What happened
On a multi-leg flight originating from Warsaw, a CASA C-295 was traveling toward Krakow with several intermediate stops. The aircraft was carrying a crew of four and 36 passengers, many of whom were returning from the 50th Annual Aviation Safety Conference. Following passenger deplaning at Powidz and Poznań-Krzesiny, the flight continued toward Mirosławiec.
During the night approach to Mirosławiec, the aircraft encountered challenging weather characterized by mist, a ceiling of only 300 feet, and visibility reduced to 2 sm. The aircraft's approach was unstable; while on short final, it descended at a rate of 6,000 feet per minute with a speed of 148 knots. The aircraft struck trees approximately 1,300 meters before the runway threshold and caught fire upon impact. The crash resulted in 20 fatalities, leaving no survivors among the occupants.
Findings
Investigations revealed that the crew experienced an inadvertent loss of spatial and situational awareness during the final stages of the precision approach. This led to an unmonitored increase in bank angle and a subsequent loss of altitude as the pilots attempted to establish visual contact with the runway lights. Several contributing factors were identified:
- Inadequate crew training and experience: The pilot in command lacked experience with this specific version of the CASA C-295, which featured different GPS/IRS configurations. Additionally, the second in command was not rated for night or IMC operations in this aircraft type.
- Equipment and technical issues: The EGPWS audio warnings were inactive because the crew had failed to perform a required pre-flight test. Furthermore, the lack of certain cryptographic modules in the onboard GPS units forced the crew to rely on handheld Garmin receivers. The airport's ILS was also inoperative at the time.
- Operational errors: There were significant discrepancies in altimeter settings between the pilots and the controller, as well as a failure to monitor radio-altimeter indications. The air traffic controller provided inconsistent instructions and failed to properly manage the approach parameters.
- Environmental and procedural factors: Poor weather conditions and the use of non-standard instrument approach procedures at the military airfield contributed to the unstable flight path.