Original subtitles

A 737 is in trouble. The pilots blinded by rain.

In the cabin, government officials

and influential businessmen.

The crash of IFO-21 shocks the world.

Did a final act of war bring the plane down?

The White House demands answers.

This was no ordinary flight -

but a military jet carrying American politicians.

When the investigation is over -

the Air Force itself is held responsible.

Wednesday April the 3rd, 1996.

A raw spring day near the city of Dubrovnik, Croatia.

Rain pelts the runway at the city's airport.

A small group of diplomats hurry through the storm,

trying to keep dry.

They're part of a delegation that's just touched down.

Among them-- the Croatian Prime minister--

and the American ambassador to the region, Peter Galbraith.

The flight into Dubrovnik was a scary flight.

We couldn't see anything at all.

At that point I'd been ambassador to Croatia

for nearly three years and I'd done a lot of shuttle

diplomacy and it certainly was one of the most uncomfortable.

The weather that made Galbraith's landing

so bad isn't letting up.

In fact, commercial flights into Dubrovnik have been canceled.

But the ambassador and the others

aren't waiting for a commercial flight.

They're here to greet IFO-21,

a US Air Force jet on a delicate mission.

The plane is a specially designed 737.

The Air Force has a small fleet of these jets to transport

high-profile guests around the world.

The cabin has everything needed to do business,

and politics 10-thousand metres in the sky.

Today the cabin is filled with what the military call DVs--

Distinguished Visitors.

This group is led by United States Secretary

of Commerce Ron Brown.

Ron Brown was a very smooth capable individual.

He was a Washington insider

and he had all the skills that go with that.

Brown is a star in the Democratic party.

He played an important role

in getting Bill Clinton elected president.

Under Clinton, Brown was appointed

the first African American Commerce secretary

in the country's history.

The United States companies that are here

today are eager to engage in dialogue with government

businesses and more importantly to do business.

Today, that job has taken

Brown to one of the most troubled areas in the world.

For four years, civil war ripped Bosnia and Croatia apart.

But just a few months ago, an uneasy peace began.

As Commerce secretary,

Brown is helping to rebuild the local economy.

The philosophy behind it was that the peace would

not be durable unless there was economic progress

in the region, that that was really critical to the peace.

Brown's three-day tour started that

morning in Tuzla, Bosnia where the group toured an electrical

plant and ate hamburgers with American troops stationed there.

Being a former army man myself,

I know what being away from home is like so we thought

we would bring a little bit of home to you.

The final stop on today's tour is the ancient

coastal city of Dubrovnik.

Before the war, it was a vital part

of the country's tourism industry.

It was my idea that Ron Brown should go to Dubrovnik.

The Croatians were very eager to get the word out that Dubrovnik

was still standing and that it was still a tourist destination.

So I thought it would be very useful to have Ron Brown

and the delegation go there.

But on this damp day Dubrovnik is not at its best

or even visible.

Fog presses down from the sky obscuring the city

and the beautiful Adriatic coast.

To the north of Dubrovnik flies IFO-21.

Its pilot is captain Ashley J. Davis.

His colleagues call him A.J.

Departure IFO-21. IFO-21 go ahead.

From the cockpit,

Davis can see some clouds ahead that he wants to avoid.

Yeah we're going to need to come left here just

a couple of miles for a buildup.

IFO-21, this is approved as requested.

Climb and maintain flight level one six zero.

Up to one six zero now. IFO-21.

It's two o'clock in the afternoon.

AJ Davis and his crew have been on the go since dawn.

While the cabin of this plane is built for comfort,

the cockpit is virtually identical

to a standard issue 737.

AJ Davis grew up in Baton Rouge Louisiana

and dreamed of being a pilot.

He made it and has been on the front line

of American military efforts.

In the past, he flew midair refuelers

high above the Persian Gulf.

But now he pilots diplomats

and other officials from around the world.

It means a lot of traveling -

and a lot of time away from his wife

and two children at Ramstein, an American base in Germany.

According to the Air Force ranks,

Shelley Kelly is a technical sergeant.

Today on IFO-21, her main job is to make sure the passengers

have everything they need.

