–35 American Forces Press Service DOD. “Air Force Releases Brown Crash…Report.” 6-13-96
–35 Baugher, Joseph F. 1973 USAF Serial Numbers. 1-5-2012 revision.
–35 Diehl. Silent Knights: Blowing the Whistle on Military Accidents…Cover-Ups. 2002, 216.
–35 Flight Safety Digest. “Dubrovnik-bound Flight Crew’s Improperly…” July-Aug 1996, p. 1.
–35 Gero, David. Military Aviation Disasters: Significant Losses Since 1908. 1999, 166.
–35 Romzek and Ingraham. Cross Pressures of Accountability: Initiative, Command… 2000.
–35 The News, Frederick, MD. “Plane crash probed; last of bodies removed.” 6-18-1996. 1.
Narrative Information
Baugher: “Boeing T-43A-BN….1149 (c/n 20696) crashed in Bosnia Apr 3, 1996 with Secretary of Commerce Ron Brown aboard. All 35 aboard killed.” (Baugher, Joseph F. 1973 USAF Serial Numbers. 1-5-2012 revision.)
Diehl: “The Pentagon’s ‘airline’ has always been a collection of compromises. Because transporting passengers is not a primary military mission, they take more shortcuts that a ValuJet comptroller….
“The military’s most basic rule is, ‘The mission is first everything else is second,’ while its next basic rule is, ‘No complaining about the first rule.’…
“the young pilots of Ron Brown’s CT-43 (the military version of the Boeing 737 airliner) are intimately familiar with both rules as their jet (call sign IFO 21) penetrates the rain-soaked clouds. Captains Tim Schafer and Ashley Davis also know this is going to be a very tricky approach – at best. But to divert to their alternate destination without at least trying to land would be unthinkable, because they have been ordered to take this mot distinguished visitor and his entourage on this mission. Schafer and Davis know all too well that even questioning the safety of such a mission could be hazardous to their careers. They have witnessed such an object lesson recently.
“Their boss, Lieutenant Colonel James Albrecht, commander of the 76th Airlift Squadron (AS), had discovered this the hard way five days earlier. He had articulated the potential dangers of such missions and was summarily fired! It seems that Albright’s boss, the commander of the 86th Airlift Wing (WG), concluded he was not a ‘team player.’[1] For the men and women of this command, the message was clear – speaking up to protect your passengers and fellow crew members has its costs.” (Diehl 2002, 217.)
“The flight crew of IFO 21…had problems with their maps. Our military fliers normally rely on aeronautical maps and charts produced by the U.S. government. Most airline pilots the world over use products sold by a private company, Jeppesen Sanderson, Inc. These ‘Jepps,’ as they are called, basically depict the same information as their government-issue counterparts. Airlines use Jepps because they are easier to read….This flight was using the Jepps, instead of the usual military maps, because they are the only maps available for places like Dubrovnik….
“Tragically, the Croatian government has miscalculated an important piece of information on the Dubrovnik airport map. The so-called minimum descent altitude (or MDA) is too low by several hundred feet. This critical cartographic inaccuracy, when combined with even a small navigational error – namely, a slight deviation left of the proper course – can put an unsuspecting aircraft into the nearby mountains. Had the USAFE properly surveyed this airport, it may have detected the Croatian government’s blunder….” (Diehl 2002, 218.)
“But Captains Schaefer and Davis know that as military ‘crew-dogs,’ they will be expected to shut up, salute smartly, and make it happen, for they have no union, no ombudsman – and no way of getting out of this dangerous dilemma. Interestingly, when it comes to military aviation, the more senior the passengers, the more the pressure and the less the safety.” (Diehl 2002, 219.)
“The crew has had to cope with four mission changes in as many days. Copilot Schafer had his sleep interrupted repeatedly the night before. Things had not gone well on the previous flight to Tuzla. They were running behind schedule because their passengers had arrived late. While inbound to Tuzla, the crew had to be reminded by the controllers that they were well left of the final approach curse. The Tuzla controllers used their radar to detect this dangerous deviation, but there is no radar installed at Dubrovnik….
“On their final flight from Tuzla to Dubrovnik, things go from bad to worse. The pilots mistakenly begin this leg on the wrong airway. Such errors are more common for fatigued and overstressed fliers. Fortunately, the controllers also catch this embarrassing gaffe, but the crew falls fifteen minutes behind schedule while correcting its navigational error. They also know the U.S. ambassador and the prime minister are waiting on the ground at Dubrovnik to meet the commerce secretary and their other distinguished passengers.
“What is worse, the Dubrovnik weather has continued to deteriorate. The clouds are descending, and thee are significant crosswinds and rain. The cloud ceiling is now only five hundred feet above the airport. This altitude is more than one thousand feet below the lowest level to which the pilots can legally descend, the so-called MDA. Because the ceiling is so low, if this were a civilian airline flight, regulations would prohibit the crew from even attempting this non-precision approach. But Captains Davis and Schafer don’t have that out.” (Diehl 2002, 219-220)
“….Pilot Davis, who is flying, allows his speed to get one hundred miles per hour too fast, as the CT-43 screams over the first beacon. Furthermore, he has not configured his craft for landing by properly extending the wing flaps and landing gear. To make matters worst, he is on the wrong course. He is nine critical degrees left of the proper track and heading directly toward the towering mountains just north of his intended flight path. But this is difficult for him to discern in the clouds with his craft’s limited instruments….
