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On 3 April 1996, United States Air Force Flight 21 veers off course and flies into a mountain while attempting to land at Dubrovnik Airport in Croatia in heavy fog, killing all 35 people on board, including the U.S. Commerce Secretary Ron Brown. The non-precision approach procedure the crew needed to follow required the use of two automatic direction finders, but the aircraft was only fitted with one.
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00:01a 737 is in trouble the pilots blinded by rain in the cabin government officials and influential
00:27businessmen the crash of IFO 21 shocks the world did a final act of war bring the plane down
00:35the White House demands answers this was no ordinary flight but a military jet carrying
00:43American politicians when the investigation is over the Air Force itself is held responsible
01:27Wednesday April the 3rd 1996 a raw spring day near the city of Dubrovnik Croatia
01:35rain pelts the runway at the city's airport a small group of diplomats hurry through the storm trying
01:43to keep dry they're part of a delegation that's just touched down among them the Croatian prime
01:51minister and the American ambassador to the region Peter Galbraith the flight into Dubrovnik was scary
01:59flight we couldn't see anything at all at that point I'd been ambassador to Croatia for nearly three
02:07years and I'd done a lot of shuttle diplomacy and it certainly was one of the most uncomfortable the
02:16weather that made Galbraith's landing so bad isn't letting up in fact commercial flights into Dubrovnik
02:24have been cancelled but the ambassador and the others aren't waiting for a commercial flight
02:34they're here to greet IFO 21 a US Air Force jet on a delicate mission the plane is a specially
02:42designed
02:43737 the Air Force has a small fleet of these jets to transport high-profile guests around the world the
02:50cabin has everything needed to do business and politics 10,000 meters in the sky today the cabin
02:59is filled with what the military call DV's distinguished visitors this group is led by United States Secretary of
03:07Commerce Ron Brown Ron Brown was a very smooth capable individual he was a Washington insider and he had
03:20all the skills that that go with that
03:25Brown is a star in the Democratic Party I obviously will do everything that is he played an important role
03:32in
03:32getting Bill Clinton elected president under Clinton Brown was appointed the first
03:38african-american commerce secretary in the country's history today that job has taken Brown to one of the most
03:59troubled areas in the world
04:06for four years civil war ripped Bosnia and Croatia apart but just a few months ago an uneasy peace began
04:19as commerce secretary Brown is helping to rebuild the local economy
04:28the philosophy behind it was that the peace would not be durable unless there was economic progress in
04:37the region that that was really critical to the peace Brown's three-day tour started that morning in
04:43Tuzla Bosnia where the group toured an electrical plant and ate hamburgers with
04:49American troops stationed there
04:50being a former army man myself I know what being away from home is like so we thought we would
04:57bring a little bit of home to you
04:59the final stop on today's tour is the ancient coastal city of Dubrovnik
05:05before the war it was a vital part of the country's tourism industry
05:11it was my idea that Ron Brown should go to Dubrovnik
05:16the Croatians were very eager to get the word out that Dubrovnik was still standing and that was still a
05:21tourist destination
05:21so I thought it would be very useful to have Ron Brown and the delegation go there
05:28but on this damp day Dubrovnik is not at its best or even visible
05:33fog presses down from the sky obscuring the city and the beautiful Adriatic coast
05:41to the north of Dubrovnik flies IFO 21 its pilot is captain Ashley J Davis his colleagues call him AJ
05:56departure IFO 21 IFO 21
06:00from the cockpit Davis can see some clouds ahead that he wants to avoid
06:04left here just a couple of miles from build-up
06:07IFO 21 this is approved as requested the climb and maintain fly level 160
06:12up to 160 now IFO 21 it's two o'clock in the afternoon AJ Davis and his crew have been
06:21on the go since dawn
06:23while the cabin of this plane is built for comfort the cockpit is virtually identical to a standard issue 737
06:33AJ Davis grew up in Baton Rouge Louisiana and dreamed of being a pilot
06:38he made it and has been on the front line of American military efforts
06:48in the past he flew mid-air refuelers high above the Persian Gulf
06:56but now he pilots diplomats and other officials from around the world
07:01it means a lot of traveling and a lot of time away from his wife and two children at Ramstein
07:07an American base in Germany
07:12according to the Air Force ranks Shelly Kelly is a technical sergeant
07:16today on IFO 21 her main job is to make sure the passengers have everything they need
07:28Mr. Secretary something to eat
07:30no no thank you I was wondering how our times look
07:32the diplomats are expecting to arrive in Dubrovnik by mid-afternoon
07:36but they've been running late all day
07:39check to find out for sure if you'd like
07:40yeah thank you early would be good
