Your News Paper account proves my point!
...The captains had never seen the Dubrovnik airport, and the lowering
rain clouds made it impossible for them to see it now.
Croatia Airlines will not let its own crews land there if both the
pilot and co-pilot have never done it before. The Air Force told
pilots based in the United States never to land there in anything but
clear weather.
But the Air Force commanders in Europe -- the captains' superiors --
decided to ignore that.
LIKE I WROTE:
International Airport Controls and Safety Standards are well adhered to
except when it's intended they not. Can you say 911?
Two more points: 24 hour weather forecast and in-flight updates are routinely
reviewed in flight.
Professional Pilots during pre-flight familiarize themselves with special
airport landing conditions, I assure you mountains are such a condition.
Two many cascading events for it not to have been another hit like
Congressmen Mickey Leeland and Senator Wellmen.
Thanks for providing the grist to prove my point.
Abati
Nalini Lasiewicz <LasiewiczN@xxxxxxx> wrote:
At the time the crash happened, I was still very involved in
researching the Balkan wars. I spoke with people who had first hand
knowledge of the incidents in 1991, when Serb forces overran the
airport and stole critical navigation equipment.
Here's a more complete overview from the NYT in 1996.
It's grotesque that this accident is now being used as propaganda to
be used against a Hillary Clinton race for the Presidency.
We ought to all be aware of the manipulations, and guard against
them.
NL
==============================================
April 28, 1996
DEADLY FLIGHT -- A special report.;In Crash That Killed Brown, Signs
of Safety Shortcomings
By TIM WEINER
Capt. Ashley Davis of the Air Force and his co-pilot, Capt. Tim
Schafer, had good reasons to forget about trying to land in the
pouring rain at Dubrovnik, Croatia, on the afternoon of April 3.
The captains had never seen the Dubrovnik airport, and the lowering
rain clouds made it impossible for them to see it now.
Croatia Airlines will not let its own crews land there if both the
pilot and co-pilot have never done it before. The Air Force told
pilots based in the United States never to land there in anything but
clear weather.
But the Air Force commanders in Europe -- the captains' superiors --
decided to ignore that.
And so Captain Davis, 35, and Captain Schafer, 33, pressed on with
Flight IFOR 21. Nearly 12 miles out, heading southeast, their
military Boeing 737 passed over a navigation beacon. They were right
on course.
But sometime during the next four minutes something went terribly
wrong. A startled United Nations military officer in the hills
outside the city heard the jet roar overhead and told a
colleague, "That guy's way off course."
The correct flight path to Dubrovnik's single runway was a course of
119 degrees.
But the pilots, flying on rudimentary instruments, followed a course
of 109 degrees -- straight at the highest mountain for miles around.
Seconds later the plane slammed into the peak and exploded, killing
all 35 people aboard, including Commerce Secretary Ronald H. Brown.
It was 98 feet shy of clearing the summit.
What went wrong that afternoon may never be known -- in part because
the Air Force never installed data or cockpit voice recorders on the
plane. Croatian authorities say the crash was caused by pilot error.
The Air Force declines comment on its inquiry.
But an examination of the crash shows shortcomings in the equipment
and procedures of the Air Force units that fly V.I.P.'s around the
world. Taken together, they made the landing at Dubrovnik more
dangerous. Acknowledging some of those shortcomings, the Pentagon
said on Friday that it would improve the safety and navigation
equipment on its passenger airplanes.
The review discloses these details:
*The plane that carried Mr. Brown to his death could not have flown
commercially in the United States because it would not have met
civilian safety standards. The Air force has resisted meeting those
standards. So the planes that fly Cabinet secretaries, lawmakers and
the President's family to far-flung airports lack safety innovations
pioneered by civilian manufacturers and the military itself.
Dubrovnik's poorly equipped airport may be typical of the third
world, but in many ways so was the 22-year-old plane.
*The pilots were navigating with a compass and a radio receiver. Air
Force generals called that equipment "primitive" and "rudimentary." A
member of the unit that flies V.I.P.'s compared it to working with a
typewriter in the computer age. The pilots of IFOR 21 had limited
experience with the outmoded navigational system used to guide planes
to the Dubrovnik airport.
