Investigation Summary
The accident occurred during a multi-leg flight across Poland. The aircraft, tail number 019, was a newer 'PO 02' series C-295M equipped with EGPWS and LN-100G inertial platforms. However, the GPS cryptographic modules required for the LN-100G were missing, rendering the integrated navigation system inaccurate and forcing the crew to rely on a handheld Garmin GPSMAP 196. During the approach to Mirosławiec, the crew faced a 300-foot cloud ceiling and mist. The Precision Approach Radar (PAR) controller, who was primarily experienced with Su-22 fighters, provided inconsistent instructions and failed to correct a significant glide slope deviation. Inside the cockpit, the crew failed to perform the EGPWS test before departure, leaving the audio warnings for bank angle and terrain closure inhibited. Discrepancies in altimeter settings (one pilot on QNH, the other on QFE) and the use of different units (feet/hPa vs meters/mmHg) further degraded situational awareness. In the final 12 seconds of flight, both pilots likely looked outside for visual cues, neglecting their instruments as the aircraft rolled into a steep bank and descended rapidly into the forest, impacting 1,300 meters short of the runway and 320 meters to the left of the extended centerline.
Final Conclusions
The investigation concluded the primary cause was the inadvertent loss of spatial and situational awareness by the crew during the final stages of the PAR approach. Contributing factors included poor crew resource management (CRM), improper flight crew selection (the First Officer was not rated for night/IMC operations), and the inhibition of the EGPWS audio warnings. The investigation also cited deficiencies in the air traffic controller's performance, the inoperative ILS at Mirosławiec, and the lack of standardized ICAO instrument approach procedures at Polish military airfields.
Video Analysis
CZARNA SERIA #2 KATASTROFA W MIROSŁAWCU — A detailed look at the 2008 Mirosławiec air disaster involving a Polish Air Force CASA C-295M, focusing on the weather conditions and crew errors.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Had no previous experience on this specific version of the C-295M equipped with EGPWS and LN-100G.
First Officer
Was not rated for night or IMC operations in the C-295M.
Systems & Failure Modes
EGPWS Mark V
Enhanced Ground Proximity Warning System; audio warnings were inhibited during the flight because the crew missed the pre-flight test, preventing alerts for excessive bank angle and sink rate.
LN-100G IRS/GPS
Inertial navigation platforms that lacked cryptographic modules, meaning they operated without GPS correction, significantly reducing accuracy.
Precision Approach Radar (PAR)
A ground-based radar system used to guide pilots to a landing; the controller failed to provide consistent guidance and allowed a non-stabilized approach.
Interesting Facts
- 01The aircraft was nearly new, having been produced in July 2007 (MSN S-043) and logging 399 flight hours.
- 02All 20 victims were Polish military personnel, including Brigadier General Andrzej Andrzejewski.
- 03The flight was a multi-leg transport mission starting in Warsaw with 45 people on board; 25 passengers deplaned at intermediate stops.
- 04The EGPWS audio warnings were inhibited because the crew failed to perform the required system test before departure.
- 05The aircraft impacted the ground with a descent rate of approximately 6,000 feet per minute and a 76-degree left bank.
- 06The ILS system at Miroslawiec Air Base was inoperative at the time of the accident.
- 07The crew used a handheld Garmin GPSMAP 196 because the aircraft's integrated GPS lacked cryptographic modules.
Safety Actions & Advisories
Personnel Dismissals
The Polish Defence Minister dismissed five air force personnel following the investigation's findings of multiple failings.
Fleet Inspection
A temporary flight ban was issued for the C-295M fleet until technical efficiency inspections were completed.