07:45as the plane nears Dubrovnik AJ Davis calls the United States Air Force weather service for an update
07:51Metro IFO 21 how copy over
07:54IFO 21 copy loud and clear weather for Lima Delta uniform as follows
07:59rain sky conditions 500 broken that would be ceiling how well do you copy
08:05Metro IFO 21 copies
08:09yeah we've been in it all day are you expecting any changes in the weather
08:15pretty much continued rain over copy rain thanks for your help so let's see the sights of Dubrovnik
08:30only four months after a peace treaty was signed the skies over this part of the world aren't guaranteed to
08:36be friendly
08:37planes are still required to fly in certain highly restricted lanes
08:42while he's aware that there are flight restrictions Davis has never flown in this part of the world before
08:48as he nears the Croatian border he gets an unexpected warning
08:53IFO 21 this is magic 5-1
08:56magic is the call sign for the peacekeeping airborne early warning aircraft that watches air corridors like a traffic cop
09:04be advised you're leaving an approved corridor please reroute immediately
09:10Davis isn't off course he's flying the exact route he had planned
09:14but without knowing it Davis and his plane are flying out of approved airspace
09:19they're flying into potentially dangerous territory
09:22leaving an approved corridor reroute
09:24Roger magic
09:26our error rerouting now to proper corridor over
09:32the second time today
09:36the approved corridors do change and Davis and his crew should have been informed
09:41to stay on an approved course Davis will have to swing out to the west
09:46it's an embarrassing situation that's going to cost them time
09:52Shelly AJ
09:54we've been directed to reroute
09:56we'll be arriving about 15 minutes late at Dubrovnik
10:01apologies to all back there
10:11ladies and gentlemen could I have your attention please
10:15unfortunately there will be a slight delay on our arrival into Dubrovnik
10:25the DV's aren't going to be happy at all
10:27the weather ahead will probably slow us down even more
10:32outside his plane the heavy rain continues to crash down
10:37flying toward an unfamiliar airport with a cabin full of businessmen and diplomats
10:42Davis has a difficult task ahead
10:44what happens to this plane and its passengers over the next several hours will capture the attention of the world
10:59a heavy rain soaks a small airport in Dubrovnik Croatia
11:05headed towards it is a U.S. Air Force 737 carrying 35 people on a trade mission
11:12leading the delegation U.S. Secretary of Commerce Ron Brown
11:17we'll see which path to pass to the next mission
11:23Dubrovnik approach IFO 2-1 level 1-0-0
11:26Dubrovnik approach good afternoon maintain 10,000 feet for beacon approach
11:31runway 1-2
11:33ok descending to 10,000 feet IFO 2-1
11:39the weather is so bad today that commercial flights have been cancelled
11:44as they approach the airport the rain isn't letting up
11:57but the crew is dealing with more than just bad weather
12:02the recent civil war has taken a heavy toll on Dubrovnik's airport
12:10it had been closed for several years and is waiting for a new landing system
12:17the airport was totally trashed by the Serbs who had taken over the airport during the 91 war
12:23they really went out of their way for the destruction
12:27they destroyed the instrument landing system
12:30the new one was on order
12:37around the world airports use sophisticated technology to help planes take off and land
12:44Doppler radar warns of incoming storms
12:51glide slopes
12:52glide slopes help pilots stay on course to land
13:00the devastated Dubrovnik airport has none of that
13:04it doesn't even have radar to see the planes that are coming in for landing
13:09instead the airport is using so-called non directional beacons to guide planes towards the runway
13:16in the aviation world it's ancient technology
13:21there are many non directional beacons used in the United States and throughout the world
13:25but they're an older navigational aid
13:26and in fact they were on the way out
13:33the system in Dubrovnik has two beacons on the ground which send out signals to the plane
13:41when the crew receives the signals they consult their charts and follow the course that will take them to the
13:47airport
13:49the crew of IFO-21 is still waiting to hear the first signal when they get a call from the
13:55ground
13:569A CRO to IFO-21
14:00IFO-21 I read you 9A CRO over
14:06another plane this one carrying ambassador Galbraith had touched down earlier in Dubrovnik
14:13the pilot of that plane is an experienced flyer who's very familiar with the area
14:17he wants to let the crew know what to expect
14:21IFO-21 we landed about an hour ago
14:26the weather was at minimum
14:28adjusting diverting to split if you have to execute the missed approach over
14:34Roger 9A CRO we read you
14:36out
14:41Diverting wouldn't be welcome news for the members of the trade delegation
14:48the pressures to get the passengers to scheduled news conferences and other activities were probably pretty high
15:00as Davis closes in on the airport the Dubrovnik tower calls again
15:05IFO-21
15:08report level
15:09IFO-21
15:125000
15:13IFO-21
15:15roger
15:16descend to 4000
15:18report Kilo Lima Papa
15:21down to 4000
15:23IFO-21
15:25let's run right away
15:27is it going?