*On Feb. 1, after an inspection, the Air Force's Air Mobility Command
forbade all United States-based planes under its control, including
V.I.P. flights from Andrews Air Force Base in Washington, from
landing at Dubrovnik except in clear weather and in daylight. The
decision by the Air Force command in Europe to fly there anyway --
which it is free to do under present procedures -- demonstrates
a "disconnect" within the Air Force, said Maj. Gen. Mike McCarthy,
director of Air Force staff operations.
*Rescue efforts were chaotic. An automatic signaling device on the
plane that should have immediately sent up the radio equivalent of a
flare did not work, Croatian officials said. The American military
took two hours to start its search and eight hours to reach the
wreckage, while the one known survivor of the crash, Sgt. Shelly
Kelly of the Air Force, lay in mortal agony on the hillside. She died
soon after she was finally found.
In addition, colleagues of Captain Davis and Captain Schafer
colleagues in the 76th Airlift Squadron, based in Ramstein, Germany,
say they must cope with "get-there-itis," which pits prudence against
punctuality when carrying distinguished passengers on tight
schedules.
"It's inherent, because you know they have important meetings," said
one squadron member. General McCarthy said "there is some pressure
from the V.I.P. to get there," but he and other Air Force officers
say they are successfully combating the problem.
Still, a flight instructor and former Air Force officer said he could
imagine Captain Davis in the cockpit "having a conversation with
himself, saying, 'What am I doing here?' but at the same time
thinking, 'I've got to get these people there.' "
The instructor, who spoke on the condition of anonymity, said: "The
bottom line is the pilot should never have attempted the approach.
He's shooting a difficult approach he's not really qualified to do --
he's never been to the airport, it's difficult, the ceilings are down
to the minimums."
On Friday, Secretary of Defense William J. Perry ordered the military
to equip its 2,800 passenger planes with much more precise navigation
gear. But why didn't Flight IFOR 21 already have the best safety and
navigation devices available?
In part, because the Air Force sees its mission as fighting wars, not
ferrying passengers, said John L. McLucas, a former Secretary of the
Air Force and head of the Federal Aviation Administration.
"A Ron Brown, let's say, walking up to an airplane, should be in a
position where he can say: This is an airplane that is subject to
Government inspection; therefore I should expect certain things,"
like "the latest and greatest safety equipment," Mr. McLucas
said. "But the Air Force doesn't look at it that way." It sees the
work of ferrying distinguished passengers as "just a thing we do in
our spare time" -- not a mission, but a job.
General McCarthy called that characterization "blatantly unfair."
Even so, Col. Kerry May, a top Air Force staff safety official,
acknowledged that "safety is not the Air Force's primary mission."
Day of Dark Clouds Conditions Risky, But Not Impossible
April 3 was a full day for the peripatetic Mr. Brown, his party of
aides and business executives and a New York Times reporter,
Nathaniel C. Nash.
Their pilot was Captain Davis of the 76th Airlift Squadron. His
friends called him A. J. He had 2,906 flying hours as an Air Force
pilot, but only 141 hours commanding military 737's, the equivalent
of four 35-hour working weeks. He flew Hillary Clinton on her trip to
Bosnia and Turkey last month. Defense Secretary Perry was a recent
and frequent passenger aboard the plane.
At daybreak, Mr. Brown and his group took off from Zagreb, the
Croatian capital, for Tuzla, headquarters of American forces in
Bosnia. The pilots flew the empty plane to Split, away from the
crowded Tuzla field, and returned to pick up their passengers after
lunch. They then left Tuzla for Dubrovnik, flying southwest toward
Split before looping southeast down the Adriatic coast.
The rain, wind and fog were bad for April -- but not as bad as early
reports about the crash suggested. Five planes landed at Dubrovnik
shortly before the accident.
"We often see that kind of weather," said Capt. Mario Sarinic, who
landed a Croatian Government Sabreliner with officials on board at
Dubrovnik at 1:19 P.M. that day, 99 minutes before the
crash. "Basically the wind was very steady -- not gusty. The
crosswind was almost nothing."