Mister secretary, something to eat?

No, no thank you.

I was wondering how our time's looking.

The diplomats are expecting to arrive

in Dubrovnik by mid-afternoon.

But they've been running late all day.

I can check to find out for sure if you'd like.

Yeah, thank you. Early would be good.

As the plane nears Dubrovnik, AJ Davis calls

the United States Air Force weather service for an update.

Metro IFO-21 how copy? Over.

IFO-21 copy loud and clear.

Weather for Lima Delta Uniform as follows.

Rain, sky conditions 5-hundred, broken. That would be ceiling.

How well do you copy? Metro IFO-21 copies.

Yeah we've been in it all day.

Are you expecting any changes in the weather?

Pretty much continued rain. Over.

Copy. Rain. Thanks for your help.

So let's see the sights of Dubrovnik.

Only four months after a peace treaty was signed,

the skies over this part of the world aren't

guaranteed to be friendly.

Planes are still required to fly

in certain highly restricted lanes.

While he is aware there are flight restrictions,

Davis has never flown in this part of the world before.

As he nears the Croatian border, he gets an unexpected warning.

IFO-21 this is MAGIC 51.

MAGIC is the call sign for the peacekeeping

Airborne Early Warning aircraft that watches air

corridors like a traffic cop.

Be advised you are leaving an approved corridor.

Please re-route immediately.

Davis isn't off course.

He's flying the exact route he had planned--

but without knowing it,

Davis and his plane are flying out of approved air space.

They're flying into potentially dangerous territory.

Repeat, you are leaving an approved corridor. Reroute.

Roger MAGIC. Our error.

Rerouting now to proper corridor. Over.

Second time today.

The approved corridors do change.

And Davis and his crew should have been informed.

To stay on an approved course,

Davis will have to swing out to the west.

It's an embarrassing situation--

that's going to cost them time.

Shelly. AJ. We've been directed to reroute.

We'll be arriving about fifteen minutes late at Dubrovnik.

Apologies to all back there.

Ladies and gentlemen,

could I have your attention please?

Unfortunately there will be a slight

delay on our arrival into Dubrovnik.

The DVs aren't gonna be happy at all.

And that weather ahead will probably slow us down even more.

Outside his plane,

the heavy rain continues to crash down.

Flying toward an unfamiliar airport with a cabin full of

businessmen and diplomats, Davis has a difficult task ahead.

What happens to this plane-- and its passengers--

over the next several hours

will capture the attention of the world.

A heavy rain soaks a small

airport in Dubrovnik, Croatia.

Headed towards it is a US Air Force 737

carrying 35 people on a trade mission.

Leading the delegation - US secretary of Commerce Ron Brown.

Dubrovnik approach IFO 21, level one, zero, zero.

Dubrovnik approach. Good afternoon.

Maintain 10-thousand feet for beacon approach runway one two.

Okay, descending to 10-thousand feet, IFO-21.

The weather is so bad today

that commercial flights have been cancelled.

As they approach the airport, the rain isn't letting up.

But the crew is dealing with more than just bad weather.

The recent civil war has taken a heavy toll

on Dubrovnik's airport.

It had been closed for several years--

and is waiting for a new landing system.

The airport was totally trashed by the Serbs who

had taken over the airport during the '91 war.

They really went out of their way for the destruction.

They destroyed the instrument landing system.

The new one was on order.

Around the world, airports use sophisticated

technology to help planes take-off and land.

Doppler radar warns of incoming storms.

Glide slopes help pilots stay on course to land.

The devastated Dubrovnik airport has none of that.

It doesn't even have radar to see the planes

that are coming in for landing.

Instead, the airport is using so-called non-directional

beacons to guide planes toward the runway.

In the aviation world, it's ancient technology.

There are many non-directional beacons used in

the United States and throughout the world but they're an

older navigational aid, and in fact they were on the way out.

The system in Dubrovnik has two

beacons on the ground, which send out signals to the plane.

When the crew receives the signals,

they consult their charts -

and follow the course that will take them to the airport.

The crew of IFO-21 is still waiting to hear the first

signal when they get a call from the ground.

9A-CRO to IFO-21.