15:30sir
15:30thank you
15:33flying above the storm the crew finally hears the radio signal from the first beacon
15:40hey age
15:41at Kilo Lima Papa we're tracking outbound at 119 degrees
15:46119 confirmed
15:54Mr. Secretary
15:55we're landing
15:58we'll take this up later
15:59Adam
16:04sound very broken up down there
16:07I can't see through it
16:09Tim?
16:10the clouds are thick
16:11the crew can't see the ground
16:13they have to trust their instruments as they descend through the storm
16:17IFO-21
16:19sir we are inside the locator
16:21inbound
16:22IFO-21 roger
16:24cleared for beacon approach
16:26runway is wet
16:28IFO-21
16:44A.J. Davis flies blind through heavy rain and cloud cover
16:48he expects to see the airport any second
17:17IFO-21
17:18do you read?
17:19IFO-21
17:20do you read?
17:26IFO-21
17:27do you read?
17:30IFO-21
17:31do you read?
17:32IFO-21
17:33IFO-21
17:33without approach radar to track the plane
17:35controllers have no idea where it is
17:42perhaps the plane has diverted to another airport
17:45perhaps the plane has diverted to another airport
17:45IFO-21 do you read?
17:47but as the minutes stretch on with no word from the American plane
17:51local controllers are taking no chances
17:54initiate emergency to pewers
18:00near the end of our shift we heard about the possibility of a missing plane
18:05we didn't know who was on the plane
18:09we had no details about the flight
18:11for situations like this there is a certain procedure
18:15and we just waited for more information
18:20Peter Galbraith is waiting at the airport with Croatia's prime minister
18:31it was clear from my own flight in that this was a very marginal landing
18:38I did not expect them to attempt the landing in Dubrovnik
18:44the Croatian prime minister came up to me and pulled me aside
18:47he said we've lost radio contact with Ron Brown's plane
18:54I got the State Department operations center on the phone
18:58and he's asked to activate the US military
19:02to start search and rescue activities
19:06word goes out to the chain of air traffic control centers
19:09the American fight
19:11if they had any contact with IFO-21
19:14but no one has had any contact with IFO-21
19:21the search and rescue effort focuses on the approach to the airport
19:24perhaps the plane had ditched into the Adriatic
19:31at the time I was about a hundred miles away
19:33I was in Brindisi, Italy
19:35we launched two of our MH-53 helicopters
19:38with special tactics air force personnel on board
19:41headed to Dubrovnik
19:44for hours there is no sign of the missing aircraft
19:47the weather conditions are getting worse
19:54fog was in
19:56thunderstorms in the area
19:57low visibility
19:58I thought one Dubrovnik approach do you read
20:03IFO-21 has a CPI or crash position indicator on board
20:09I thought 21 do you read
20:11if the plane went down
20:13the CPI should be sending out an ultra-high frequency signal
20:17but the Dubrovnik airport as well as lacking radar
20:21does not have the equipment to pick up the signal
20:24IFO-21 Dubrovnik approach do you read
20:28IFO-21 do you read
20:32IFO-21 do you read
20:35as the hours pass
20:37poor visibility frustrates the searchers
20:41they arrived
20:42off the coast
20:43and they were over water looking for the crash
20:52hours after the plane disappears
20:54police respond to a tip
20:56a local villager has seen something on the hill above his house
21:01it's a long way from the coast where the search is concentrated
21:09we went up with two vehicles to check the mountains
21:13the weather was extremely horrible
21:14strong rain and thick fog
21:17so we went on foot for about an hour up that mountain
21:21then we came close
21:25it's almost 7.30 at night
21:27four and a half hours after the crew called for clearance to land
21:31the crash of IFO-21 is finally confirmed
21:44the news races from Dubrovnik to America
21:48the crash site has been reached by Croatian police
21:51and I've just received word that there's also a Croatian doctor on the scene
21:59the tail section is the only substantial piece of IFO-21 that's left
22:05debris and bodies are scattered across the mountain
22:13these were hard moments as we were walking over the boulders
22:18not knowing if we're going to step on someone's body
22:21these are the moments that you can't forget
22:26then almost miraculously police make a heartening discovery
22:32inside the tail section they find a survivor
