WASHINGTON (AFNS) -- The Air Force released June 7 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, April 3, 1996.
The aircraft, carrying a delegation from the Department of Commerce led by Secretary of Commerce Ronald H. Brown, crashed into a mountainside while attempting an instrument approach into the Cilipi airport near Dubrovnik. All 35 people aboard the aircraft were killed.
The investigation into this accident was an exhaustive and collaborative one. More than two dozen civilian and military technical experts assisted the board. The board conducted 150 interviews, obtained more than 3,200 pages of testimony and conducted extensive analyses of airborne and ground-based radar magnetic tapes and of the aircraft's instrumentation.
The accident investigation board was headed by Maj. Gen. Charles H. Coolidge Jr., commander of the 22nd Air Refueling Wing, McConnell Air Force Base, Kan., and representatives of the National Transportation Safety Board and the Federal Aviation Administration. 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. 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 U.S. Air Forces in Europe, 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, 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, or ADFs, 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 the crew was 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, or 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 (KLP) nondirectional beacon as the navigational aid providing the course guidance, but the approach was designed using both KLP and the second beacon (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 automatic direction finders 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 the investigation, including all testimony and exhibits, in full, was provided to the families of those lost in this tragic accident and to the public. In addition, Air Force briefing teams met separately 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 and Air Force level, and throughout DOD, 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 USAFE commander 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.
--- Air Force 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 directed the Chairman of the Joint Chiefs of Staff to ensure lessons learned are shared among all services.
Finally, Gen. Michael Ryan, the USAFE commander, has appointed Maj. Gen. Tad Oelstrom, 3rd Air Force commander, RAF Mildenhall, England, 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.