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CRASH REPORT
JUNE 7, 1996
TRANSCRIPT
Charlayne Hunter-Gault talks with General Ronald R. Fogelman, the Airforce chief of staff, about the investigation of the crash that killed Commerce Secretary Ron Brown and thirty-four others.
CHARLAYNE HUNTER-GAULT: Sec. Brown and his party of business leaders and government officials were in the Balkans on a trade and economic development mission. On April 3rd, the Secretary stopped at Tuzla, the headquarters for American troops stationed in Bosnia with the international protection force. After greeting soldiers, the secretary and his party headed for Dubrovnik, a coastal city in Croatia, and a major tourist site before it was heavily shelled by Serbs in the civil war. Approaching the Dubrovnik Airport in rain and poor visibility, the Air Force CT-43 passenger plane crashed into a mountain, killing all 35 passengers and crew. The Air Force today issued a 22-volume, 7,000-page report and cited three major causes: command mistakes, errors by the flight crew, and outdated navigation equipment at the Dubrovnik civilian airport.
CHARLAYNE HUNTER-GAULT: For more on the report, we have Air Force Chief of Staff General Ronald Fogleman joining us from the Pentagon. Thank you for being here, General. Could you in the simplest of terms take us through the causes of Ron Brown's plane crash, starting with the beginning of the chain of failures, the failure of command?
GEN. RONALD R. FOGLEMAN, Air Force Chief of Staff: (Washington) Charlayne, I'd be pleased to do that. With the end of the Cold War, we began to expand our flight operations into the former Warsaw Pact countries. And as we did that, the set of commercially available approach plates needed to make instrument approaches began to become somewhat suspect in certain cases. As a result, the Air Force at this headquarters level issued an instruction to our lower major commands that said before they would use these approaches in the future that they would individually check each approach. That guidance was issued in November of 1994, and the command in Europe failed to implement the guidance. The wing, which was a subordinate unit of that command, was aware of the restriction and failed to inform its air crews that they should not be using those approaches unless they had been previously checked.
CHARLAYNE HUNTER-GAULT: Now this was the wing in, in Germany?l
GEN. FOGLEMAN: The 86th Wing at Ramstein, Germany.
CHARLAYNE HUNTER-GAULT: Mm-hmm. And so what, what explains how that happened?
GEN. FOGLEMAN: Well, I must tell you that it was not something that occurred because somebody had evil motives. As we have begun to trace back through that audit trail, what we have discovered is that when the wing received the guidance, they felt that if they immediately implemented it, it would have an adverse impact on their ability to support people flying throughout the theater, and because they had been flying these approaches for years and years, the wing leadership thought that they were safe. Having said that, they came back to the headquarters and requested a waiver from this requirement to check the approaches. That waiver was denied in January of 1996. That denial was transmitted to Europe, and the fact that the waiver had been denied was transmitted from the headquarters in Europe to the 86th Wing.
CHARLAYNE HUNTER-GAULT: So it was just ignored?
GEN. FOGLEMAN: It was ignored not because anybody, as I said, had an evil intention but because they thought that it was safe to fly the approaches and that it would adversely impact their ability to support people.
CHARLAYNE HUNTER-GAULT: So how has this part of the cause been corrected, if you've corrected it?
GEN. FOGLEMAN: We have corrected this by sending a message to all of our major commands, informing them and reiterating the fact that an Air Force level instruction must be complied with and no major command or subordinate unit has the authority to violate or im--to ignore higher headquarters' instructions.
CHARLAYNE HUNTER-GAULT: And you've removed three of the people who were at the top of this chain of command in the, in this unit?
GEN. FOGLEMAN: I have not removed them but their immediate commander, the 17th Air Force commander, removed them from command for a loss of confidence. This move--this removal was, in fact, an administrative action.
CHARLAYNE HUNTER-GAULT: Does it stop there, or will more action be taken?
GEN. FOGLEMAN: Well, as a result of this safety investigation being an open and releasable report and because of the facts and circumstances and the data that has been collected, the commander of the U.S. Air Forces in Europe, General Mike Ryan, has appointed an independent general officer to come in and further review all of this evidence and conduct an independent inquiry as to see what further action or what further action might be taken against those individuals or additional individuals.
CHARLAYNE HUNTER-GAULT: So there could be others relieved of command or some other action taken against them?
GEN. FOGLEMAN: Yes. But that will be determined by the results of this additional inquiry.
CHARLAYNE HUNTER-GAULT: All right. The next cause cited was pilot and crew error. In the simplest terms, because I listened to the briefing today and I couldn't follow some of it, it was too technical, in the simplest terms, tell us what that, what happened there?