“The only persons who can salvage this predicament is the man in the right-hand cockpit seat, copilot Schafer. But he is so fatigued that he has not adequately challenged any of these deviations. And like Davis, he is very confused….Like his aircraft commander, he cannot figure out their position in relation to the airport….” (Diehl 2002, 221)
“Enlightened safety professionals always advocate proactive prevention measures. But some organizations, such as the Pentagon, tend to wait until after a major catastrophe has occurred before even considering safety enhancements. These types of reactive measures are sometimes called ‘tombstone mandates’.” (Diehl 2002, 223)
Flight Safety Foundation.
“On April 3, 1996, the crew of the U.S. Air Force CT-43A (Boeing 737-200) was flying a nondirectional radio beacon (NDB) approach in instrument meteorological conditions (IMC) to Runway 12 at the Cilipi Airport, Dubrovnik, Croatia, when the aircraft collided with a 702-meter (2,300-foot) mountain. All six crew members and all 29 passengers were killed in the accident….
“The crew’s mission was to transport U.S. Department of Commerce Secretary Ronald H. Brown and a delegation of U.S. industry executives from Zagreb, Croatia, to various locations in Bosnia-Herzegovina and Croatia during a three-day period. The accident occurred on the first day, on the fourth leg of a five-leg trip.
“The itinerary was changed four times before the flight began. The crew planned the mission on April 1 (two days before the accident flight), based on the information in Change 1 to their itinerary. A stop in Dubrovnik was not listed in the change….” (FSF 1996, 1)
“At 1247, the aircraft landed at Tuzla, where the passengers reboarded. ‘The (Department of Commerce) added two Croatian nationals to the party, bringing the total passengers to 29.’…The accident flight departed Tuzla for Dubrovnik at 1355….” (FSF 1996, 4)
“At 1450, the pilot of a Croatian aircraft on the ground at Dubrovnik radioed the accident crew and asked the crew to contact him on a frequency of 123.47 megahertz (MHz)). (This was a different frequency from the one being used for the approved tower communication.) The accident aircraft was equipped with two very high frequency (VHF) communication transceivers; therefore the crew could communicate with the pilot on the ground and simultaneously with the tower frequency.
“The pilot on the ground at Dubrovnik had landed one hour earlier with the U.S. Ambassador to Croatia and the Prime Minister of Croatia, who were awaiting the arrival of Secretary Brown. The pilot later testified that he told the accident crew that he had landed one hour earlier, and the weather was at the minimum required for the approach. ‘He (the pilot on the ground) also testified that he told the IFO21 pilot that if he had to execute a missed approach, he should proceed to Split,’ the report said. ‘The (Dubrovnik) pilot testified (that) he conversed with the IFO21 pilot for not more than 20 seconds…” (FSF 1996, 5-6)
“The report noted: ‘The Jeppesen approach procedure for Dubrovnik does not specifically indicate what type of equipment is necessary to fly the entire procedure. However (U.S.) Air Force pilots are responsible for recognizing the factors which go into an approach and determining if the aircraft is properly equipped. If the crew had accurately reviewed the approach procedure, they would have recognized that two ADF receivers were required’.” (FSF 1996, 19)
“Because Jeppesen published the only approach charts for Dubrovnik, the crew should not have flown the NDB approach in other-than-VFR conditions until the approach procedure had been reviewed by a USAFE TERPs [terminal instrument procedures] specialist, the report said.[2]” (FSF 1996, 19)
“The report added: ‘The approach flown by the (accident) crew had not been reviewed by the major command and, in accordance with AFI 11-206, should not have been flown’.” (FSF 1996, 24)
“The report also faulted U.S. Air Force command for failing ‘to provide adequate theater-specific training,’ the report said. ‘This was a substantially contributing factor in the (accident). Knowing operational support airlift crews in Europe were routinely flying into airfields using non-DOD-published instrument-approach procedures, commanders did not provide adequate theater-specific training on these instrument-approach procedures,’ the report said.
“The report concluded: ‘Pilots with a thorough understanding of these non-DOD instrument-approach procedures would have identified the requirement to have two (ADFs) to fly the (NDB) approach into Dubrovnik – one for final-approach guidance and one for identifying the missed-approach point….” (FSF 1996, 24-25)
“FSF CFIT Checklist”
“Flight Safety Foundation (FSF) has designed a controlled-flight-into-terrain (CFIT) risk-assessment safety tool as part of its international program to reduce CFIT accidents. Listed below are some of the risk factors that were identified in the ‘FSF CFIT Checklist’…that are applicable to the Dubrovnik accident:
- No radar coverage available for the approach;
- Airport located in or near mountainous terrain;
- Nondirectional radio beacon approach;
- Controllers and pilots speak different primary languages;
- Arrival airport in Eastern Europe; and,
- Instrument meteorological conditions during approach.” (FSF 1996, 18)
(Flight Safety Foundation. “Dubrovnik-bound Flight Crew’s Improperly Flown Nonprecision Instrument Approach Results in Controlled-flight-into-terrain Accident.” Flight Safety Digest. July-August 1996, pp. 1-25.)
