ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Saturday, June 8, 1996 TAG: 9606090050
SECTION: NATIONAL/INTERNATIONAL PAGE: A-1 EDITION: METRO
DATELINE: WASHINGTON
SOURCE: Associated Press
NOTE: Above
RON BROWN'S PLANE was brought down by a combination of leadership flaws, lack of equipment and pilot error, the Air Force said Friday.
A warning beacon should have told the harried, behind-schedule pilots of Commerce Secretary Ron Brown's plane they were dangerously off course.
But the crew flew on, unaware they lacked the equipment to properly monitor the warnings and should not have even taken off for fog-shrouded Dubrovnik on the Croatian coast. These errors, combined with commanders who failed to train their crews adequately and ignored tough restrictions on flying into substandard civilian airports, led to the April 3 crash of Brown's CT-43A aircraft into a mountainside, the Air Force said Friday. The crash killed Brown and 34 other people.
The plane was two miles off course.
``The CT-43A accident was caused by a failure of command, air crew error, and an improperly designed instrument approach,'' concluded the report, prepared by a panel headed by Air Force Maj. Gen. Charles Coolidge Jr. In the absence of any one of those factors, the accident would not have happened, the report said.
In effect, the report blamed the 86th Airlift Wing commanders, the pilots of Brown's plane, and the Croatian civilians who designed the airport's instrument landing procedures. Three senior officers with the air wing have already been relieved of command; the pilots were killed in the crash. The Croatian government protested the report's conclusions about their landing procedures.
Relatives of the pilots said they had expected the military to blame them. And the family of one victim, businessman Frank Maier, is preparing to file a claim for unspecified millions of dollars against the U.S. government.
Maier, 50, president of the Dallas-based natural gas company Enserch International Ltd., was among a dozen businessmen killed on the trade mission. He left a wife, Diane, and two college-age daughters.
``It's incredible that so many mistakes were made,'' said John Howie, the family's attorney. ``It could have been prevented at so many levels.''
President Clinton, a close friend of Brown's, told reporters Friday that the briefing he received the night before was ``a very painful, personal experience.''
``I kept thinking that this peculiar mix of circumstances - if only one or two little things had happened, the crash might not have happened,'' Clinton said.
Clinton noted that some corrective steps have already been taken, with more to come. They include more training for pilots and commanders, minimum equipment requirements for military planes to handle all types of navigational situations, and a strict ban on landing at international airports deemed unsafe by the Defense Department. Defense Secretary William Perry had previously ordered a retrofit of all military passenger planes with ``black box'' recorders and the most modern navigational devices.
A two-month investigation that produced 22 volumes of detail found that the pilots, Capts. Ashley Davis and Timothy Shafer, had mapped out a prohibited flight path from Tuzla in neighboring Bosnia. Fixing the error in flight put them 15 minutes behind schedule and caused them to rush their approach. As it neared the runway, the plane was flying at about 250 mph, roughly 90 mph faster than recommended, leaving them less time to monitor the wavering needle that was guiding them to a landing.
``This kind of crew put great stock in arriving on time at a location,'' said a grim Gen. Ronald Fogleman, the Air Force chief of staff, at a Pentagon news conference. Fogleman refused to place all the blame on the pilots but added: ``Clearly, it is ultimately the air crew's responsibility to flight plan and execute the mission. People who wear these wings know that from the first day they're pinned on their chest.''
In addition, the pilots erred in setting their course heading into the Dubrovnik runway, according to the investigation. The mistake meant they were not compensating for a strong crosswind, which blew them off course. They also failed to notice from their navigational system that they were drifting toward the mountainous coast.
The critical pilot error, Coolidge said, came beforehand, when the crew failed to realize that an instrument landing at Dubrovnik would require a two-channel receiver to gain directional headings from two ground-based beacons that use 1930s technology.
The military version of the Boeing 737 was equipped with a one-channel receiver. Knowing this, the pilots should not have taken off for Dubrovnik, he said.
Every indication at the crash site was that they had little or no warning of the approaching disaster. The plane hit the mountain wheels down, flaps up at 160 mph without wavering from its incorrect course.
Investigators did find the No.1 engine of the aircraft at full throttle, the only indicator that the pilots saw the crash coming and tried to avoid it. According to witnesses, the plane never descended out of the cloud cover. It hit the 2,300-foot mountain 125 feet below the summit.
LENGTH: Medium: 94 lines ILLUSTRATION: PHOTO: (headshot) Coolidge. color.by CNB