[DefenseLINK NEWS RELEASE]

Reference Number: No. 342-96

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(703)695-0192(media)

(703)697-3189(copies)

(703)697-5737(public/industry)

June 7, 1996

IMMEDIATE RELEASE

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AIR FORCE DETAILS RESULTS OF CT-43 ACCIDENT INVESTIGATION

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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