Gero: “…Near Dubrovnik, Croatia….
“This mission of economic revitalization of a war-torn nation would end in tragedy on a rocky mountainside due to a series of errors by an experienced flight crew and flaws reaching into the upper levels of the Air Force command structure.
“The aircraft involved had been converted from a navigational trainer so as to have passenger-carrying capability. Having taken off earlier from Tuzla, on the next to last segment of a five-leg flight to various locations within Bosnia-Herzegovina and Croatia, the twin-engine jet was to have landed at Cilipi Airport, serving Dubrovnik, but it crashed and burned during the final phase of a non-directional beacon (NDB) instrument procedure approach to Runway 12.
“Including a crew of six military personnel, all 35 persons aboard were killed; the other occupants consisted of a contingent of American business officials, headed by US Secretary of Commerce Ron Brown. Searchers found in the wreckage one passenger showing signs of life, but she was pronounced dead after being taken to a hospital.
“With its undercarriage extended and flaps set at 30 degrees, the CT-43 had slammed into St John Hill at an approximate elevation of 2,200ft (670m), or only about 100ft (30m) below its summit, 2 miles…to the left of the runway threshold. Impact speed was calculated to have been approximately 170mph (270kph).
“At the time, the meteorological conditions in the area consisted of a low overcast, with broken clouds at 400ft (120m) and solid coverage at 2,000ft (600m), and a visibility of about 5 miles (10km) in light rain. The wind at ground level was from a direction of 120 degrees at 12 knots.
“The investigation of the crash was conducted without the use of either a flight data recorder or a cockpit voice recorder, which normally would have been installed on an equivalent civil jet transport, relying instead on examination of the wreckage and reconstruction of the aircraft’s flight path.
“Although the flight of 73-1149 from Tuzla was actually slightly ahead of schedule, this was somewhat disrupted when the crew attempted to take a course through restricted air space, which resulted from improper planning on their part. This mistake was corrected by an air-traffic controller in an E-3 Airborne Warning and Control System (AWACS) aircraft, but the re-routing of the flight added some 15 minutes to the trip.
“During its descent in preparation for landing, the aircraft’s air speed was too high for the application of the correct flap setting, as required by Air Force directives, but instead of entering a holding pattern in order to effect such stabilization, the pilots began their approach to the runway without clearance from the controlling air-traffic facility, also in violation of prescribed procedures. Clearance was obtained following passage of the final approach fix (FAF), but the speed at the time remained around 90 to 115mph (145-185kph) above the norm.
“From the FAF to the point of impact, 73-1149 maintained a heading of 110 degrees, a deviation from the correct course of 119 degrees. When considering the 25-knot wind blowing from a south-easterly direction at the flight altitude, a course correction of 6 degrees would have been required, with the crew using the aircraft’s radio magnetic indicator and setting the heading ‘bug’ on its horizontal situation indicator to 125 degrees. The ‘bug’ was in fact set at 116 degrees, and the pilot’s course select window also indicated the wrong bearing.
“Whereas the NBD procedure at Dubrovnik required two automatic direction finder (ADF) receivers, examination revealed the single unit with which the CT-43 was equipped to be tuned to the FAF beacon, designated ‘KU’. The crew could not have identified the missed approach point without a second ADF, and the tuning of the same receiver to different beacons during a final approach would not have been allowed under Air Force regulations.
“Examination of the ground-proximity warning system (GPWS) installed on 73-1149 indicated that it did not activate at any time prior to impact, this because it was not designed to respond to this combination of terrain profile, aircraft configuration and flight path. The system would in fact have been desensitized when the aircraft’s undercarriage and flaps were extended, so as to avoid false alerts. (It was noted in the accident report that a newer, enhanced GPWS would have provided nearly 40 seconds of early warning to the crew of the CT-43.)
“The fact that both engines were at higher-than-normal power settings at the time of the crash indicated that the crew may have been initiating a missed approach procedure or pulling up after making visual contact with the ground. That the aircraft had even attempted to land at Dubrovnik Airport represented a failing by the Air Force Command to comply with governing directives from higher headquarters, as the non-precision approach procedure being used there had not been authorized. These directives required a review of all instrument approach procedures not approved by the US Department of Defense to consider the overall safety of the procedure, including the accuracy of navigational facilities and obstacle clearance. A waiver had been requested, but was denied by higher authorities. The approach at Dubrovnik was found to be improperly designed with regard to obstacle clearance and featured an excessively low minimum descent altitude. Nor was radar monitoring available there.
“In an effort to reduce controlled-flight-into-terrain type accidents, the US Air Force distributed 100 video tapes on the subject to various flying wings, and also announced the development of a greatly-improved terrain avoidance system for use in some of its aircraft.” (Gero. Military Aviation Disasters: Significant Losses Since 1908. 1999, 166.)
