civil Aviation (“Chicago Convention”), on December 19, 2010 submitted its comments to the draft Final Report prepared by the Russian Federation that acted as the State of Occurrence, the State of Design, and State of Manufacturer and conducted the investigation into the crash of the Tu-154M aircraft tail number 101 dated April 10, 2010 (“Smolensk Crash”). The Tu-154M aircraft, flight 101 from Warsaw, Poland to Smolensk, Russia, carried the President of Poland and 95 Polish citizens traveling for the commemoration of the 70thieth anniversary of the Katyn Crime.
The Remarks of the Republic of Poland to the draft Final Report of the Russian Federation dated December 19, 2010 (“Polish Response”) were submitted to the Russian Federation in Polish and Russian languages but were not officially translated into English. [3] Therefore, the families of the Smolensk victims hired the most renowned international firm Transperfect Translations to perform the translation of the Polish Response to the draft Final Report of the Russian Federation on the Smolensk Crash into English. [4] The Russian Federation, acting through the Interstate Aviation Committee (IAC) as the investigator-in-charge, disregarded the Polish Response, in particular the Polish objection as to the causes of the crash, and announced its Final Report with its own conclusions as to the causes of this crash at a press conference in Moscow on January 13, 2011 (“IAC Final Report”).

In its investigation into the Smolensk Crash, the Russian Federation requested the assistance of the United States with respect to recovering the TAFS and FSM readings by the US manufacturer of these systems - Universal Avionics Systems Corporation from Redmond, Washington. The United States acting through the National Transportation Safety Board provided the requested assistance, however did not receive the status of the accredited representative to participate in the investigation to the Smolensk Crash as allowed by article 5.23 of the Chicago Convention. At least one citizen of the United States lost his life in the Smolensk Crash.

The objections to the investigation of the Russian Federation into the Smolensk Crash are multifold and of fundamental nature. They range from challenging the credibility of the IAC by virtue of its members acting in direct conflict with their official positions with the designer, manufacturer and servicer of Tu-154M aircraft to challenging the IAC investigation and the conclusions of the IAC Final Report in its entirety, as presented by the Republic of Poland in the Polish Response. The Polish objections to the Russian investigation process range from denying the Republic of Poland access to the investigation by preventing the Polish Accredited Representative from participating in the IAC meetings, denying Polish requests for information and assistance, to destroying, falsifying and manipulating the evidence, providing inadequate rescue and medical assistance to the victims of the crash, conducting the investigation in violation of ICAO standards, and drafting the IAC Final Report in violation of Annex 13 to the Chicago Convention. This Status Report does not intend to address all issues arising in connection with the Russian investigation into the Smolensk Crash, but rather highlights the most important problems and the most representative violations.

IAC Investigation Conducted in Violation of International Agreements

Three days after the Smolensk Crash, the Republic of Poland and the Russian Federation entered into an agreement to proceed with the investigation of the Smolensk Crash in accordance with the Chicago Convention. The parties agreed to proceed in accordance with Annex 13 to the Chicago Convention that governs aircraft accident and incident investigation (“Annex 13”). Accordingly, the Russian Federation as the State of Occurrence was in charge of conducting the investigation while the Republic of Poland designated its Accredited Representative to participate in the investigation in accordance with Article 5.18 of the Chicago Convention.

In the course of the investigation, the Polish Government acting through its Accredited Representative filed numerous motions and requests with respect to the investigation in accordance with Article 5.25 of Annex 13. Specifically, the Polish side submitted 222 inquiries for information to the Russian Federation. Only 34 inquiries were answered. The Russian Federation ignored or refused to acknowledge 169 inquiries, and partially answered 19 inquires. As a result of this lack of cooperation from the Russian side, the Polish Accredited Representative and his advisers were unable to fulfil their responsibilities under Annex 13.

Among the motions ignored or refused was a request for information regarding the assessment of the minimum airdrome conditions at the Smolensk airport, a request for video recordings of radar display readings by the Chief Air Traffic Controller on April 10, 2010 with respect to landing approach of the following flights: Il-76, Yak-40, Tu-154M, a request for photographic documentation from the crash scene, a request for data of the fly-around performed soon after the crash, and requests for inspection of communication and navigation aids. The Polish side did not receive any technical expertise of the wreckage debris or any data of two failed attempts of Il-76 landings prior to the crash of PLF 101. A motion to authorize the Polish Accredited Representative and two specialists to take part in the fly-around procedure was denied. A protest against this refusal was ignored as well as the protest against the refusal of the inspection of the RSP-6M2 radar system in Smolensk.

