1996 Croatia USAF CT-43 crash

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U.S. Air Force Flight IFO-21
USAF CT-43A crash 1996.jpg
A USAF MH-53J Pave Low helicopter hovers near the wreckage of Flight IFO-21. The tail number of the accident aircraft is shortened as 31149.
Accident
Date3 April 1996 (1996-04-03)
Summary Controlled flight into terrain
Site3 km (1.9 mi) north of Dubrovnik Airport, Dubrovnik, Croatia
42°35′54″N18°15′08″E / 42.59833°N 18.25222°E / 42.59833; 18.25222
Aircraft
Aircraft type Boeing CT-43A
Operator United States Air Force
Registration 73-1149
Flight origin Zagreb International Airport, Zagreb, Croatia
Stopover Tuzla International Airport, Tuzla, Bosnia-Herzegovina
Destination Dubrovnik Airport, Dubrovnik, Croatia
Occupants35
Passengers30
Crew5
Fatalities35
Survivors0
73-1149, the aircraft involved, seen in 1993 73-1149 Boeing CT-43A USAF - Ramstein Open Day 1993.jpg
73-1149, the aircraft involved, seen in 1993

On 3 April 1996, a United States Air Force Boeing CT-43A (Flight IFO-21) crashed on approach to Dubrovnik, Croatia, while on an official trade mission. The aircraft, a Boeing 737-200 originally built as T-43A navigational trainer and later converted into a CT-43A executive transport aircraft, was carrying United States Secretary of Commerce Ron Brown and 34 other people, including corporate CEOs. While attempting an instrument approach to Dubrovnik Airport, the airplane crashed into a mountainside. An Air Force technical sergeant, who was the stewardess, and the only passenger who survived the initial impact, Shelly Kelly, died en route to a hospital. [1]

Contents

The aircraft was operated by the 76th Airlift Squadron of the 86th Airlift Wing, based at Ramstein Air Base in Germany. Unlike civilian 737s, the military CT-43A version was equipped with neither a flight data recorder nor a cockpit voice recorder. [2]

Investigation

Croatia location map.svg
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Zagreb Pleso Airport
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Tuzla Airport
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Dubrovnik Čilipi Airport
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Crash Site St John's Hill
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Location of crash site and departure and destination airports
Summary of the NDB approach to runway 12 from the USAF accident report Lddu ndb 12.JPG
Summary of the NDB approach to runway 12 from the USAF accident report

The official US Air Force accident investigation board report noted several reasons that led the Boeing CT-43A, callsign "IFO-21" (short for Implementation Force), [3] to crash. [4] Chief among the findings was a "failure of command, aircrew error and an improperly designed instrument approach procedure". [3]

The Boeing CT-43A used for this flight was formerly a T-43A navigator training aircraft that was converted for distinguished visitor travel. The flight was on an instrument flight rules non-directional beacon (NDB) approach, which is a non-precision type of instrument approach, to Runway 12 when it strayed off course. Non-precision approaches are those that do not incorporate vertical guidance. [5] While NDB approaches are essentially obsolete in the United States, they are still used widely in other parts of the world. Because of their infrequent use in the United States, many American pilots are not fully proficient in performing them (a NASA survey showed that 60% of American transport-rated pilots had not flown an NDB approach in the last year). [2] The investigation board determined that the approach used was not approved for Department of Defense aircraft, and should not have been used by the aircraft crew. [6] The board determined that the particular NDB approach used required two operating ADFs, the instrument used to fly such an approach, on board the aircraft, but this aircraft only had one ADF installed. To successfully fly the approach, one ADF was required to track the outbound course of 119° from the Koločep NDB (KLP), while another ADF was required to observe when the aircraft had flown beyond the Cavtat NDB (CV), which marked the missed approach point. [7] Further, the board noted that the approach was rushed. The aircraft passed the final approach fix at 80 knots (150 km/h) above the proper approach speed and had not received the proper clearance from the control tower to initiate the approach. [6]

The crash site, on a 2,300-foot (700 m) hill, was 1.6 miles (2.6 km) northeast of where the aircraft should have been on the inbound course to the NDB. The published NDB approach brings the inbound aircraft down a valley, and has a minimum descent height of 2,150 ft (660 m) at the missed approach point (where they should have climbed and turned to the right if the runway was not in view), which is below the elevation of the hills to the north. The runway is at 510 ft (160 m) above sea level. Five other aircraft had landed prior to the CT-43A and had not experienced any problems with the navigational aids. No emergency call from the pilots occurred, and they did not initiate a missed approach, though they were beyond the missed approach point when they hit the hill at 2:57 pm local time. [2] [3]