22:35it's technical sergeant Shelly Kelly
22:42as we arrived at the tail section one policeman went inside and found the body of a stewardess
22:49and he tried to help
22:51that was our hope we wanted to help
22:54we wanted to save every life and hers was our chance
22:58we were counting on it
23:00we were counting on it
23:06in the darkness they realize that Kelly needs immediate medical attention if she's going to survive
23:15when I realized that there was no one to help I radio the police central station in Dubrovnik
23:22and got them the location of the crash site
23:25by then it was completely dark
23:34St. John's Hill is alive with close to a hundred Croatian policemen and military
23:41American forces are also rushing to the scene
23:46enormous rocks and treacherous conditions make the wreck site difficult to reach
23:51but there are also remnants of the recent war
23:58Mike Canavan is in charge of the US crash recovery operation
24:03I've met a Croatian major
24:05he told me that he was going to be the guide
24:07that would take us up to the top of the mountain
24:10and at that time he happened to mention that
24:12there were several minefields between where we were and the crash site
24:19it takes almost two hours for Canavan to finally make it up the rocky hill
24:25we had been walking for some time
24:28and it was very dark
24:30and all of a sudden I saw something that was darker
24:32and I didn't know what it was
24:35and I reached out and it was an aircraft engine
24:41on top of the hill the weather is making it impossible for helicopters to land
24:46emergency workers can't wait for the weather to clear
24:49they have to get Technical Sergeant Kelly off the mountain immediately
24:56she has a broken spine and other severe injuries
24:59but if she can be kept alive rescuers hope she can shed some light on what went wrong
25:14with Kelly off the mountain the search for other survivors continues
25:26finally in the darkness rescue workers find the body of Ron Brown the US Commerce Secretary
25:36in fact as rescuers continue to comb the hillside all they find are bodies
25:46AJ Davis and the rest of the crew were probably killed instantly
25:54all the other members of the trade delegation are also killed
26:02as dozens of emergency workers continue their grim search a call comes from Dubrovnik
26:11Technical Sergeant Shelley Kelly is pronounced dead in the ambulance on route to hospital
26:19no one has survived the crash of IFO 21
26:27a grim spring rain hammers down on the mountains of Croatia
26:33near the Dubrovnik airport a 737 has crashed
26:37the jet was an American air forces plane on a trade mission through the region
26:45police and members of the military have searched for survivors
26:48but all 35 people who were on the flight are now dead
26:57including the American Secretary of Commerce Ron Brown
27:03in the darkness the rescuers begin a very different job
27:09Mike Canavan is with the US Special Forces
27:13once we realized there were no survivors
27:16the mission changes
27:18there's no one to rescue
27:20now
27:22you have to recover
27:23remains
27:30by dawn the weather has improved
27:32Peter Galbraith gets his first glimpse of the crash site
27:41we walked up the mountain the weather was somewhat better
27:47and near the top
27:49there was the fuselage of the plane
27:52rear part of it
27:54and debris all over the place
27:57and then on the other side of the ridge were the bodies
28:02there's nothing in the world that compares to a plane crash
28:09one thing that my folks did on the mountain
28:11and then down in Dubrovnik
28:13is they did this with dignity and respect
28:17and I thought it was done exceptionally well
28:28the vice president and first lady and the members of the cabinet and I wanted to come here
28:35to be with the employees of the Commerce Department at this very difficult hour
28:42Hillary and I have just come from
28:46Ron Brown's home visiting with Alma and Michael and their family and friends who were there
28:53as the truth sets in
28:55the hard questions begin
28:57how had a specially redesigned US Air Force 737
29:01crashed on a hillside in Croatia
29:04was it simply bad weather
29:06or in a war ravaged part of the world
29:09was there another cause
29:16purpose of the accident investigation team
29:18I can guarantee you that they will be extremely thorough in their analysis
29:22in trying to determine the causes of this accident