IFO-21. I read you 9A-CRO. Over.

Another plane -

this one carrying Ambassador Galbraith -

had touched down earlier in Dubrovnik.

The pilot of that plane is an experienced flyer,

who is very familiar with the area.

He wants to let the crew know what to expect.

IFO-21, we landed about an hour ago.

The weather was at minimums.

Suggesting diverting to Split

if you have to execute a missed approach. Over.

Roger 9A-CRO. We read you. Out.

Diverting wouldn't be welcome

news for the members of the trade delegation.

The pressures to get the passengers to scheduled news

conferences and other activities were probably pretty high.

As Davis closes in on the airport,

the Dubrovnik Tower calls again.

IFO-21. Report Level. IFO-21 five thousand.

IFO-21 Roger.

Descend to four thousand, report Kilo Lima Papa.

Down to four thousand, IFO-21.

You'll have to put that away. Seatbelt? Sir, thank you.

Flying above the storm,

the crew finally hears the radio signal from the first beacon.

There it is.

At kilo lima papa we're tracking outbound at 1-1-9 degrees.

1-1-9 confirmed.

Mister Secretary? We're landing.

Okay. We'll take this up later Adam.

It's not very broken up down there.

I can't see through it. Tim?

The clouds are thick - the crew can't see the ground.

They have to trust their instruments

as they descend through the storm.

IFO-21. Sir we are inside the locator. Inbound.

IFO-21. Roger. Cleared for beacon approach.

Runway is wet.

IFO-21.

AJ Davis flies blind

through heavy rain and cloud cover.

He expects to see the airport any second.

IFO-21. Do you read?

Just before three o'clock in the afternoon,

Dubrovnik Tower loses all contact with IFO-21.

Without approach radar to track the plane,

controllers have no idea where it is.

Perhaps the plane has diverted to another airport.

IFO-21. Do you read?

But as the minutes stretch on

with no word from the American plane,

local controllers are taking no chances.

Initiate emergency procedures.

Near the end of our shift

we heard about the possibility of a missing plane.

We didn't know who was on the plane.

We had no details about the flight.

For situations like this there is a certain procedure,

and we just waited for more information.

Peter Galbraith is waiting at the airport

with Croatia's Prime Minister.

It was clear from my own flight

in that this was a very marginal landing.

I did not expect them to attempt the landing in Dubrovnik.

The Croatian prime minister came up to me and pulled me aside.

He said we have lost radio contact with Ron Brown's plane.

I got the state department operations

center on the phone and asked to activate the US

military to start search and rescue activities.

Word goes out to the chain

of Air Traffic Control centers--

But no one has had any contact with IFO-21.

The search and rescue effort

focuses on the approach to the airport.

Perhaps the plane had ditched into the Adriatic.

At the time I was about a hundred miles away.

I was in Brindisi, Italy.

We launched two of our MA 53 helicopters with special

tactics air force personnel onboard headed to Dubrovnik.

For hours, there is no sign of the missing aircraft.

The weather conditions are getting worse.

Fog was in, thunderstorms in the area. Low visibility.

IFO-21 Dubrovnik Approach. Do you read?

IFO-21 has a CPI

or Crash Position Indicator on board.

IFO-21. Do you read?

If the plane went down,

the CPI should be sending out an ultra-high frequency signal.

But the Dubrovnik Airport, as well as lacking radar,

does not have the equipment to pick up the signal.

IFO-21. Do you read? IFO-21. Do you read?

As the hours pass,

poor visibility frustrates the searchers.

They arrived off the coast.

They were over water looking for the crash.

Hours after the plane disappears,

police respond to a tip.

A local villager has seen something

on the hill above his house.

It's a long way from the coast

where the search is concentrated.

We went up with two vehicles to check the mountains.

The weather was extremely horrible,

strong rain and thick fog.

So we went on foot for about an hour up that mountain.

Then we came close.

It's almost 7:30 at night,

four and a half hours after the crew

called for clearance to land.

The crash of IFO-21 is finally confirmed.

The news races from Dubrovnik to America.

The crash site has been reached by Croatian police

and I've just received word

that there's also a Croatian doctor on the scene.