Romzek and Ingraham 2000: “This article analyzes the accountability dynamics facing various military officials involved with the crash of a military transport plane (the military equivalent of a Boeing 737–200) in Dubrovnik, Croatia on April 4, 1996. The flight carried a group of passengers led by U.S. Secretary of Commerce Ron Brown; the Brown party was visiting potential business contacts and sites in Bosnia–Herzegovina. All 35 people aboard the plane died. In this case, the airlift commanders and the pilots were working to accomplish their mission under difficult circumstances. Officers made some decisions and judgment calls reflecting a “can do” approach to problem solving that they knew were inconsistent with directives from headquarters. The resulting “mishap flight” (as it is characterized by the United States Air Force) provides insight into the cross pressures between initiative, command, and accountability.
“To conduct this research, the authors interviewed members of the Accident Investigation Board appointed by Major General Ryan, Commander of the U.S. Air Force in Europe (USAFE), to investigate the crash of the air transport carrying Secretary of Commerce Ron Brown and his entourage to Dubrovnik. In addition to interviews with investigators, we reviewed official reports of the Accident Investigation Board and transcripts of testimony before the Board.” (Romzek and Ingraham 2000, 241.)
“In early 1996, U.S. Air Force Europe (USAFE) and the entire European Theater were struggling with fewer resources and more tasks. Headquarters (HQ) USAFE, other operations at Ramstein Air Base, and other European bases had a pervasive sense of intense tasking tempo, or in the words of one of the former Operations Group commanders of “doing too many things with too few people.” At the time of the crash, Ramstein and other European bases were heavily involved in support activities for both the Bosnian and Saudi Arabian military actions. HQ USAFE staff were distracted by preparation for Operation JOINT ENDEAVOR,[3] including the absence of staff due to frequent temporary duty (TDY) commitments.[4] In the crash investigation, one officer described operations tempo as so intense that, “…[sometimes] it outweighed rational thought.”[5] As one investigator explained it, staff reductions had not been accompanied by infrastructure reductions—in other words, they were expected to do more with less….” (Romzek and Ingraham 2000, 243.)
“Officers seek to avoid situations where they have to tell higher-ups that they cannot accomplish their assigned mission. To do otherwise, to complain about lack of resources or question one’s assignment, is to risk being labeled a “whiner” or “not a team player,” either of which could hurt one’s promotion prospects, or more broadly, damage the image of the service.” (Romzek and Ingraham 2000, 243.)
“Accompanying the shift from fighter wing to airlift duties, the 86th Wing lost wartime (Cold War) urgency as a justification for flying into airports without DoD-approved approach procedures for landing. Prior to this time, the procedures allowed fighter pilots to fly into airports using non-DoD approach procedures when it was deemed necessary.
“The most widely recognized non-DoD source for local host air traffic control approach procedures is a commercial publishing house, Jeppesen, Sanderson, Inc. Jeppesen reformats, translates, and publishes host nation instrument approach procedures utilized by air traffic controllers in the host nation. Even though all major civilian airlines use Jeppesen approaches … Jeppesen procedures were a source of controversy within the Air Force and USAFE.
“In 1994, Air Force headquarters deemed there had been too many approach-related close calls and changed the regulations to require only the use of DoD-approved approaches. An Air Force Instruction (AFI 11-206), issued in 1994, directly addressed the use of Jeppesen approach procedures. It clearly stated that, unless an approach is published by the DoD or the National Oceanic and Atmospheric Administration, it requires an additional Terminal Instrument Procedures Review (TERPS) before it can be flown by an Air Force crew. An exception is allowed if visual flight rules are possible.
“This created a problem for airlift wings because their distinguished visitor duties often required them to fly into airports previously inaccessible to the American military and thus unlikely to have DoD-approved approaches. The former 76th squadron commander, before his departure, advised his Operations Group wing commander that, in his long experience, he had not seen any problems flying Jeppesen approach procedures. The OGC, who had no personal experience with these types of approaches, took this advice as the best available.
“The colonel who served as OGC believed that both the waiver process and the required flight approach review process would severely limit the ability of the Wing to carry out its mission. The flight approach review unit of USAFE was also coping with staff downsizing and task increases, hence they were slow in getting these time-intensive reviews done.
“On November 30, 1994, via email to the USAFE director of operations, the 86th Wing’s OGC requested a blanket waiver (from AFI 11-206) to allow the 86th to fly Jeppesen procedures to the minimums published in Jeppesen, rather than the more conservative minimums contained in the USAFE supplement. An information copy of the email was sent to the commander of the 17th Air Force, who responded—also via email—“I have not approved. Do not go to USAFE for a flying waiver on anything until I have approved” (Report 1996, Tab CC-1.9/5).
“A series of misunderstandings, miscommunications, and decisions to ignore directives followed….In summary form, for about a three-week period the Wing believed that it had permission to fly unchecked Jeppesen approaches (waive AFI 11-206) and announced that position to pilots. The waiver was, however, denied by USAF Headquarters. When notified of this denial, the Wing’s OGC and his staff chose not to rescind the flight control information files, but to continue “ops normal” (meaning that pilots could continue to fly the approaches down to
Jeppesen published minimums).
“The rationale for the OGC’s decision was that not being able to fly Jeppesen approaches would have a severe impact on the unit’s ability to accomplish its mission. And since the approaches had been flown successfully for a long time, safety should not be compromised by continuing to do so (Report 1996, 4443–45). This decision effectively continued the practice of placing the airlift pilots, including those on distinguished visitor missions, in the position of flying into airports never flown or reviewed by the Wing or by other Air Force crews. The colonel who served as OGC noted later that “I expected somebody to come back and tell me if that was the wrong approach” (Report 1996, 4442). In other words, since his superiors were kept informed of their actions via email copies, he assumed they tacitly approved his actions.
