This discusses the errors attributed to the fatal crash of the United States Air Force T-43A aircraft, flight IFOR 21, carrying US Secretary of Commerce Ron Brown and other US Government personnel. The T43A crashed on an approach to Dubrovnik airport, Croatia, on April 3, 1996, killing all aboard. The accident airplane, a military version of the civilian 737-200, crashed ninety-eight feet below the summit of a hill to the east of the NDB (Non-directional Beacon Runway) ,some 1.5 miles off course of Runway 12 approach to Dubrovnik.
The invesigator's Statement of Opinion, limited in its possible uses by regulation 10 U.S.C. Section 2254, attributes the accidents to:
a faliure of command,
aircrew error,
an improperly designed instrument approach procedure,
The approach consisted of : MDA (Minimum Descent Altitude) for both straight-in and circle-to-land Runway 12; flown at 2150ft. There are two NDBs; KLP at 11.8 miles (Final Approach Fix 4000ft) and CV at 1.9 miles (Missed-Approach Point of 2175ft) they are both in line with the runway extended centerline.
There was a chain of critical events leading up to the fatal accident of flight IFOR 21. The pilot and copilot spent the last minutes of their lives rushing through unfamiliar procedures with inadequate equipment aboard. Military aircraft haven't been installed with "black box" recorders as of yet, though Defense Secratary William Perry has ordered a retrofit of all military passenger planes to be installed to aid investigators in the recovery of vital information.
Five planes landed at Dubrovnik shortly before the accident. The wind was very steady not gusty. According to a Croatian government Saberliner Captain, who landed ninety nine minutes prior to the a ccident said, "The weather was bad but we often see that kind of weather."
The weather was reported at the time of the crash to be: moderate rain, no lightning, broken clouds at four hunderd feet and a overcast sky at two thousand. Wind twelve knots and five miles visibility. The weather was forcasted at proposed time of arrival was: twenty five thousand overcast with thirteen miles visability and light and variable winds.
These same type of conditions would have not permitted any attemt to land at Dubrovnik by a US based Air Force jet transporting VIPs, almost a thousand feet lower than the published minimums.
The first mistake made by the crew was over looking the stirct ban on landing at international airports deemed unsafe by the Department of Defense. The reason for the ban of these airports is the lack of training for this type of approach procedure. The crew failed to apprecitate that the NDB approach demanded the presence of two ADF's (Automatic Direction Finder). The T-43A was outfitted only with one reciever. This would be considered a hidden agenda, the pilot must have known this was a breach of orders with the possiblity of being court martialed. But proceded to fly into the airport knowingly deviating from policy and regulation of the USAF.
The crew of flight IFOR 21 neither had prior experiences with this particular approach or an approach of this type. Showing their dangerous anti-autority; the crew proceeded with the flight. Croatia Airline's policy will not allow its crews land if both pilot and copilot have never done it before.
The report says the crew rushed the approach in order to meet the tgith schedule of the Secratary. At impact the gear and flaps were retacted and the aircraft was flying eighty knots above the final approach speed some nine degrees left of track. This exhibits their complanentcy for detail and lack of check lists. Showing the pilots were invulnerable due to their lack of situational awareness, meaning the crew didn't think it could happen to them even though they were off course and unaware of the hills around them. The obstacles were clearly depicted on the chart and should have been noted.
The aircraft was some fifteen minutes behind schedule indicating that the short vectors to final were used to cut time from the approach. Showing their overriding desire to get to a destination which impaired their decision making process.
There are many holes in the report of this crash due to the lack of voice and flight data recorders, but what has been disscused the accident could have been prevented and will be in the future with the addition of GPS (Global Positioning Systems) aboard all transport aircraft in the military.
Had the copilot been more assertive in his actions this accident would have never occured. He should have been brought to the attention of the pilot that they were lacking the proper equipment to even think about getting into Dubrovnik.
Not every question could be answered because the T-43A was not equipped with voice and cockpit data recorders tha could provide key evidence, but the evidence shows this accident was attibutted to a failure of command, Aircrew Error and an improperly desinged instrument approcah procedure.
