Air Force Releases Brown Crash Investigation Report
By Linda D. Kozaryn
American Forces Press Service
WASHINGTON, June 13, 1996 A combination of mistakes caused the April 3 CT-43 jet crash in Croatia that killed Commerce Secretary Ron Brown and 34 others, according to an Air Force investigation board.
Calling the board "detailed and thorough," Defense Secretary William J. Perry said its report shows no single cause of the crash, but that several mistakes occurred simultaneously. The board findings, announced June 7, blamed the crash on a failure of command, aircrew error and an improperly designed instrument approach procedure.
President Clinton said the Air Force was thorough, prompt and brutally honest in its investigation. Gen. Ronald R. Fogleman, Air Force chief of staff, and Maj. Gen. Charles H. Coolidge Jr., head of the investigation board, briefed Clinton on the findings prior to public release.
"The American people should feel reassured that the top leadership of the Air Force got to the bottom of this, did it in a hurry and was completely honest with no back-covering at all in its straightforward report on this accident," Clinton said.
Military and civilian aviation experts from the National Transportation Safety Board, the Federal Aviation Administration and Croatian Civil Aviation authorities made up the board. They conducted more than 150 interviews, obtaining more than 3,200 pages of testimony. They also analyzed airborne and ground-based radar magnetic tapes and aircraft instrumentation records.
"As with any mishap, the investigation uncovered a chain of events and decisions which, if broken, would have prevented this tragedy," said Air Force Secretary Sheila Widnall during a Pentagon news conference.
The CT-43, the military version of a Boeing 737 aircraft, was part of 76th Airlift Squadron, 86th Airlift Wing, Ramstein Air Base, Germany. The jet was carrying a delegation of Commerce Department employees and American business leaders on a trip to the Balkans to help with the economic restoration following civil war in Bosnia-Herzegovina when it crashed.
"Those who perished were on a noble mission to restore hope and a normal life to the people in the Balkans," Widnall said. "Their work and their vision for that war-ravaged land represents the best of America."
After visiting troops at the American headquarters in Tuzla, Bosnia, the delegation was on its way to Dubrovnik, Croatia, to meet with U.S. and Croatian officials when the aircraft crashed into a mountainside while attempting an instrument approach to Cilipi airport. Air Force officials said instrument approach procedures are used when visibility is limited. They enable pilots to fly to a fixed point from where they can see the air field, officials said.
The instrument approach flown by the CT-43 aircrew should not have been flown, the board concluded. Investigators said wing leaders failed to comply with directives requiring prior review of instrument approach procedures not approved by DoD.
"Prior to 1994, non-DoD approaches were routinely flown by the Air Force," Coolidge said. "A change in the directive in 1994 required major commands to review non-DoD approaches such as the procedure for Dubrovnik for their accuracy and reliability prior to their use. The 86th Airlift Wing routinely went into many airfields in Eastern Europe that do not have the DoD-approved approaches."
The wing requested a waiver to continue flying non-DoD approaches at European airports without review, Coolidge said. While awaiting a formal reply to the waiver request, U.S. Air Force Europe officials told wing leaders they could continue to fly the approaches. In January 1996, however, Headquarters, U.S. Air Force, denied the waiver request, and U.S. Air Force Europe withdrew their permission to fly the approaches.
But "the wing chose to continue using non-DoD approaches," Coolidge said. "Based on a history of using the approaches for years, the wing leaders erroneously believed the approach procedures to be safe. The day after the accident the wing rescinded the aircrew authorization to fly non-DoD approaches."
Prior to public release of the report, the 17th Air Force commander relieved the three top 86th Airlift Wing officers due to the investigation, according to Air Force officials.
Aircrew errors also contributed to the crash, investigators reported. During mission planning the crew failed to note the Dubrovnik approach required two automatic direction finders. The CT-43 had only one. An error in planning the route added 15 minutes to the planned flight time and may have caused the crew to rush the approach.
According to the report, the pilots did not properly configure the aircraft for landing before starting the final approach. They came in 80 knots above final approach speed, without clearance from the tower. The rushed approach, late configuration and a radio call from a pilot on the ground distracted the crew from adequately monitoring the final approach, which proved to be nine degrees left of the correct course, Coolidge said.
The pilots also failed to identify the missed approach point. If they were unable to see the runway at that point, they should have executed a missed approach. If they had done so, they would have turned away into a holding pattern and would not have hit the mountain, which was more than a mile past the missed approach point.
An improperly designed instrument approach for Dubrovnik also contributed to the crash, according to the report.
Weather was not found to be a substantial contributing factor in the crash, the board reported, even though weather conditions required the crew to do an instrument approach.