“The Mishap Flight
“At the time of the crash, the crew was attempting an instrument landing at an airport without DoD-approved instrument approach procedures. During the attempt, the pilots came in too high, too fast, and without properly configuring the aircraft for landing. The crew had not accurately identified the missed approach point, the aircraft’s flaps were not set for landing, and the aircraft was on a heading nine degrees off course (Report 1996, 23). Any one of these errors might not have resulted in the fatal mishap if adjustment had been made in a timely fashion. In fact, earlier on the same day, the pilots had made some of the same mistakes in their approach to Tuzla without tragic consequences.” (Romzek and Ingraham 2000, 246.)
Operational Discrepancies in Mishap Flight
- The Dubrovnik airport did not have DoD-approved approach procedures. Without these procedures, pilots are only allowed to land when visual landing conditions apply. Weather conditions at the time they landed did not afford visual landing conditions. Weather as the approach began clearly mandated an instrument approach.
- En route to Dubrovnik, the pilots planned their route through air corridors that were closed due to security reasons. They were required to reroute the flight.
- The plane was equipped with only one automatic direction finder (ADF), whose purpose is to receive the signal from the non-directional missed approach point beacon. The Dubrovnik approach required an aircraft to have two ADFs.
- The pilots flew past the final approach fix without Dubrovnik control tower clearance and had to be cleared for final approach after the fact.
- The crew failed to execute a timely missed approach. Procedures require that, if at the time they reach a missed approach point, pilots cannot see the runway, they are directed to pull out of descent, climb, and come around for another approach.
“The plane, which was not on automatic pilot at the time of impact, crashed into a mountain left of the runway and approximately two nautical miles past the missed approach point. The investigation found significant command discrepancies and pilot error.
Command Discrepancies
- The wing commander sought a waiver to the prohibition on use of Jeppesen procedures (in Air Force Instruction 11–206), even though his commanding officer had told him via email that he did not approve the decision to request a waiver.
- Several flight directives contradicted each other.
- Because the supplement to AFI 11–206 also conflicted with the AFI, following the guidelines in the supplement required requesting a waiver from AFI 11–206. The waiver request was denied but the commander decided to continue to allow his crews to fly Jeppesen approaches while he appealed the denial.
- The Air Force was slow in getting information about changes in rules and regulations to the troops.
- Units were slow to provide training and evaluation “check flights” to pilots of the airlift wing specializing in distinguished visitor flights.
- The Air Force had difficulty making timely reviews of approach procedures for those airports needing DoD approach approvals.
- There was inadequate theater-specific pilot training on Jeppesen approach procedures.
“….We turn now to an analysis of the Air Force’s reaction to the mishap flight to gain insight into the accountability expectations and behavioral standards reflected in its official actions….One investigator summed up a key puzzle of the inquiry in this way: “How could professional pilots fly like amateurs all day long?”
“The Air Force Accident Investigation Board concluded that the 86th Wing failed for a variety of reasons, including failure of command to comply with governing directives from higher headquarters, aircrew errors, and improperly designed instrument approach procedures (Report 1996, 71). The Air Force responded to the crash and to these findings in several ways. The Air Force adopted and revised procedures to increase accountability, initiated training and retraining on instrument procedures, adopted new equipment standards, and upgraded equipment aboard passenger aircraft. In addition, the commander of USAFE took a variety of actions to change institutional arrangements that may have contributed to events. The changes were targeted to improve tasking, command, and control of airlift activities, standardization and evaluation procedures, and to clarify responsibility and accountability.
“Some changes reflected the availability of institutional supports. For instance, the Air Force ordered the Air Mobility Command to produce worldwide Airfield Suitability Reports and a Summary of Airfield Restrictions publications (which would subsequently become part of the “rules” under which units operated). The Air Force also established minimum equipment standards for all operational support aircraft and reviewed pipeline training of aircrews on instrument approach procedures. And it reprogrammed $264 million in USAF funds to upgrade/accelerate passenger aircraft safety equipment installation to include flight data and cockpit voice recorders and global positioning systems (which would be helpful in any subsequent mishap investigations)….” (Romzek and Ingraham 2000, 247.)
“Within days of the plane crash the commander of USAFE convened an Accident Investigation Board, staffed with experts in safety, construction, flight standards, air traffic control, theater operations, human factors, propulsion, and so on (Report 1996, 8). The investigation was headed by Major General Charles H. Coolidge, Jr. and, in addition to AF experts, had members of the National Highway Safety Board, Federal Aviation Administration, Boeing Aircraft, and Pratt and Whitney. The Board conducted 150 interviews, obtained over 3,200 pages of testimony, and conducted extensive analyses of radar magnetic tapes and of aircraft instrumentation….” (Romzek and Ingraham 2000, 247-248.)
