Crash of Brown's jet was months in making Report by Air Force apportions responsibility


WASHINGTON -- The Air Force jet that carried Commerce Secretary Ron Brown through the clouds over Dubrovnik, Croatia, April 3 was flying to a catastrophe that had been months in the making but might have been avoided seconds before it smashed into a mountain, killing 35.

The chain of causes began with erroneous Croatian landing guidelines and ended with a harried air crew, rushing fatally through its landing procedures, flying off course and almost 90 mph too fast.

In between, the Air Force said in a 21-volume crash report released yesterday, top commanders of the jet's squadron had baldly ignored Air Force orders that forbade landings at airports like Dubrovnik's in poor visibility.

The report also said that while the jet, a military version of the Boeing 737, lacked on-board navigational aids needed to land in bad visibility at Dubrovnik, the crew was unaware of that.

It condemned Air Force training procedures for not having its pilots properly schooled in the difficulties of landing at poorly equipped airports of the former Soviet Bloc.

And, in wrenching detail, it described how Air Force Sgt. Shelly A. Kelly, 36, a flight attendant from Zanesville, Ohio, survived with a broken back for almost seven hours in the rain and wreckage before dying when rescue crews finally reached the site.

Kelly was the only one to survive the 50-to-100 Gs exerted on the victim's bodies by the impact. Brown and 33 others on the jet were probably killed instantly, the Air Force said.

The report was blunt -- as was a grim Air Force chief of staff Ronald Fogleman at an afternoon Pentagon briefing. President Clinton said the Air Force had been "thorough and prompt and brutally honest in its evaluation of what went on."

Three Air Force officers -- including a veteran brigadier general -- already have been relieved of duty because of the crash, and Fogleman said an investigation is under way to see if they or others will be court martialed.

The tragedy occurred when Brown and an entourage of Commerce Department officials and private businessmen were on the first day of a fast-paced trip to the Balkans to help rejuvenate the region's war-torn economies.

The report said their neither the pilot, Capt. Ashley J. Davis, 35, of Baton Rouge, La., nor the co-pilot, Capt. Tim Schafer, 33, of Newport Beach, Calif., had ever flown into Dubrovnik's Cilipi airport before.

With bad visibility, the pilots had to use their instruments to find the runway. But the main instrument aid on the ground was a crude beacon that broadcast a radio signal from an island off the Croatian coast.

The Air Force had recently banned such landings because it feared the approach instructions about altitude and other factors might be incorrect.

But commanders in charge of Brown's plane had disregarded the ban because they had to fly into such poorly equipped Eastern European airports regularly.

There were further problems. The pilots had a device on board called an automatic direction finder (ADC) to pick up the airport's radio beacon.

But there was a second radio beacon at the north end of the runway that was designed to warn the pilots if they were overshooting their approach.

To pick up the signal from the second beacon, however, the jet needed a second ADC, which it did not have.

Finally, perhaps because they were rushing, they simply steered the wrong course.

Pub Date: 6/08/96

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