Croatian and Air Force officials say there was moderate rain, no
lightning, broken clouds at 400 feet, an overcast sky at 2,000 feet,
a 12-knot wind and five miles of visibility at the airport at the
time of the crash.
A Canadair Challenger, another executive jet, carrying Prime Minister
Zlateko Matesa of Croatia and the American Ambassador, Peter
Galbraith, landed safely at 2:10 P.M. Forty minutes later, Capt. Amir
Sehic, the Challenger pilot, spoke with Captain Davis and Captain
Schafer from his cockpit. Mr. Brown's plane was due in 10 minutes. "I
was sure they would land," Captain Sehic said.
But he warned the pilots that the lowering rain clouds were near the
minimum ceiling allowed by the airport, 2,150 feet above ground
level. Those same conditions would have forbidden any attempt to land
at Dubrovnik by United States-based Air Force jets transporting
V.I.P.'s.
Captain Sehic said he told the pilots that if they could not land,
they should turn back to Split.
The pilots of Flight IFOR 21 flew on.
Ill-Equipped Airport
Air Tower Missing Vital Instruments
Before war fractured Yugoslavia, the Dubrovnik airport had what is
called an instrument landing system, an electronic navigation aid
that guides pilots both horizontally and vertically.
Pilots prefer the system -- so much so that the Air Force refused to
fly United States troops into Tuzla last year until American
technicians installed one. American and Croatian officials say the
system would have significantly reduced the chance of a crash at
Dubrovnik because it would have warned the pilots they were off
course.
But Dubrovnik lost its instrument landing system in 1991, when
advancing Serb forces overran the airport and stole it. The United
Nations, NATO and European nations did not respond to Croatia's pleas
for $400,000 to buy a new one. Then, in September 1994, the European
Bank for Reconstruction and Development offered a $22 million loan to
upgrade all of Croatia's airports.
The new instrument landing system was to be in place by October 1995.
But the Croatian Parliament took six months to approve the contract,
and then Croatian attacks on Serb separatists in Croatia held up the
loan again. The system was still being shipped by sea from the United
States on the day of the crash.
Anatomy of a Disaster Difficult Approach, And a Slow Drift
As the rain beat down on the runway, IFOR 21's instruments searched
for a radio beacon on the tiny island of Kolocep, 11.8 miles from the
Dubrovnik airport. It was one of two beacons along the coast sending
signals to set the pilots on the path to the runway.
The pilots were unable to see through the clouds. They lacked any
guidance from an instrument landing system or, better still, data
from the military's Global Positioning System, which can pinpoint a
plane's location anywhere in the world and which the Pentagon
promised on Friday to install on its 2,800 passenger planes.
Those radio signals from the beacon on Kolocep island were the
pilots' strongest link to the world below the clouds.
A beacon approach is "difficult, especially in bad weather, and when
you don't know the terrain," said Fran Gavranovic, a pilot with
Croatia Airlines who flies Boeing 737's to Dubrovnik. The beacons are
old technology, now rare at major American airports, but still used
in Europe, Africa, Central Asia and the former Soviet Union -- all
destinations for the 76th Squadron's V.I.P.'s.
Instead of the newer, more accurate alternatives, IFOR 21's
instrument panel had a compass and a single radio receiver, called an
Automatic Direction Finder, what a member of the 76th Squadron
described as the navigational equivalent of a typewriter.
The A.D.F., as the receiver is called, points at the beacons when
tuned in to the proper frequency. As the pilots approached the first
beacon, with their receiver set to a frequency of 318 AM, they picked
up a constantly repeating Morse code signal: Da dit da, dit da
diddit, dit da da dit. K,L,P, or Kilo Lima Papa.
Tapes from Croatia's nationwide radar system, which is monitored in
Zagreb, were reviewed after the crash and show the plane was on
course at the point it crossed over that beacon, according to
Croatian investigators. Now the pilots' main task was to keep the
plane on track, a course of 119 degrees.
The second radio beacon stands 1.9 miles from the Dubrovnik runway,
broadcasting the Morse code letters Charlie Victor on a different AM
frequency. Pilots typically tune in this signal after they fly over
Kilo Lima Papa. If they are on course, the needle on their A.D.F.
will point straight toward the runway.