29:28because of the high profile nature of the passengers
29:31rumors begin swirling immediately
29:36Howard Swansea is one of dozens of experts assigned to the team
29:41in every accident there's always a lot of speculation
29:45in this particular case you had a high ranking US government official
29:49and so by the time we had even got to the crash site
29:51there was just quite a bit of media attention around it
29:57there were fragments pieces of aircraft miles away from the wreckage
30:04so my idea was to get as much information
30:06or collect as much artifacts of physical evidence as I could
30:13right from the start the investigation team is at a disadvantage
30:18they discover that there's no cockpit voice recorder
30:21or flight data recorder on the plane
30:24what's standard for passenger jets is not required in the Air Force
30:32I had assumed
30:36that the Air Force and these VIP flights had higher safety standards than commercial flights
30:42and so I was really shocked to learn that the standards were generally lower than those for commercial aviation
30:52without the standard tools investigators can't afford to overlook anything
30:59the wreck is almost three kilometers from the airport
31:02how did a trained crew get so far off course
31:11as Swansea examines the wreckage
31:14as Swansea examines the wreckage
31:16Nelson Spornheimer is brought in to look at other evidence
31:22an expert in aerial navigation
31:24he plots the plane's doomed final minutes
31:28to trace the last moments of the flight
31:30he turns to the sky and the US Air Force radar plane which had been patrolling the region
31:36IFO 2-1 this is magic 5-1
31:40be advised you are leaving an approved corridor
31:44please reroute immediately
31:45rerouting now to proper corridor
31:48over
31:53apart from heading out of approved airspace
31:56Spornheimer finds nothing unusual about the plane's flight
32:00until the end
32:03the radar track that I was given was from an AWACS aircraft
32:07and showed that the en route portions of the flight
32:10from about a hundred miles prior to the airport
32:12were entirely nominal
32:16the last segment of the flight however
32:18beginning 20 kilometers from the airport
32:21is different
32:23on their final approach the plane begins to head off course
32:27they start flying in a straight line
32:30which heads right into the mountains
32:35my initial
32:36look at the flight track of the aircraft
32:39showed a 7 degree bearing error in the final segment of the approach
32:45a small error when traveling at hundreds of kilometers an hour
32:49could quickly lead to an enormous problem
32:53but why would the plane get off course at the end of the trip
32:56if the rest of the flight showed no major navigational problems
33:00even in bad weather
33:02how had the crew become so lost
33:09Spornheimer examines the outdated navigational equipment at the airport
33:14badly damaged during the recent war
33:17perhaps it had malfunctioned
33:20two separate navigational beacons are used for landing in Dubrovnik
33:25one guides planes to the runway
33:27the other lets them know if they've gone too far
33:31the first is located on nearby Coliseb Island
33:35it transmits a specific Morse code signal to make it easily identifiable
33:41when they hear it all Davis and his crew need to do is fly a heading specified on their landing
33:47charts
33:48if they do they should eventually arrive at the airport
33:52the second beacon is located at the airport itself
33:55it's a fail-safe device
33:57if the crew hears the beacon before they see the airport
34:01they have to declare a missed approach and circle around to try landing again
34:09in fact the plane that brought Peter Galbraith to Dubrovnik just minutes before IFO 21 only landed on its second
34:17attempt
34:18IFO 21 I read you 9ACRO over
34:22adjusting the learning to split if you have to execute the missed approach
34:26over
34:28Roger 9ACRO we read you
34:31out
34:33but after studying the equipment
34:36Spornheimer doesn't believe it played a role in the crash
34:39both the non-directional beacons were found to be operating normally by flight tests within a few days after the
34:44accident
34:47there are bizarre rumors of an even more sinister theory
34:51perhaps Davis was following a decoy beacon put in the mountains on purpose
34:56in a troubled region
34:58was this an attack on the trade mission?