The Republic of Poland as the State having suffered fatalities of its President, First Lady, nine generals and the top leadership, was denied access to the relevant factual information with respect to rescue, first aid, survival data and autopsy examination in direct violation of Article 5.27 of Annex 13. As a result, the Polish side was unable to provide its response to vitally important parts of the IAC Final Report, including sections 1.13 Medical Tracing Examination, 1.14 Data on the Survival of Passengers, Crew Members and Others of the Aircraft Incident, and 3.1. Findings. In particular, the Russian side failed to provide to the Polish side the following information:

1) documentation of forensic examination of the crew of the aircraft, together with the results of toxicological and identification examination;

2) report of the inspection of the site; the Polish side has no knowledge as to where the specific inspection areas were located and how they were marked. [5]

The IAC Final Report provides no information about the rescue actions taken at the scene of the accident. The Polish side has not received any transcripts of communication or situational plans, reports of participants of the rescue and fire fighting teams, photographic documentation, including film footage, which is essential for proper assessment of the security level of Smolensk “Severny” airfield regarding fire fighting services, rescue operations and medical security. The Polish side was not given access to the protocol of surveillance of the location of the occurrence thus was not able to reply to Finding 3.1.67.

Similarly, the Polish side was not in the position to respond to Finding 3.1.68 of the IAC Final Report that the Commander-in-Chief of the Polish Air Forces General Andrzej Blasik was present in the cockpit at the time of the impact with the ground. Furthermore, the Polish Side was not in the position to respond to the statement that the coronary examination revealed 0.6‰ of ethanol in the blood of the Commander-in-Chief of the Polish Air Forces. Results of testing the concentration of alcohol in the blood of the Polish Air Force Commander Blasik cannot be independently verified because of the unavailability of the source documentation. No authorized toxicological data and information as to when and how the material was secured for analysis was provided to the Polish side. [6]

All requests of the Polish side regarding the information with respect to smoke present in the vicinity of the airport on the day of the crash were denied. Regular citations made by the meteorologist from 4.00 a.m. UTC indicated the presence of smoke. The Polish inquiry as to the source of fires and smoke in the area surrounding the airport at the time of the crash and its adverse effect on atmospheric conditions was ignored as well. No information about the rescue and extinguishing of fires was provided. No reports regarding testing for traces of explosive materials were provided. Testing for non-conventional explosions were not made.

Only 19 full post-mortem reports were provided; the remaining 77 are either grossly inaccurate or not provided. Medical and pathological reports for some victims contain descriptions of organs that had been surgically removed from the victims long before the crash. [7]

The list of 169 Polish requests unanswered by the IAC as of December 19, 2010 remained unchanged after the official presentation of the IAC Final Report on January 13, 2010. In August 2011, the Polish side officially confirmed that no additional information regarding the outstanding 169 Polish inquires has been received from the Russian Federation. [8]

IAC Final Report Does not Comply with Annex 13

The Polish Response to the IAC Final Report the Republic of Poland points out that the IAC Final Report violates the standards of Annex and has been prepared in violation of the guidelines contained in the ICAO Document Number 9756 entitled 'Manual of Aircraft Accident and Incident Investigation,' (“ICAO Investigation Manual”). According to Annex 13, the first chapter of the final report, entitled “Factual Information,” should contain only facts; while the analysis should be included in the second chapter entitled “Analysis.” Thus, the Republic of Poland objects to the inclusion of the so-called ‘psychological analysis’ as “Factual Information.” The psychological analysis presented in this chapter is not based on facts and is not supported by evidence. To the contrary, it is based on assumptions of highly speculative nature and stands in contradiction to the Cockpit Voice Recorder (“CVR”) readings obtained by the Polish side. [9]

Furthermore, contrary to ICAO Investigation Manual, the analysis presented in the second chapter of the IAC Final Report is based on assumptions and hypotheses rather than facts and relevant evidence presented under “Factual Information.” Hypotheses not supported by facts should have been abandoned. Unfortunately, the hypotheses based on assumptions were not abandoned, but instead were presented without conditional clauses as explained in the Polish Response below:

The analysis should examine the evidence already presented in Chapter 1. Factual Information, and develop circumstances and situations that might occur. This should lead to the formulation of possible hypotheses that should be discussed in the context of the evidence gathered. Hypotheses unsupported by evidence should be rejected. Hypotheses may not be treated as certainties, and their proof may not rely on hypothetical evidence. The listed items are presented as statements in the form of axioms; and conditional expressions, such as likely, possible, etc., were not used even once. The analysis contains many repetitions as well as references to many facts that were not included in the Factual Information. It does not focus on the description of possible variants of the course of action and the assessment of the course of individual flight sequences. The activities of the Flights Management Group were not evaluated neither the impact of decisions taken outside the Flights Management Group on these activities. It mainly focused on proving that the activities of the controllers at the traffic control were correct. [10]

While the analysis of the psychological pressure presumably exerted on the Polish pilots by third persons was based on speculations not supported by any evidence contained in the Factual Information of the IAC Final Report, the analysis of psychological pressure exerted on the Russian air traffic controllers on the ground was entirely disregarded. The outside psychological pressure on the Russian Chief Air Traffic Controller (“CATC”) – who was the only person suggesting that the Tu-154M aircraft should be sent to an alternate aerodrome but was overruled by a third person present in the Flight Control Tower (“FCT”) – was not even mentioned. The IAC merely stated that the activities of the FCT controllers were correct.