“Political. Although initially convened as a safety investigation, the inquiry was quickly changed to an accident investigation before key investigative personnel even arrived on the scene. The importance of going directly to an accident investigation is that it limits candidness because of liability concerns. Portions of safety investigation findings are not subject to public disclosure. The decision to pursue an accident investigation, with its greater public disclosure, represented an effort to be responsive to key external stakeholders: the president, Congress, family members of the crash victims, and the general public. The Air Force determined such an effort to be important for public confidence in their ability to investigate AF officers. The Air Force wanted to display this information to the public because it recognized that this was a high-profile case. This was only the second time the Air Force had bypassed the more confidential safety investigation and gone immediately to an accident investigation. The earlier incident was the friendly-fire shootdown of a Black Hawk jet over Iraq.
“Board decision making procedures embodied the principle of responsiveness to key external clientele as well. With a concern that it avoid any appearance of bias, the Board adopted a practice of voting on possible issues for investigation, with the understanding that it had to be demonstrable that an issue was not relevant before the Board would dismiss it. The Board did not want to appear to be quick to dismiss possible explanations.
“Another way the Air Force showed sensitivity and responsiveness to external stakeholders is by publicly announcing the names of some of the officers punished. While privacy is the norm in such disciplinary matters, the Air Force said that it released the names of those receiving the most significant sanctions to demonstrate the “Air Force’s commitment to ensure accountability for, and to learn from, the tragic events of April 3,” and added that “the substantial public interest” had shaped the decision to publicly announce the names…
“While the accountability emphasis expanded to include legal and political types with their emphasis on the need to be cognizant of external stakeholders, reliance on internal accountability relationships intensified as well. The investigation found flaws in the operation of the command system and in individual officers’ judgments, in essence pointing to breakdowns of both hierarchical and professional accountability. The response was to reemphasize the hierarchical command structure.
“Hierarchical. The accident investigation found that USAFE did not have an effective system of command and control as it related to air traffic. For example, the investigative board found that, because of poor communications equipment and control systems, HQ USAFE did not know at any one time where all its airplanes were located. Another example of a breakdown of hierarchical accountability was evident in the board’s finding that the OGC of the 86th Airlift Wing knew that he was doing something that regulations prohibited, that his boss also knew, and that other officers who had complementary duties failed to meet their command responsibilities as well.
“The breakdown of the hierarchical accountability relationships was also evident in the more casual approach to email communications than officers would normally take toward fully staffed and signed reports from a higher up. Email communications typically involved lower level officers communicating with each other and bypassing their commanding officers (COs). The pattern was for subordinates to copy their COs via email to keep them informed, with the expectation that if the CO objected he would surely make those objections known. This practice led officers lower in the hierarchy to believe that decisions had been made by higher authorities when in fact they had not….
“Hierarchical accountability actions are also reflected in the disciplinary actions taken against the various officers found to be responsible for different aspects contributing to the mishap. Major General Michael Ryan, commander of the USAFE and convening authority of the investigation, directed actions against 16 Air Force officers.[6] These reprimands represent judgments by General Ryan that these officers’ reliance on their own judgment regarding flying Jeppesens in the Eastern European theater was inappropriate….
“Letters of reprimand were presented to two other officers for failures of hierarchical or command accountability.[7] Twelve other officers faced disciplinary actions. Four colonels received administrative letters of admonishment. Two lieutenant colonels received administrative letters of admonishment. Two lieutenant colonels received administrative letters of counseling. Two majors received administrative letters of counseling. And two lieutenant colonels received verbal counseling.
“Professional. To the extent that the pilots did not fly in a manner consistent with established practice and flight safety rules, their errors in judgment represent clear failures of professional accountability. Investigators conjecture that the failure of the plane to be appropriately configured for landing was due to the pilots trying to do too many tasks simultaneously as they approached landing. None of the usual navigation adjustments that are typically the responsibility of the copilot had been done by the time of the crash. Investigators think that the copilot was busy talking on the radio instead. In such circumstances, it would have been prudent to execute a missed approach, get their bearings, and take time to properly configure the plane….
“Post-mishap efforts by the Air Force to reinforce the professional credentials and expertise of aircrews are reflected in mandates for refresher training on instrument procedures and flight evaluations for operational support aircrews. USAFE commanders were directed to provide theater-specific training with an emphasis on non-DoD approaches, and operational support aircrews in Europe received refresher training on instrument procedures and are receiving flight evaluations.
“Another example of a vulnerability due to professional accountability is manifested in the improperly designed instrument approach procedure used by air traffic controllers at Dubrovnik. After the mishap both DoD and the Federal Aviation Administration published Notices to Airmen to give appropriate warnings of instrument approach design errors for Dubrovnik….” (Romzek and Ingraham 2000, 248-249.)
Conclusion
“When the plane crash examined here occurred, the military was responding to a routine civilian request. That request pushed them to areas of uncertainty that exceeded personal, professional, and organizational capacity. In this case we see how Air Force officers can get caught between the cross pressures of initiative and command. The circumstances of this case are not unique to the military. Rather, they are conditions that characterize the American political culture and government management generally. While managerial reform rhetoric touts entrepreneurial management, leadership, and worker empowerment as preferred modes of operation, the reality is that the American political culture continues to emphasize a “gotcha” approach to accountability. The American public, which has never been particularly trusting of government, has shown an increasing intolerance for any missteps in government. This gap between the rhetoric of a “can do” mind set and a “gotcha” culture of accountability means that a single error can be fatal to one’s standing or career. This has been the pattern in this case. The mishap was a career-ending incident for at least two commanders. The general in command of the Airlift Wing retired early. The colonel in charge of the Operations Group of Wing retired at rank of major.
