The Air Force today released the report of the Accident
Investigation Board convened to determine the relevant facts and
circumstances and the cause of the crash of an Air Force
CT-43A aircraft near Dubrovnik, Croatia, on April 3, 1996. The
aircraft, a military version of the Boeing 737-200 passenger
aircraft, was carrying a delegation from the Department of
Commerce led by Secretary Ronald H. Brown. It crashed into a
mountainside while attempting an instrument approach into the
Cilipi airport near Dubrovnik. All 35 persons aboard the
aircraft were killed.
The investigation into this accident was an exhaustive and
collaborative one. The accident investigation board was headed
by Maj. Gen. Charles H. Coolidge Jr., and included
representatives of the National Transportation Safety Board and
the Federal Aviation Administration. More than two dozen
civilian and military technical experts assisted the Board. The
board conducted 150 interviews, obtained over 3,200 pages of
testimony and conducted extensive analyses of airborne and ground-
based radar magnetic tapes and of the aircraft's instrumentation.
The board president found that this accident was caused by a
failure of command, aircrew error, and an improperly designed
instrument approach procedure.
Command failed to comply with governing directives from
higher headquarters. Air Force directives require prior review
of instrument landing approach procedures not approved by the
Department of Defense (DOD). The major command is required to
conduct such a review for safety, accuracy, and obstacle
clearance before a non-DOD instrument approach procedure is used
by Air Force aircraft. The airport at Dubrovnik had such an
approach procedure, and it had
not yet been reviewed by United States Air Forces in Europe
(USAFE), the major command. A waiver to fly non-DOD approaches
for airports in Europe prior to review had been requested on
behalf of the 86th Airlift Wing at Ramstein Air Base, Germany,
and had been denied by Headquarters, U.S. Air Force. Although
informed that the waiver request had been denied, commanders
failed to rescind aircrew authorization to fly the non-DOD
approach procedures without prior review. The instrument
approach flown by the aircrew should not have been flown.
The aircrew made errors while planning and executing the
mishap flight, which, when combined, were a cause of the mishap.
During mission planning, the crew's review of the Dubrovnik
approach failed to determine that it required two automatic
direction finders (ADF) and that it could not be flown with the
single ADF onboard their aircraft. Additionally, the crew
improperly flight planned their route which added 15 minutes to
their flight time. The pilots rushed their approach and did not
properly configure the aircraft for landing prior to commencing
the final segment of the approach. They crossed the final
approach fix flying at 80 knots above final approach speed, and
without clearance from the tower. As a result of the rushed
approach, the late configuration, and a radio call from a pilot
on the ground, the crew was distracted from adequately monitoring
the final approach. The pilots flew a course 9 degrees left of
the correct course. They also failed to identify the missed
approach point and to execute a timely missed approach. If they
were unable to see the runway at that point and descend for a
landing, they should have executed a missed approach no later
than the missed approach point. Had they accomplished this, they
would have turned away from the mountains into a holding pattern,
and would not have impacted the high terrain which was more than
one nautical mile past the missed approach point.
The nondirectional beacon (NDB) approach for Dubrovnik was
not properly designed. This NDB approach did not provide
sufficient obstacle clearance in accordance with internationally
agreed upon criteria. Additionally, the depiction reflected the
first nondirectional beacon (referred to on most aeronautical
maps as KLP) as the navigational aid providing the course
guidance, but the approach was designed using both KLP and the
second beacon (referred to as CV) for course guidance. If
properly designed, the minimum descent altitude (MDA) would have
been higher. The aircraft descended to the incorrectly designed
MDA and impacted the mountain. A properly designed MDA would
have placed the aircraft well above the point of impact, even
though the aircrew flew 9 degrees off course.
In addition to these three causes, the Board president found
that inadequate theater-specific training was a substantially
contributing factor. Although operational support airlift
aircrews in Europe were flying into airfields using non-DOD
published instrument approach procedures, commanders did not
provide adequate theater-specific training on these instrument
approach procedures. Proper training would have better enabled
this aircrew to recognize that they needed two ADFs to fly the
instrument approach into Dubrovnik.
The board president found that the following areas did not
substantially contribute to this accident: aircraft maintenance,
aircraft structures and systems, crew qualifications,
navigational aids and facilities, and medical qualifications.
Although the weather at the time of the accident required the
aircrew to fly an instrument approach, the weather was not a
substantially contributing factor in this mishap.
The complete report of investigation, including all
testimony and exhibits, in full, is being provided to the
families of those lost in this tragic accident and to the public.
In addition, Air Force briefing teams are meeting individually
with each of the families to discuss the results of the
investigation and to answer questions.
The Air Force has worked for and achieved an outstanding
flying safety record over the years. This investigation has
identified problems that need to be fixed and improvements that
need to be made if that record is to be maintained. At USAFE, HQ
USAF, and throughout the Department of Defense, corrective
actions have been and will continue to be taken to address the
issues identified and to minimize further the risk of future
tragedies. Those actions include the following:
-- All non-DOD instrument approaches in the USAFE theater
of operations have been clearly prohibited until reviewed and
approved; additional personnel and resources have been made
available to accelerate the review process; the number of host
nation approaches in DOD flight information publications is being
expanded to provide aircrews with reliable information;
-- USAFE commands have been directed to ensure strict
compliance with Air Force flight directives and to provide
theater-specific training, with emphasis on non-DOD approaches;
-- Operational support aircrews in Europe are receiving
refresher training on instrument procedures, and are receiving
flight evaluations;
-- The commander, USAFE has taken a variety of actions to
improve tasking, command and control of airlift throughout the
command, to improve standardization and evaluation procedures in
the command, and to clarify responsibility and accountability;
-- Croatian and international officials, and the publisher
of the approach have been notified of the instrument approach
design errors for Dubrovnik, and DOD and FAA have published
notices to airmen to give appropriate warnings;
-- The Air Force is examining its regulations process to
ensure consistent guidance and is tasking the Air Mobility
Command to produce worldwide airfield suitability reports and a
summary of airfield restrictions publications which will be
applicable to all Air Force operations.
-- The Air Force will also will establish minimum
equipment standards for all operational support aircraft and
review pipeline training of aircrews to ensure adequacy of world-
wide instrument procedures instruction;
-- As a result of tasking from the secretary of Defense,
the Air Force has reprogrammed $264 million to upgrade/accelerate
passenger aircraft safety equipment installation to include
flight data and cockpit voice recorders and global positioning
systems;
-- The secretary of Defense has directed the chairman,
Joint Chiefs of Staff, to ensure lessons learned are shared among
all services.
Finally, the USAFE commander, Gen. Michael Ryan has
appointed Maj. Gen. Tad Oelstrom, 3rd Air Force Commander, as a
Uniform Code of Military Justice inquiry officer to review all
the facts of this matter and to recommend to him any
administrative or disciplinary actions that may be appropriate.
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