35:07to get a signal that is strong enough to be heard you have to have a very large ground system
35:11which is difficult to establish in rocky sandy soil
35:15so it would be very expensive and very time consuming to set up an NDB in the mountains
35:22such an elaborate scheme would be nearly impossible to pull off
35:26no evidence is ever found of a decoy beacon
35:29the investigation continues
35:39in the wreckage of the air force flight investigators discover an important piece of the puzzle
35:44the planes ADF or automatic direction finder is recovered
35:50it appears to be working
35:52but only one of the units had been installed on this jet
35:55to perform a proper landing in Dubrovnik
35:58a plane requires two ADFs
36:07the device listens to the signals put out by the land-based beacons
36:11but it can only listen to one at a time
36:14we're still not past it
36:16I'm tuned back to KLP
36:18flying with one ADF
36:20the crew can listen to either the beacon which is telling them how to get to the airport
36:24or the beacon which is telling them they've gone too far
36:27they can't do both at the same time
36:32that would have required two ADF receivers in the aircraft
36:36which the accident aircraft had only one
36:40and only having one ADF restricted their ability to follow the approach accurately
36:47I got CV
36:48we're still not past it
36:49I'm tuning back to KLP
36:51by quickly tuning back and forth between the two beacons
36:54the crew can use one ADF to listen to two signals
36:58but it would have added stress to an already difficult landing
37:03and it's another surprise
37:04the Air Force jet wasn't adequately equipped to land at this airport
37:13you're talking in a very short time span of making the approach
37:17it's going to become rather difficult
37:20in trying to dial both to keep listening to the code
37:23if you're also trying to search for your course and headings
37:27as he continues to study the path that IFO 21 took
37:32Nelson Spornheimer focuses on an S-shaped curve in the plane's flight
37:38it's the sort of path a plane would take when looking for a signal from a non-directional beacon
37:44but just when the crew should be looking for the beacon signal
37:47the S-turns disappear
37:50about two or three miles inside the final approach fix
37:53for the next seven or eight, nine miles
37:55the flight track is perfectly straight
38:00instead of trusting the navigational system that was in place
38:03even though it was primitive
38:05the crew suddenly seems to give up
38:08and Spornheimer thinks he knows why
38:14fighting heavy rain and hampered by a single direction finder
38:19Spornheimer believes the crew resorted to another even older piece of technology to find the runway
38:24something called INS or inertial navigation system
38:30an INS system uses gyroscopes to maintain an awareness of how much the airplane turns and banks
38:38after entering a specific geographical position at the beginning of a flight
38:42an inertial navigation system tracks all the turns a plane makes
38:46it's a self-contained system on the aircraft
38:50but there is a potentially enormous problem
38:54if the gyroscopes don't perfectly calculate every single manoeuvre of the plane
38:59a pilot can be off course
39:07it's not very broken up down there
39:09I can't see through it
39:11down?
39:13the crew might have thought that switching to this system would help them find their way
39:18but in this case it might have put the plane dangerously off course
39:24INS drift in this case was probably
39:26in my view the primary reason the aircraft ended up where it was
39:40investigator Howard Swansea examines the Jepsen approach chart the crew was using as they attempted to land
39:48hampered by poor visibility and relying on the inertial navigation system
39:52their charts would have been a key aid
39:58but when he takes a closer look at it
40:00he notices something peculiar
40:03a key figure
40:04the minimum descent altitude isn't accurate
40:08the minimum descent altitude is the height where pilots must be able to see the airport
40:13if you can't see it at that height you have to abort the landing
40:18each country
40:20has the responsibility of
40:23developing these procedures and then publishing information
40:27so that other
40:29nationalities as well as their own air crews can fly those approach procedures
40:34Swansea discovers that the minimum descent altitude on the chart doesn't meet American aviation standards
40:41given the mountainous terrain it should have been more than 2800 feet
40:46but the chart the crew was using said it was just over 2100 feet
40:52it means that the crew could have flown almost 700 feet lower than experts in the US thought was safe
40:58without having to abort the landing
41:02combined with the other problems the crew was dealing with the non-standard chart sealed their fate
41:08struggling to find the airport
41:10they were straining to see through the clouds
41:12assuming they were still safely above the mountains
41:34but why wasn't an air force jet properly equipped to land in Dubrovnik?
41:43and why didn't the crew have the right landing?
41:45and why didn't the crew have the right landing charts that would have made even a difficult flight safer?
41:54the answers are found at an American military base in Germany
41:58with some of the most senior members of the air force
42:09in the spring of 1996
42:11a US air force jet crashed just outside the airport in Dubrovnik, Croatia
42:16pull up!
42:23pull up!
42:24pull up!
42:25pull up!
