Polish defence minister Bogdan Klich has dismissed five air force personnel after an accident investigation concluded that multiple failings contributed to the 23 January crash of an EADS Casa C-295 transport which killed 20 people, including senior service personnel.
The investigation found that aircraft 019 - one of the air force's two newest C-295s and assigned to its 13th Air Transport Squadron- was fully serviceable at the time of the accident, and that a mix of bad weather, air crew inexperience and air traffic control failings led to its loss near Miroslawiec air base.
As a result of the investigation, the airport commander at Miroslawiec, two air traffic controllers and an officer from the Air Operations Centre have been dismissed, along with 13 Sqn's commanding officer. Several dozen other personnel could also lose their jobs.
The C-295 crew reported in to Miroslawiec control and descended to 8,000ft (2,440m), but received inaccurate information about weather conditions, which included a cloud base of 60-90m and visibility worsening to 3km (1.6nm), with haze and a crosswind. Air traffic controllers also reported altitude in metres rather than feet, as displayed on the C-295's instruments.
© EADS Casa
The crew aborted their first landing attempt, reporting: "We can't see runway lights". During the second approach, controllers gave six commands to come left onto the correct glide path, but failed to give height indications. At 2.8km from the runway the aircraft was 390ft too high, but controllers reported: "019, you are exactly on glide path", prompting the crew to disconnect the autopilot and make a 7° bank to the left.
Following an air traffic control command to change heading, bank increased to 19° and the pilot changed the flap position to 4° - insufficient to correct a now uncontrolled rate of bank, which rapidly increased to 5-6°/s. The report says the crew lost spatial orientation while looking out of the window for runway lights and preparing to land.
An aural ground proximity warning should have been provided as bank exceeded 40°, but remained switched off. The aircraft reached a pitch of 76° and 21° bank at 175kt before its left wing struck the ground 4,260ft short of the runway.
The investigation concluded that the pilot was performing his first flight with the latest version of the C-295, while his co-pilot was not fully trained to operate under instrument flight conditions, and blamed a "temporary" training standard and inadequate documentation. The instrument landing system at Miroslawiec was also inoperative, and its controllers were not trained to handle types other than the Sukhoi Su-22.