At the same time, they are supposed to descend from 4,000 feet to a
level flight at 2,150 feet. Then they look down. If they still cannot
see the runway by the time they are over the second beacon, they must
abort their approach, turn right toward the sea and try again -- or
land elsewhere.
IFOR 21 had the most cumbersome possible equipment for navigating an
approach with two radio beacons.
Airliners that frequently make approaches using two beacons are
typically equipped with two A.D.F. receivers, each tuned to one
beacon. Other planes, such as the 737's flown by Croatia Airlines,
have a single A.D.F. that switches between preset frequencies with
the flick of a switch.
IFOR 21 had neither. Its receiver had to be manually -- and quickly --
retuned, with the co-pilot twirling a metallic knob as he strained
to hear the Morse code signals through the static.
Until they tune in the second beacon, pilots must calculate their
course from the tail end of the A.D.F. needle as it points backward
at the first beacon.
"It's one of the most difficult things we teach in flying," said
Michael Swanigan, vice president of flight operations at Alaska
Airlines, which frequently lands at airports with beacons. "In my own
experience in the military, it's one of the most difficult things to
grasp and understand," said Mr. Swanigan, a 737 captain and a former
Air Force instructor.
Watching their one A.D.F. needle, trying to tune in the second
beacon, talking to the control tower, flying through turbulence and
gauging the wind, looking out the window for the ground, configuring
the airplane for a steep descent and getting ready to decide whether
to land, the pilots were busy. Perhaps too busy to see that they had
been drifting dangerously off course.
The Final Minutes The Fatal Mistake Remains a Mystery
No one knows what happened next.
The pilots might have been unable to tune in the second beacon, or
had trouble navigating away from the first one. A sudden change in
the wind might have blown them off course, although the pilots are
trained to overcome that. Croatian investigators say there was no
lightning, but any electrical storm could have thrown off their
compass.
Were the pilots adequately trained to use the beacons for their
approach?
The question is a "significant part" of the official inquiry, said a
spokesman for the crash investigation board. Captain Davis had made
four beacon landings since January, and Captain Schafer six, the Air
Force said.
However, a pilot with the 76th Squadron said those landings probably
were training sorties at the Saarbrucken airfield in Germany, an
approach they knew quite well.
Flying a beacon approach to a familiar airfield gives a pilot "a home-
court advantage," General McCarthy said; a strange airport is "an
away game." Col. Robert Rhodes, the 76th's Squadron's commander from
1991 to 1993, said he would never send a crew to a place they had
never been unless they were highly experienced and had done "intense,
intense" analysis of the approach and the airfield.
Did the pilots ever tune in the second beacon? Miljenko Radic, an
experienced pilot and member of the Croatian investigating team,
believes they did not. If they had, they would have seen the arrow on
their compass pointing farther and farther off the proper 119 degree
course, an unmistakable sign of approaching disaster.
Were the beacons working properly? Croatian officials say they were.
And they were when other planes landed that day. A few days after the
accident, the Federal Aviation Administration tested the beacons and
found them to be in good order.
Three days after the crash, the chief of maintenance at the Dubrovnik
Airport, Niko Jerkic, killed himself. In recent interviews, neighbors
said he was despondent over a failed romance, and Croatian officials
say his suicide had nothing to do with the accident.
The pilots' final radio transmissions to the tower gave no hint of
trouble. In their last communication, they calmly asked for
permission to land. The tower responded at 2:56 P.M.: all clear on
the runway.
About two minutes later, the plane hit the top of St. John the
Baptist, a mountain 1.6 miles north of the runway, and exploded.
A Search Delayed Conflicting Signals Let Rescuers Stray
An American search and rescue team took until the next day to reach
the crash site, a delay that may have cost the only known survivor
her life.
The crash site should have been located immediately. But the plane's
crash position indicator, a device that emits a signal from a downed
plane, did not work, according to Croatian investigators. Boeing, the
plane's maker, refused to comment publicly.
