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On 3 April 1996, a
United States Air Force The United States Air Force (USAF) is the Air force, air service branch of the United States Department of Defense. It is one of the six United States Armed Forces and one of the eight uniformed services of the United States. Tracing its ori ...
Boeing CT-43A (Flight IFO-21) crashed on approach to
Dubrovnik Dubrovnik, historically known as Ragusa, is a city in southern Dalmatia, Croatia, by the Adriatic Sea. It is one of the most prominent tourist destinations in the Mediterranean Sea, Mediterranean, a Port, seaport and the centre of the Dubrovni ...
, Croatia, while on an official trade mission. The aircraft, a
Boeing 737-200 The Boeing 737 is an American narrow-body aircraft produced by Boeing at its Renton factory in Washington. Developed to supplement the Boeing 727 on short and thin routes, the twinjet retained the 707 fuselage width and six abreast seating ...
originally built as a T-43A navigational trainer and later converted into a CT-43A executive transport aircraft, was carrying
United States Secretary of Commerce The United States secretary of commerce (SecCom) is the head of the United States Department of Commerce. The secretary serves as the principal advisor to the president of the United States on all matters relating to commerce. The secretary rep ...
Ron Brown Ronald Harmon Brown (August 1, 1941 – April 3, 1996) was an American politician and lobbyist who served as the 30th United States Secretary of Commerce during the first term of President Bill Clinton. Before this, he was chairman of the Democ ...
and 34 other people, including corporate CEOs. While attempting an
instrument approach In aviation, an instrument approach or instrument approach procedure (IAP) is a series of predetermined maneuvers for the orderly transfer of an aircraft operating under instrument flight rules from the beginning of the initial approach to a lan ...
to
Dubrovnik Airport Dubrovnik Ruđer Bošković Airport (; ), also referred to as Čilipi Airport (), is the international airport of Dubrovnik, Croatia. The airport is located approximately 15.5 km (9.5 mi) from Dubrovnik city center, near Čilipi. It was ...
, the airplane crashed into a mountainside. All aboard died in the crash except one who died en route to a hospital. The aircraft was operated by the
76th Airlift Squadron The 76th Airlift Squadron is part of the 86th Airlift Wing at Ramstein Air Base, Germany. It operates executive airlift aircraft, including the Learjet C-21A and Gulfstream C-37A Gulfstream V. The squadron was first activated during World W ...
of the
86th Airlift Wing The 86th Airlift Wing (86 AW) is a United States Air Force wing, currently assigned to the Third Air Force, United States Air Forces in Europe – Air Forces Africa. The 86th AW is stationed at Ramstein Air Base, Germany. The wing's primary mi ...
, based at
Ramstein Air Base Ramstein Air Base is a United States Air Force installation located in Rhineland-Palatinate, southwestern Germany. It serves as the headquarters for the United States Air Forces in Europe – Air Forces Africa (USAFE-AFAFRICA) and NATO Alli ...
in Germany. Unlike commercial 737s, the military CT-43A version was equipped with neither a
flight data recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
nor a
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
.