Each country is responsible for publishing the approach charts, including minimum descent heights, for its airports, and the investigators noted that the minimum in mountainous terrain in the United States is 2,800 ft (850 m), as compared to the 2,150 ft (660 m) on the chart given to the crew of IFO-21. [7] It was a requirement of the US Air Force to review and approve all charts, and to ban flights into airports for which the charts did not meet American aviation standards. [7] The commander of the 86th Operations Group, Col. John E. Mazurowski, [8] revealed that he had requested (but not yet received) approval to waive the review for Dubrovnik, as the approach had worked for years, and the delay of a full review could hamper the interests of the American diplomatic mission. [7]

Victims

Thirty-five people, six military crewmembers, and twenty-nine civilians died in the crash or from their injuries. Technical Sergeant Shelly Ann Kelly died later that night while being transported to hospital. [9] Thirty-three of the victims were Americans and two were Croatians. Twelve Department of Commerce officials, including Secretary Brown, were among the deceased. [10]

Government officials

Businesspeople

Flight crew

The crew consisted of pilot Captain Ashley "AJ" Davis, aged 35, employed by the U.S. Air Force since 1989, who had qualified to fly the Boeing CT-43 in 1992 and accumulated 2,942 flight hours in his career with 582 hours on the Boeing CT-43; and co-pilot Captain Timothy Shafer, aged 33, employed by the U.S. Air Force since 1988, with 2,835 flight hours of which 1,676 hours were on the Boeing CT-43.

Outcomes

Dubrovnik Airport was singled out for an improperly designed approach and landing procedure. [7]

A number of US Air Force (USAF) officers were found to have contributed to a failure of command. The general commanding the 86th Airlift Wing, Brig. Gen. William E. Stevens, vice-commander Col. Roger W. Hansen, and the commander of the 86th Operations Group, Col. John E. Mazurowski, were all relieved of their posts. [8] [11] Mazurowski was later found guilty of a dereliction of duties and was demoted to major, while 12 other officers were reprimanded. [7]

The USAF ordered all military aircraft to be equipped with a flight data recorder and a cockpit voice recorder. [7]

American military aircraft are no longer allowed to fly into airports without explicit approval from the United States Department of Defense, not even for high-ranking diplomatic missions. [7]

Legacy

The area of the crash site is identified by a large stainless steel cross on Stražišće peak. Hikers can reach the peak via the "Ronald Brown Path", which is named in commemoration of the U.S. Secretary of Commerce who died in the crash. [12]

A memorial room has been installed in the Ronald Brown memorial house in the old city of Dubrovnik. It features portraits of the crash victims as well as a guest book. [13]

The head of navigation at Dubrovnik Airport, Niko Jerkuić, was found dead three days after the accident with a bullet wound to his chest. The police investigation concluded that the case was a suicide. [14]

The crash of IFO-21 was covered in "Fog of War", an episode from the fourth season (2007) of the internationally syndicated Canadian TV documentary series Mayday . [7]

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References

  1. ↑ "Najpotresnije zrakoplovne nesreće u hrvatskoj povijesti". Index.hr. 22 August 2008.
  2. 1 2 3 Hughes, David "USAF, NTSB, Croatia Probe 737 Crash", Aviation Week & Space Technology, 8 April 1996
  3. 1 2 3 Dr. Sheila E. Widnall; et al. (7 June 1996). "DOD News Briefing". DefenseLINK. Archived from the original on 27 February 2004. Retrieved 6 February 2023.
  4. ↑ Walters, James M.; Sumwalt, Robert L. III (2000). Aircraft Accident Analysis: Final Reports . McGraw Hill. ISBN   9780071351492.
  5. ↑ FSF ALAR Briefing Note 7.2 – Constant Angle Nonprecision Approach Flight Safety Foundation
  6. 1 2 DoD news release Archived September 29, 2007, at the Wayback Machine
  7. 1 2 3 4 5 6 7 8 9 "Fog of War". Mayday . Season 4. Episode 8. Cineflix. 3 June 2007. Discovery Channel Canada.
  8. 1 2 "Press Briefing". United States Department of Defense. 31 May 1996. Archived from the original on 31 August 2020. Retrieved 22 April 2020.
  9. ↑ "Airforce: Together We Served"
  10. ↑ "List of crash victims - Apr. 4, 1996". CNN . Retrieved 19 June 2021.
  11. ↑ Shenon, Philip (31 May 1996). "Air Force Ousts 3 From Duties In Brown Case" . The New York Times . Retrieved 22 April 2020.
  12. ↑ Dubrovnik Online website Archived 2014-03-12 at the Wayback Machine Retrieved: 17 October 2009
  13. ↑ Ronald Brown memorial house Archived 2014-03-12 at the Wayback Machine Retrieved: 17 October 2009
  14. ↑ "Avionom je, ipak, najsigurnije" [By Plane, However, Is the Safest]. Slobodna Dalmacija . 9 September 2008. Archived from the original on 9 September 2008.

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