The psychological pressure exerted by persons present in the FCT but not belonging to the Flights Management Group on the decision making process of the Smolensk 'Severny' controllers was not evaluated by the Russian side at all. After the official presentation of the IAC Final Report, the IAC, under pressure from the Polish side, published additional transcripts from the recording that confirmed the Polish allegations that a third person not belonging to the Flights Management Group was present in the FCT at the Smolensk 'Severny' airfield on April 10, 2010. [11] The presence of a third person in the FCT represents an important piece of factual information that shall be included in any accident investigation report. A full analysis of the situation at the Smolensk 'Severny' FCT should be carried out as part of the official IAC investigation in accordance with Annex 13. The analysis should evaluate the influence of that third person present in the FCT over the decision making process of the CATC.

Furthermore, the analysis presented in the IAC Final Report does not include any analysis of possible alternative courses of action and does not present any assessment as to the course of individual flight sequences. Such examination of alternative scenarios is indispensable in arriving at the final conclusion with respect to the causes of any crash.

The first chapter of the IAC Final Report emphasizes "psychological analysis" but does not address the history of the flight. According to Annex 13 and the ICAO Investigation Manual, the history of the flight should contain reconstruction of the significant portion of the flight path and location.

In violation of article 2.25(h) of Annex 13, the Accredited Representative of the Republic of Poland was not allowed to inspect the expert report on the activities of the group directing flights on 10 April 2010.

Violation by the Russian Federation of Rules and Procedures of the Chicago Convention, its Annexes and ICAO Regulations

Flight Management Group

In the IAC Final Report the Russian Federation states that the Chief Air Traffic Controller Pavel Pliusnin and Landing Zone Controller Viktor Ryzenko [12] underwent medical examinations and were authorized to perform air traffic control functions by a doctor on duty at the medical point JW 06755. According to the statement given to the public prosecutors of the Russian Federation on 10 April 2010, the medical point was closed at that time. Both controllers decided themselves that ‘there were no obstacles to fulfil their duties’ judged on their well-being. In his statements made before the public prosecutor on April 10, 2010 between 2 and 4 PM, the Landing Zone Controller stated that the medical unit was closed at the time. The statement also contains the following text:

“I felt good on 10 April 2010. Around seven o'clock that day, Pliusnin and I underwent a medical examination at the Military Health Facility unit 06755: [ Translator's Note: before the word “underwent” the word “did not” is added / as a result of which it was concluded that I was in good health / Translator's Note: the deleted words are deleted in the original protocol], since there was nobody at the medical unit, but as I already stated, I felt good and nothing happened that would affect my ability to carry out my official duties.” [13]

The Polish side pointed out that above statement is inconsistent with Par. 1.5.3 of the IAC Final Report entitled “Details of the ground crew.” In the table regarding CATC under “Medical examination before shift” the following text appears: At 05:15, authorised for air traffic control by the doctor on duty of Military Unit 06755, while in the table regarding Landing Zone Controller under "Medical examination before shift" the following text appears: At 06:50, authorised for air traffic control by the doctor on duty of Military Unit 06755. [14]

The IAC disregarded the vital information as to the eligibility of the CATC to perform his duties at the airport that day. There is no record that the Air Traffic Controller was authorized to work in difficult meteorological conditions. During questioning by the IAC on 18 April 2010, the Air Traffic Controller admitted it was only his second time in this role ever at the Smolensk airport. His first ever shift took place on April 7. Within the 12 month prior to this accident, he had undertaken this role only nine times altogether. Again, there is no documentation provided as to whether the Landing Zone Controller had ever been trained or authorized to operate and supervise the Precision Approach Radar RSP-6M2 System in Smolensk.