“Management reforms in the military, downsizing, reorganizing, and task shifting, have created pressures for entrepreneurial management within the Air Force. The military variation of entrepreneurial management occurs when commanders must figure out ways to be responsive to HQ and get their jobs done. They must do this despite cross pressures between the expectation that they accomplish their mission and operational rules and conditions that severely constrained their ability to fulfill their mission. The wing commanders in this case were caught between regulations that conflicted. The commanders were seeking a way to be responsive to HQ by finding a way to accomplish their mission anyway. In doing so, they used individual discretion to ignore the organizational rules. The commanders of the 86th Wing felt that HQ did not understand the challenges they faced and the conditions under which they worked. Such circumstances often lead to a subculture that views administrative superiors as part of the problem and dismisses their concerns as bureaucratic red tape.
“In accountability terms, this case represents an instance where commanders were seeking to be responsive to some of their key stakeholders, the distinguished visitors they were transporting around the arena, and their own superior commanders. From a career officer’s perspective, when given a mission to accomplish, no officer wants to be the one to say to USAFE, “We can’t do this.” Such actions, even when rarely taken, could affect one’s own performance appraisals, reputation as a team player, and subsequent prospects for promotion. Instead, individuals and groups find ways to accomplish their mission, even if it means ignoring rules on occasion. In this case, commanders made individual judgment calls to ignore rules that conflicted with their operational needs….
“…accountability relationships under which these officers worked did not reflect an emphasis on initiative. Entrepreneurial management, which involves cutting red tape (ignoring rules) and pushing the administrative envelope, necessitates standards of accountability that defer to expertise and encourage responsiveness to key stakeholders. When events went awry, entrepreneurial management and leadership rhetoric were downplayed. These officers were judged by whether they had obeyed commands (hierarchical standard) rather than whether their decisions reflected reasonable exercises of their discretion (professional standard). In essence, while the institutional rhetoric and managerial conditions encouraged entrepreneurial behavior, the administrative reality still emphasized a risk-averse, rules-oriented approach to accountability when things went wrong….
“Families of eight victims in the crash filed a lawsuit against Jeppesen, Sanderson, Inc. in U.S. District Court claiming that the Air Force pilots were misguided by the Jeppesen charts used in the Dubrovnik approach….” (Romzek and Ingraham 2000, 249-250.)
(Romzek and Ingraham. “Cross Pressures of Accountability: Initiative, Command, and Failure in the Ron Brown Plane Crash.” Public Administration Review, 60/3, May/June 2000, pp. 240-253.)
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… though weather conditions required the crew to do an instrument approach.” (American Forces Press Service, DOD. “Air Force Releases Brown Crash Investigation Report.” 6-13-1996.)
Newspapers
June 18, AP: “Dubrovnik, Croatia (AP) — NATO helicopters carried the last body bags off a hillside Friday where Commerce Secretary Ron Brown and 34 others died in a plane crash. Investigators focused their search for a cause on the Dubrovnik airport’s landing guidance system….
“Croatia observed a day of official mourning, with flags at half-staff. State radio played somber music, theater performances were canceled and sports events were ordered to observe a minute’s silence….
“Sunshine broke through Friday after two days of high winds and heavy rains. The wreckage remained scattered above the seaside homes and blue green waters of the Adriatic Sea….” (The News, Frederick, MD. “Plane crash probed; last of bodies removed.” 6-18-1996. 1.)
June 18, AP (Frederick, MD News): “Washington (AP) – Technology dating to the pioneering days of air travel was guiding the jetliner that smashed into a Croatian hillside with Commerce Secretary Ron Brown and 34 others aboard. “It is the kind of an approach (system) that’s been around for a while, there’s no question about that,” Air Force Lt. Gen. Howell Estes III said of the landing at Dubrovnik. “But it’s still a very valid approach.”
“Yet Ward Baker of the Air Line Pilots Association pointed out that the radio beacons used to guide airplanes to Cilipi Airport are “the oldest type of navigation aid there is.”
“U.S. and local officials said the airport was missing a more modern piece of computerized precision landing equipment, taken by the Yugoslav army in Croatia’s 1991 war, that would help planes to land in any weather.
“Thus, the Air Force T-43 was following a low-frequency radio beam through a battering thunderstorm Wednesday toward the airport nestled between mountains and the Adriatic Sea. Veering off course between the airport’s two radio beacons, the [plane] slammed into a hillside killing all aboard….
“Complicating their [joint Special Commission of Inquiry] task is the fact that the plane had no flight data recorder to track the craft’s movements. In 1974, the Air Force decided that its new planes would be fitted with the devices, but did not install them in the existing fleet because of the cost involved. The plane that crashed Wednesday had been purchased just a year too soon.
“Defense Secretary William Perry, who used the same plane only days earlier, called the crash “a classic sort of an accident that good instrumentation should be able to prevent.”