GEN. FOGLEMAN: Oh, I think fundamentally the crew made the following errors: First of all, it is an air crew responsibility to do the flight planning and to successfully execute a mission. That's why when we receive these wings, they become almost sacred. It is a, a big ceremony. It is a well-earned distinction. This air crew had an obligation to properly flight plan every one of the legs that they were going to fly, every route that they were going to fly. We were able to determine that they incorrectly flight-planned at least two of the legs and one of those flight planning errors resulted in the mission being 15 minutes late on its scheduled arrival time at Dubrovnik. A second error that was made by the crew is that during the flight plan they should have reviewed the commercially available approach plate for that airport. Had they done that correctly, they would have determined that their aircraft was not properly equipped to fly the published approach.
CHARLAYNE HUNTER-GAULT: Approach plate is the landing strip.
GEN. FOGLEMAN: It is the instrument procedure that will get you from in the weather to a point where you would be able to see the runway and land. And then the third set of errors began as the crew made its descent into Dubrovnik. We do not know why but it appears as though the crew at this point, possibly because they were now behind their scheduled arrival time, appeared to be rushed in this approach. So as they were descending, they were about 80 knots faster than their prescribed final approach air speed. They did not, in accordance with Air Force regulations and guidance, slow the aircraft and configure it before departing the final approach fix to the air field.
CHARLAYNE HUNTER-GAULT: Do you have any explanation for any of that?
GEN. FOGLEMAN: We, we are only speculating at this point. We have no hard evidence.
CHARLAYNE HUNTER-GAULT: But there has been, I heard in the, in the News Summary clip we used, some discussion about inadequate theater specific training. And I'm assuming that--well, you tell me what that means and if this is a part of what you're talking about.
GEN. FOGLEMAN: Yes. Of course, the third cause of the accident was listed as an improperly designed approach procedure.
CHARLAYNE HUNTER-GAULT: Oh, and that goes into this category.
GEN. FOGLEMAN: And then--
CHARLAYNE HUNTER-GAULT: Well, excuse me, before--I must have jumped the gun. Let's just go back to the things that you just cited and tell me how you can correct for what you've just described, inadequate preparation of a flight plan, if you can correct for any of those.
GEN. FOGLEMAN: Yes. And, and that gets to what was not a primary cause of the accident but was, in fact, what we call a substantially contributing factor, and that was the lack of specific theater training. Head--the headquarters, the United States Air Forces in Europe, and the 86th Air Lift Wing, put into place adequate theater specific training. This air crew would have been trained to look at that approach procedure and know that their aircraft was not properly equipped to fly the approach.
CHARLAYNE HUNTER-GAULT: So how do you correct for that?
GEN. FOGLEMAN: What we have done is we have now designed, implemented, and put into place a specific theater training program.
CHARLAYNE HUNTER-GAULT: Mm-hmm. Did the weather have anything to do or have any part to play in this part of the problem?
GEN. FOGLEMAN: Weather was not really a factor or a cause of this accident. Clearly, the fact that there was weather in the area complicated the task of the crew to try and land at this airport. But had the crew properly executed the procedure, as they, as they were published, and as they were required to do, the weather would not have caused this accident.
CHARLAYNE HUNTER-GAULT: In your view, is there any one thing that could have been done differently, any major thing that stands out in your mind after all of this investigation now that if only that had been done, all of this could have been avoided?
GEN. FOGLEMAN: Unfortunately, Charlayne, what you determine in this, as you go back over it, is that there were three causes, any one of which had there been corrective action it would have prevented the accident.
CHARLAYNE HUNTER-GAULT: Is there anything that haunts you in your own mind about this, that, you know, that you feel is left undone or has to be addressed in a different kind of way that we haven't already discussed?
GEN. FOGLEMAN: Well, I guess the thing that hurts me the most is that the United States Air Force is the world's most respected air and space force. We are respected around the world. We have nearly 800,000 young men and women, active duty, Air National Guard, reserves, civilians, who perform missions that are assigned to them in an outstanding manner 99.9 percent of the time, and we, we are hurt deeply by the cause, by the loss of life, and by the fact that no one in the chain, starting at the headquarters United States Air Force who issued the instructions to the people who did not implement the instructions, no one was aware of this until this unfortunate accident occurred.
CHARLAYNE HUNTER-GAULT: But you're confident now that things are in place to correct for all of these, just briefly, sir?
GEN. FOGLEMAN: We are very confident that we have taken the appropriate corrective action at each level.
CHARLAYNE HUNTER-GAULT: All right. Well, General, thank you for joining us.
GEN. FOGLEMAN: Thank you, Charlayne.
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