Ronald Brown Crash Avoidable, AF Report Says

The Air Force conceded Friday that the crash that killed Commerce Secretary Ronald H. Brown in Croatia last April could have been averted if the pilots and their senior commanders had followed rules for instrument landings at poorly equipped airports.

In an unusually blunt report, the service said the failure of the senior commanders to inspect the Dubrovnik airport properly--and mistakes made by the pilots in guiding the plane toward the landing field--were the primary causes of the crash, which claimed 35 lives.

Gen. Ronald R. Fogleman, the Air Force chief of staff, said the service took full blame for the mishap. “The United States Air Force was given the mission to provide operational support airlift” for Brown, he told reporters at a briefing. “We failed to execute that mission.”

Fogleman, who earlier this month relieved the three senior commanders involved, disclosed Friday that the Air Force has appointed a special inquiry officer to review the case and determine whether anyone involved should be court-martialed as a result of the crash.

The conclusions came in a 22-volume, 7,100-page report detailing the errors that led to the tragedy and outlining dozens of steps that the Air Force is taking to avoid future accidents in similar circumstances.

President Clinton, who was briefed on the investigation Thursday, called the report “completely thorough and prompt and brutally honest.” He added: “I kept thinking that . . if only one or two little things had happened, the crash might not have occurred.”

The report, compiled with the help of a 10-member advisory group, brushed aside several factors that it said did not contribute to the crash--including the stormy weather and possible pressure from Brown and his staff to fly to Croatia despite it.

But the document cited a series of contributing causes, from the failure of senior commanders to carry out instructions that would have banned instrument landings under such conditions to mistakes made by the pilots while the aircraft was on approach.

Specifically, the report said the pilot and co-pilot made mistakes in planning and routing the flight, began their approach too soon, flew too fast and on an improper course and failed to identify a critical turnaround point.

It said that, as a result, the aircraft not only was flying too fast but was too low and much closer to the mountains that surrounded the airport than it should have been. The plane eventually crashed into the rocky hillside.

Fogleman told reporters that, apart from the tragedy itself, what concerned him most was that commanders of the 86th Airlift Wing, which had responsibility for the jetliner, had not followed Air Force instructions in prohibiting instrument landings at that airfield.

He said a recent survey of pilots attached to the unit had shown that 50% of them were unaware that they were forbidden to make instrument landings at airports that are not formally certified for such approaches.

Fogleman cited dozens of steps that the Air Force is taking to prevent such crashes in the future, from stepping up training for pilots to reviewing its worldwide safety standards--and tightening prohibitions on instrument landings at poorly equipped airfields.

The Air Force chief said he does not know why the performance of the two pilots was so far below par on the day of the crash, except to suggest that a delay caused by improper routing may have made them eager to rush through the landing phase in an effort to touch down on time.

“What you begin to see was a series of events that put pressure on the crew to get in on time,” he said.

Besides command errors and mistakes by the pilots, the report also blamed what it said was a badly designed Croatian instrument landing system, which used primitive equipment that was not up to the job in the kind of terrain common to the area.