42:35none of the 35 people on board IFO 21 survived
42:41the plane was a specially redesigned 737
42:45but the investigators have found that the crew didn't have the equipment it needed
42:50to safely land in the war-ravaged airport
42:54and that the charts they were using weren't up to American aviation standards
43:01to discover why the crew were attempting to land in such difficult circumstances
43:06the investigators question Colonel John Mazeroski
43:10he's the operations group commander for the airlift wing in charge of the flight
43:15his job is to provide transportation for a growing number of distinguished visitors
43:20but these are tight budget times
43:24Mazeroski has been told to do more with less
43:27what I'd like to talk about now is the Jepson approach subject
43:34one of the major focuses of the investigators is the Jepson landing charts the crew were using
43:40the charts drawn up for most major airports give crews a vast amount of information
43:46including what to do in the case of a missed approach
43:50but investigator Howard Swansea has already found that these charts were not up to U.S. standards
44:02the Air Force had a directive that required
44:07all procedures in foreign countries to have gone through a U.S. or their evaluation process prior to
44:13an Air Force crew being able to fly that approach
44:18landing at the Dubrovnik Airport had not been approved
44:21the Jepson landing charts that did exist for the airport had not been reviewed
44:26it's the reason that Howard Swansea found a difference between what the charts said
44:31and what was considered safe by the Defence Department
44:41Mazeroski believed that restricting his planes to approved airports would severely limit some of his missions
44:47it takes time to check all the airports out
44:50he had asked for the review to be waived for some airports including Dubrovnik
44:56this Jepson approach waiver what caused you to initiate this
45:01it just seemed like we had been using these approaches for years
45:05safety didn't seem to be in question
45:09but the Defence Department waiver was never granted
45:13the approach for Dubrovnik was never approved
45:16yet even without the safety clearance the Air Force continued to land there
45:26the airport in Dubrovnik was far below modern standards
45:30the charts used to land there hadn't been checked by the Department of Defence
45:35nevertheless
45:36senior Air Force officials had decided to permit landing at Dubrovnik
45:40and other airports they were flying into
45:46in fact none of them have been approved in this timeframe
45:49not to my knowledge sir
45:53no
46:01in the end a fatal combination of factors had come together to cause the crash of IFO-21
46:10Dubrovnik approach
46:11IFO-21 level 1-0-0
46:14Dubrovnik approach good afternoon
46:16maintain 10,000 feet for beacon approach
46:19runway one turn
46:21IFO-21
46:23the crew were fighting bad weather
46:25they were landing in an unfamiliar airport
46:28which was hobbled by old technology
46:31the unapproved charts made a bad situation much worse
46:45after an investigation involving nearly 150 interviews
46:50the final report on the crash of IFO-21 exceeds 7,000 pages
47:02how much of the weeping we have done this last week
47:05because there were so many brilliant young people on that plane with him
47:13from different backgrounds and different racial groups
47:16why because Ron Brown could see in them
47:19the promise of a new tomorrow
47:30the results of the investigation fault several individuals and institutions
47:36Dubrovnik airport is singled out for an improperly designed instrument approach procedure
47:46today automatic direction finders are no longer needed to land at Dubrovnik
47:51the airport has replaced its approach equipment with the instrument landing system which was being delivered at the time of
47:58the accident
48:00I got CV
48:02the final report says AJ Davis and his cockpit crew are responsible for flight errors
48:09and like a bullet piercing the heart of Air Force operations
48:13leading military figures are blamed for a failure of command
48:21in the aftermath of the report
48:23two senior members of the Air Force are relieved of their posts
48:29the Air Force severely reprimands Colonel John Mazeroski for dereliction of duty
48:34he is demoted and eventually retires as a major
48:39thirteen other officers are also singled out for their roles in connection with the crash
48:46the Air Force also changed the way it did business
48:49all military aircraft were ordered to carry flight data recorders and cockpit voice recorders
48:55no aircraft is allowed to fly into an airport without approval from the Department of Defense
49:01not even for high ranking diplomats
49:08IFO 2-1
49:10sir we are inside the locator inbound
49:13IFO 2-1 roger
49:15cleared for beacon approach
49:16runway is black
49:19IFO 2-1
49:26the Air Force Command was held accountable for the accident
49:29but it's the pilots
49:31the crew and the passengers of IFO 2-1
49:35who paid the ultimate price for oversights made by the 86th Airlift Command
49:40too far along
49:42IFO 2-1
49:44IFO 2-1
49:45the Air Force sang the North
49:46IFO 2-1