A Third Person in the Flight Control Tower

The assessment of the role of Colonel Krasnokutsky at the Flight Control Station in Smolensk during the landing of the Tu-154M PLF 101 presented in the IAC Final Report contradicts the evidence and therefore is disingenuous and wrong. According to the IAC Final Report, Deputy Chief of Military Unit 21350 Colonel Krasnokutsky was delegated to the Military Unit 06755 “for the purposes of organizational control and assistance to the head of this Unit (who was not an aviation specialist) with arriving VIP flights on April 7 and 10. Actually this person from April 2 to April 10 was delegated the functions of coordination and control of all aerodrome services involved in accepting the arriving flights.” [15] The Russian side further claims that:

During the flights of 10.04.2010, according to the ATC recorder and his [Krasnokutsky] own explanations, this person was at the BSHP [ACT Near Control Place] from time to time (including the time of the accident) providing general coordination of various services, informing (by phone) of different officials on the actual situations concerning the accepted flights and weather conditions as well as coordination of alternate aerodromes. He was not directly involved in the air traffic control. [16]

The Polish side responded to the above statement as follows:

According to the recordings (reel 9 channel 4) he [Colonel Krasnokutsky] took an active part in conducting radio communications, despite several suggestions from the CATC to discontinue the approach of the Tu-154M aircraft by a clear command “Allowing them till 100 m only, 100 m no questions” and cuts off any further attempts of CATC to send the aircraft to a reserve aerodrome.

Clearly, Colonel Krasnokutsky was the most active member of the ground crew who talked directly to the Polish pilot and not only gave him detailed reports about the aircraft position and the situation at the airport but also made the critical final decision to bring the airplane down to 100 meters. According to the Polish side, the active role of Colonel Krasnokutsky in directing the flight that interfered with the decision of CATC requires a psychological evaluation of the situation at the FCT. The role of Colonel Krasnokutsky in the decision-making process not to send the Tu-154M aircraft to an alternative airport should be closely scrutinized. Numerous requests of the Polish side for information on the authorization of Col. Krasnokutsky to direct the flights at the FCT Near Control Place in Smolensk on April 10, 2010 were ignored by the Russian side. [17] Furthermore, the Russian side refused to provide any information about another person with whom Colonel Krasnokutsky had spoken via cell phone during the landing of the Tu-154M aircraft.

Continue to part 2

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Footnotes

[1] According to the “Head” Instruction that governs the transportation of the officials of the Polish Republic such as the President, Prime Minister, Chairperson of the Lower House of the Parliament and the Senate, the designation “PLF 101” mean that the President is on board.

[2] This Status Report was prepared by a multidisciplinary team of experts that supports the families of the Smolensk victims.

[3] No attempts by the Polish Government have been made to translate the Polish Response to the R3ussian investigation into English. It is entirely up to non-governmental organizations and private persons that the Western reader can learn of this official Polish Response and confront the scope of irregularities of the Russian investigation into the Smolensk Crash.

[4] Sponsors of the English translation of the Polish Response (“Polish Response in English”) are: The Katyn 2010 Family Association, Ul. Chełmżyńska 98C, 04-247 Warszawa, Poland, Mobile (Poland): +48 784 756 531 Mobile (UK): +44 793 555 7562; +44 796 936 2341 e-mail: polish.remarks@gmail.com.

[5] The Polish Response in English, p. 60.

[6] The Polish Response in English, p. 143. In January 2011 IAC published on its website a document nr. 37 dated April 11, 2010 that purportedly represents testing of Gen. Błasik's blood. Medical experts point out that a natural alcohol is produced in the body within 24 hours from death and can reach even 1 percent. Therefore other tests are required to verify such findings. However the Russian side did not produce any other tests and did not present supporting documents. See also: www.rp.pl/artykul/593062_Ekspert--Blasik-niekoniecznie-pil.html and www.naszdziennik.pl/index.php?dat=20110131&typ=po&id=po51.txt and http://www.naszdziennik.pl/index.php?dat=20110115&typ=po&id=po02.txt

[7] See also:
http://wiadomosci.gazeta.pl/wiadomosci/10,114927,10009206,_Rosja_nie_przekazala_pelnej_dokume ntacji_dot__sekcji.html http://www.rmf24.pl/raport-lech-kaczynski-nie-zyje-2/fakty/news-parulski-kompletne-materialy-z- sekcji-tylko-18-ofiar,nId,319018

[8] Official Statement of the Polish Ministry of Internal Affairs of August 2011.

[9] See further discussion under 'Contradictions in the IAC Final Report.'

[10] The Polish Response in English, page 101.

[11] The fourth microphone track represents recordings from the open microphone at the Near Control Place of the Flight Control Tower.

[12] CATC Assistant W.W. Lubancev was also on duty that day.

[13] Polish Response in English, p. 33.

[14] Ibid.

[15] IAC Final Report, English translation, p. 128

[16] Ibid.

[17] The Polish Response in English, pp. 111, 113, 114.