Investigation

The official US Air Force accident investigation board report noted several reasons that led the Boeing CT-43A,
callsign In broadcasting and radio communications, a call sign (also known as a call name or call letters—and historically as a call signal—or abbreviated as a call) is a unique identifier for a transmitter station. A call sign can be formally assi ...
"IFO-21" (short for
Implementation Force The Implementation Force (IFOR) was a NATO-led multinational peace enforcement force in Bosnia and Herzegovina under a one-year mandate from 20 December 1995 to 20 December 1996 under the codename ''Operation Joint Endeavour''. Background In ...
), to crash. Chief among the findings was a "failure of command, aircrew error and an improperly designed instrument approach procedure". 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 In aviation, instrument flight rules (IFR) is one of two sets of regulations governing all aspects of civil aviation aircraft operations; the other is visual flight rules (VFR). The U.S. Federal Aviation Administration's (FAA) ''Instrument Fl ...
non-directional beacon A non-directional beacon (NDB) or non-directional radio beacon is a radio beacon which does not include directional information. Radio beacons are radio transmitters at a known location, used as an aviation or marine navigational aid. NDB are i ...
(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.''FSF ALAR Briefing Note 7.2 – Constant Angle Nonprecision Approach'' Flight Safety Foundation
/ref> 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 The National Aeronautics and Space Administration (NASA ) is an independent agencies of the United States government, independent agency of the federal government of the United States, US federal government responsible for the United States ...
survey showed that 60% of American transport-rated pilots had not flown an NDB approach in the last year).Hughes, David "USAF, NTSB, Croatia Probe 737 Crash", ''Aviation Week & Space Technology'', 8 April 1996 The investigation board determined that the approach used was not approved for
Department of Defense The United States Department of Defense (DoD, USDOD, or DOD) is an executive department of the U.S. federal government charged with coordinating and supervising the six U.S. armed services: the Army, Navy, Marines, Air Force, Space Force, ...
aircraft, and should not have been used by the aircraft crew.DoD news release
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 Cavtat (, ) is a village in the Dubrovnik-Neretva County of Croatia. It is on the Adriatic Sea coast south of Dubrovnik and is the centre and the main settlement of Konavle municipality. History Antiquity The original city was founded by the ...
NDB (CV), which marked the
missed approach point Missed approach point (MAP or MAPt) is the point prescribed in each instrument approach at which a missed approach procedure shall be executed if the required visual reference does not exist. It defines the point for both precision and non-precis ...
. Further, the board noted that the approach was rushed. The aircraft passed the final approach fix at above the proper approach speed and had not received the proper clearance from the control tower to initiate the approach. The crash site, on a hill, was 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 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 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 Missed approach is a procedure followed by a pilot when an instrument approach cannot be completed to a full-stop landing. Initiation A missed approach may be either initiated by the pilot or instructed by air traffic control (ATC). The instru ...
, though they were beyond the missed approach point when they hit the hill at 2:57 pm local time. 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 , as compared to the on the chart given to the crew of IFO-21. 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. The commander of the
86th Operations Group The 86th Operations Group (86 OG) is the flying operational component of the 86th Airlift Wing, United States Air Force. The group is stationed at Ramstein Air Base, Germany. The mission of the 86 OG (Tail Code: RS) is to conduct airlift, aird ...
, Col. John E. Mazurowski, 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.


Victims

Thirty-five people—six military crewmembers and twenty-nine civilians—died in the crash or from their injuries. Technical Sergeant Shelly Ann Kelly, who survived the initial accident, died later that night while being transported to the hospital. Thirty-three of the victims were Americans and two were Croatians. Twelve
Department of Commerce The United States Department of Commerce (DOC) is an United States federal executive departments, executive department of the Federal government of the United States, U.S. federal government. It is responsible for gathering data for business ...
officials, including Secretary Brown, were among the deceased.


Government officials

*
Ron Brown Ronald Harmon Brown (August 1, 1941 – April 3, 1996) was an American politician and lobbyist who served as the 30th United States Secretary of Commerce during the first term of President Bill Clinton. Before this, he was chairman of the Democ ...
, Secretary of Commerce * Duane Christian, security officer to the Secretary of Commerce * Adam Darling, confidential assistant to the Secretary of Commerce * Gail Dobert, Deputy Director for the Office of Business Liaison * Carol Hamilton, Press Secretary to the Secretary of Commerce * Kathryn Hoffman, senior advisor for strategic scheduling and special initiatives to the Secretary of Commerce * Steve Kaminski, Counselor to the Secretary of Commerce * Kathy Kellogg, Office of Business Liaison official * Charles Meissner, Assistant Secretary of Commerce for international trade * William Morton, Deputy Assistant Secretary of Commerce for international economic development * Lawrence Payne, Foreign Service officer * Naomi Warbasse, international trade specialist with the Department of Commerce