At 3:30 P.M., Croatian authorities concluded the plane had crashed,
and they began a search. Ambassador Galbraith immediately relayed
that news to the State Department in Washington. But the American
military did not order a search for another 80 minutes.
The United States Special Forces command in Brindisi, Italy, says in
an official chronology that it received conflicting intelligence
reports about the plane's fate, including one report, more than an
hour after the crash, that the plane was still in the air. French
NATO forces based at the Croatian town of Ploce further muddled the
picture by reporting that the plane had crashed in the sea, near the
island of Kolocep. When the Special Forces helicopters finally took
off from Brindisi at 5:30 P.M., they spent hours skimming the
Adriatic, looking for wreckage that was not there.
Where technology failed, a villager succeeded. Ivo Djurkovic of the
tiny town of Velji Do, population 45, was taking hay to his cattle
when he heard the plane passing overhead. "I heard something bump in
the mountain and explode," he said. "I thought, are they shelling it
again or what?" The village was on the front lines back in 1991, and
the surrounding hills had been shelled periodically since.
Three hours later, the fog lifted a little and Mr. Djurkovic saw the
white tail of the plane on the mountainside. There being no phone in
his village, he got in his small Fiat, drove five miles down a narrow
winding road to a friend's house, and called the police in Cavtat.
At about 7:20 P.M., two policemen and Mr. Djurkovic arrived at the
site, having hiked the last several hundred feet up the steep, rocky
slope in the cold rain. Cutting through twisted metal, they found one
survivor, in the tail of the plane, crushed by galley equipment. It
was Sergeant Kelly, 36, of Zanesville, Ohio. She tried to stand up,
and lost consciousness, Croatian investigators said.
Croatian officials relayed the crash coordinates to Mr. Galbraith
within 20 minutes. He passed them to the State Department's
operations center. It took 45 minutes for this information to reach
American soldiers who had landed at Dubrovnik's airport, according to
the military's official chronology. The American rescue teams did not
drive immediately to the foothills of the mountain, a 45-minute hike
from the crash site, because they were "unable to obtain vehicles,"
according to the chronology.
Croatian soldiers had already scaled the peak on their own and were
searching for survivors. At 10 P.M. they found Sergeant Kelly alive,
but bleeding badly. Fearing she had a spinal injury, they did not
move her.
Special Forces helicopters tried to reach the site, but were defeated
by fog and rain. When the Croatian rescuers realized that the
helicopters were not coming, they began taking Sergeant Kelly down
the mountain in a stretcher. She died on the way. At 1:36 A.M.,
Croatian medical authorities told the American military she had been
pronounced dead on arrival at the hospital, the military's chronology
said.
Fifty-four minutes later, the first American soldiers reached the
wreckage of IFOR 21.
The Crash of Flight IFOR 21: What Went Wrong?
On April 3, in pouring rain, the plane carrying Commerce Secretary
Ronald H. Brown and 34 others began its final approach to the
Dubrovink airport. At 2:53 P.M., the plane passed over the first
navigation beacon 11.8 miles from the second beacon and the airport.
But for undetermined reasons, the pilots followed a course of
109degrees. Some five minutes later the plane crashed into the peak
of a mountain killing all aboard.
THE PLANE The 22-year-old Boeing CT-43, the military version of the
737-200, lacked many safety features found on commercial aircraft.
Equipped as it was, the plane would not have been permitted to fly a
commercial route in the United States.
THE PILOTS Air Force Capt. Ashley Davis and Capt. Tim Schafer had
never landed at the Dubrovnik airport. Croatia Airline forbids its
own crews to land there if neither the pilot nor co-pilot has done it
before. Also, the Air Force pilots had limited experience withe the
outmoded navigational system.
Correction: May 17, 1996, Friday
Articles on April 5, 6 and 28 about the April 3 crash of an Air Force
jet in Dubrovnik, Croatia, included a misspelled version of the co-
pilot's surname, supplied by the Defense Department. He was Capt.
Timothy W. Shafer, not Schafer.
This article is based on reporting by Raymond Bonner,Jane Perlez,
Matthew L. Wald and Tim Weiner and was written by Mr. Weiner.
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