“A senior Air Force official, who spoke on condition of anonymity, said the plane had a ground proximity warning system that should have sounded as the plane neared the hillside. But, depending on the speed of the plane and the amount of room for maneuver, there may not have been enough time to respond. Warning time is a problem in mountainous terrain where a hillside can loom up suddenly, as opposed to a plane gradually descending to a lower altitude.
“Nondirectional radio beacons like those used to navigate into Dubrovnik date to the 1930s, when the first attempts were made to use radio to guide planes flying in the dark and through bad weather. Since then, many more modern, complex and costly systems have been developed.
“Many nations, including the United States, are planning to install new satellite-based aids called the Global Positioning System. Aviation experts note that GPS has not yet won approval for use in precision landings, however. Meanwhile airports around the world use a variety of guide systems including the radio beacons.” (The News, Frederick, MD. “Navigation system outdated on commerce secretary’s plane.” 6-18-1996. 1.)
Sources
American Forces Press Service, DOD. “Air Force Releases Brown Crash Investigation Report.” 6-13-1996. Accessed 3-12-2012 at: http://www.defense.gov/News/NewsArticle.aspx?ID=40796
Baugher, Joseph F. 1973 USAF Serial Numbers. 1-5-2012 revision. Accessed 3-11-2012 at: http://www.joebaugher.com/usaf_serials/1973.html
Diehl, Alan E. Silent Knights: Blowing the Whistle on Military Accidents and Their Cover-Ups. NY: Bristol Park Books, 2002.
Flight Safety Foundation. “Dubrovnik-bound Flight Crew’s Improperly Flown Nonprecision Instrument Approach Results in Controlled-flight-into-terrain Accident.” Flight Safety Digest. July-August 1996, pp. 1-25. Accessed 3-12-2012 at: http://flightsafety.org/fsd/fsd_jul-aug96.pdf
Gero, David. Military Aviation Disasters: Significant Losses Since 1908. UK and Newbury Park, CA: Patrick Stephens Limited, an imprint of Hayes Publishing, 1999.
Romzek, Barbara S. and Patricia Wallace Ingraham. “Cross Pressures of Accountability: Initiative, Command, and Failure in the Ron Brown Plane Crash.” Public Administration Review, Vol. 60, No. 3., May/June 2000, pp. 240-253. Accessed 2-3-2016 at: http://academic.udayton.edu/richardghere/POL%20305/Fall%202010/Ron%20Brown.pdf
The News, Frederick, MD. “Navigation system outdated on commerce secretary’s plane.” 6-18-1996. 1. Accessed at: http://newspaperarchive.com/FullPagePdfViewer.aspx?img=33934571
The News, Frederick, MD. “Plane crash probed; last of bodies removed.” 6-18-1996. 1. Accessed at: http://newspaperarchive.com/FullPagePdfViewer.aspx?img=33934571
[1] Cites: Bradley Graham. “Crash-Probe Depositions Speak Volumes.” Washington Post. 6-17-1996, p. 15. However, according to an Associated Press story “that his concerns pertained to Sarajevo, the capital of Bosnia-Herzegovina and regular stop for U.S. dignitaries, and not to little-visited Dubrovnik, where the crash occurred. “It’s a war zone, so it’s completely different,” he said of Sarajevo. Col. Albright also said his being relieved of duty was “completely unrelated” to his safety concerns, but declined further comment.” (The News, Frederick, MD. “Plane crash probed; last of bodies removed.” 6-18-1996. 1.)
[2] For that matter the pilots should not have been ordered to fly into Dubrovnik for the same reason.
[3] “Operation JOINT ENDEAVOR got underway in December 1995 as a NATO-led Bosnian peacekeeping force of 60,000 members—one-third…American—from 15 nations. The mission is to enforce a 600-mile-long separation between warring factions.” (Romzek and Ingraham 2000, fn 3, p. 243..)
[4] United States Air Force. Accident Investigation Board Report: United States Air Force CT-43A, 73-1149 (Vol. 1). Washington, DC: USAF, 1996, p. 54.
[5] Ibid., p. 3333.
[6] Romzek and Ingraham fn 16: “These actions ranged from punishment under Article 15 of the Uniform Code of Military Justice (UCMJ) to counseling. Two officers received reprimands under Article 15…The brigadier general who commanded the 86th Airlift Wing at the time of the crash was punished for dereliction of duty for negligently failing to ensure that non-DoD published instrument approaches were not used unless they had been subjected to terminal instrument procedures (TERPS) review and approval from USAFE. The colonel who was the 86th OGC was punished for dereliction of duty for willfully failing to ensure that USAFE regulations regarding aircrew use of non-DoD published instrument approaches were not used unless prior TERPS had been reviewed and approved…”
[7] Romzek and Ingraham footnote 17: “The major general who served as director of operations, HQ USAFE, was reprimanded for failing to delineate responsibilities within his organization, failing to exercise effective oversight of AF flight directives, and for not inquiring into the apparent failure of the 86th Airlift Wing to comply with AF directives. The colonel who served as vice commander of the 86th Airlift Wing was reprimanded for failing to ensure that the wing complied with the requirement to have non-DoD published instrument approaches reviewed for
safety before they were flown.”