Businesspeople

* Barry L. Conrad, chairman and CEO of Barrington Group * Paul Cushman III, chairman and CEO of Riggs International Banking Corp. * Robert E. Donovan, president and CEO of ABB Inc. * Claudio Elia, chairman and CEO of Air & Water Technologies Corp. * David Ford, president and CEO of InterGuard Corp. of Guardian International * Frank Maier, president of Enserch International Ltd * Walter Murphy, senior vice president of AT&T Submarine Systems Inc. * Leonard Pieroni, chairman and CEO of Parsons Corp. * John A. Scoville, chairman of Harza Engineering Co. * Donald Terner, president of Bridge Housing Corp. * Stuart Tholan, high-ranking
Bechtel Bechtel Corporation () is an American engineering, procurement, construction, and project management company founded in San Francisco, California in 1898, and headquartered in Reston, Virginia in the Washington metropolitan area. , the '' E ...
executive * Robert A. Whittaker, chairman and CEO of Foster Wheeler Energy International


Flight crew

* Captain Ashley Davis, pilot * Captain Tim Shafer, pilot * Staff Sergeant Gerald Aldrich, flight mechanic * Technical Sergeant Cheryl Turnege, steward * Technical Sergeant Shelly Ann Kelly, steward * Staff Sergeant Robert Farrington Jr., steward The crew consisted of pilot
Captain Captain is a title, an appellative for the commanding officer of a military unit; the supreme leader or highest rank officer of a navy ship, merchant ship, aeroplane, spacecraft, or other vessel; or the commander of a port, fire or police depa ...
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 Captain is a title, an appellative for the commanding officer of a military unit; the supreme leader or highest rank officer of a navy ship, merchant ship, aeroplane, spacecraft, or other vessel; or the commander of a port, fire or police depa ...
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 Dubrovnik Ruđer Bošković Airport (; ), also referred to as Čilipi Airport (), is the international airport of Dubrovnik, Croatia. The airport is located approximately 15.5 km (9.5 mi) from Dubrovnik city center, near Čilipi. It was ...
was singled out for an improperly designed approach and landing procedure. 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. Mazurowski was later found guilty of a dereliction of duties and was demoted to major, while 12 other officers were reprimanded. The USAF ordered all military aircraft to be equipped with a
flight data recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
and a
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
. American military aircraft are no longer allowed to fly into airports without explicit approval from the
United States Department of Defense The United States Department of Defense (DoD, USDOD, or DOD) is an United States federal executive departments, executive department of the federal government of the United States, U.S. federal government charged with coordinating and superv ...
, not even for high-ranking diplomatic missions.


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.Dubrovnik Online website
Retrieved: 17 October 2009
A memorial room has been installed in the Ronald Brown memorial house in the old city of
Dubrovnik Dubrovnik, historically known as Ragusa, is a city in southern Dalmatia, Croatia, by the Adriatic Sea. It is one of the most prominent tourist destinations in the Mediterranean Sea, Mediterranean, a Port, seaport and the centre of the Dubrovni ...
. It features portraits of the crash victims as well as a guest book.Ronald Brown memorial house
Retrieved: 17 October 2009
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 Suicide is the act of intentionally causing one's own death. Risk factors for suicide include mental disorders, physical disorders, and substance abuse. Some suicides are impulsive acts driven by stress (such as from financial or ac ...
.


In popular culture

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 Mayday is an emergency procedure word used internationally as a distress signal in voice-procedure radio communications. It is used to signal a life-threatening emergency primarily by aviators and mariners, but in some countries local organiz ...
''.


References


Further reading

*


External links


USAF accident report
* {{DEFAULTSORT:Croatia USAF CT-43 crash, 1996 1996 disasters in Croatia Accidents and incidents involving the Boeing 737 Original Accidents and incidents involving United States Air Force aircraft April 1996 in Europe Aviation accidents and incidents in 1996 Aviation accidents and incidents in Croatia Aviation accidents and incidents involving controlled flight into terrain Croatia–United States military relations Airliner accidents and incidents caused by pilot error