The tail section is the only substantial

piece of IFO-21 that's left.

Debris and bodies are scattered across the mountain.

These were hard moments,

as we were walking over the boulders, not knowing

if we're going to step on someone's body.

These are the moments that you can't forget.

Then, almost miraculously,

police make a heartening discovery.

Inside the tail section, they find a survivor.

It's technical sergeant Shelley Kelly.

As we arrived at the tail section one policeman went

inside and found the body of a stewardess and he tried to help.

That was our hope. We wanted to help.

We wanted to save every life and hers was our chance.

We were counting on it.

In the darkness, they realize that Kelly needs

immediate medical attention if she's going to survive.

When I realized that there was no one to help

I radioed the police central station in Dubrovnik

and got them the location of the crash site.

By then, it was completely dark.

St. John's hill is alive

with close to 1-hundred Croatian policemen and military.

American forces are also rushing to the scene.

Enormous rocks and treacherous conditions

make the wreck site difficult to reach.

But there are also remnants of the recent war.

Mike Canavan is in charge of the US crash recovery operation.

I met a Croatian major.

He told me that he was gonna be the guide that would take us

up to the top of the mountain

and at that time he happened to mention that there were

several minefields between where we were and the crash site.

It takes almost two hours for Canavan

to finally make it up the rocky hill.

We had been walking for some time

and it was very dark and all of a sudden

I saw something that was darker and I didn't know what it was,

and I reached out and it was an aircraft engine.

On top of the hill, the weather is making it

impossible for helicopters to land.

Emergency workers can't wait for the weather to clear.

They have to get Technical Sergeant Kelly

off the mountain immediately.

She has a broken spine and other severe injuries.

But if she can be kept alive,

rescuers hope she can shed some light on what went wrong.

With Kelly off the mountain,

the search for other survivors continues.

Finally, in the darkness, rescue workers find

the body of Ron Brown, the US Commerce Secretary.

In fact, as rescuers continue to comb the hillside,

all they find are bodies.

A.J. Davis and the rest of the crew

were probably killed instantly.

All the other members of the trade delegation

are also killed.

As dozens of emergency workers continue their grim search,

a call comes from Dubrovnik.

Technical Sergeant Shelley Kelly is pronounced dead

in the ambulance en route to hospital.

No one has survived the crash of IFO 21.

A grim spring rain

hammers down on the mountains of Croatia.

Near the Dubrovnik Airport, a 737 has crashed.

The jet was an American Air Forces plane

on a trade mission through the region.

Police and members of the military have searched

for survivors but all 35 people who were on the flight are

now dead including the American Secretary of Commerce Ron Brown.

In the darkness, the rescuers begin a very different job.

Mike Canavan is with the US Special Forces.

Once we realized there were no survivors,

the mission changes.

It goes from there's no one to rescue.

Now you have to recover remains.

By dawn, the weather has improved.

Peter Galbraith gets his first glimpse of the crash site.

We walked up the mountain.

The weather was somewhat better

and near the top there was the fuselage of the plane or

the rear part of it and debris all over the place

and then on the other side of the ridge were the bodies.

There's nothing in the world that compares to a plane crash.

The one thing that my folks did on the mountain,

and then down in Dubrovnik is they did this

with dignity and respect.

I thought it was done exceptionally well.

Ladies and gentlemen, the vice president

and first lady and the members of cabinet

and I wanted to come here to be with the employees

of the Commerce Department at this very difficult hour.

Hilary and I have just come from Ron Brown's home

visiting with Alma and Michael and their family

and friends who are there.

As the truth sets in, the hard questions begin.

How had a specially re-designed US Air Force 737 crashed

on a hillside in Croatia?

Was it simply bad weather or in a war-ravaged

part of the world, was there another cause?

The purpose of the accident investigation team.

I can guarantee you that they will be extremely

thorough in their analysis in trying to determine

the causes of this accident.

Because of the high-profile nature

of the passengers, rumours begin swirling immediately.

Howard Swancy is one of dozens of experts assigned to the team.

In every accident there's always

a lot of speculation.

In this particular case, you had a high-ranking US government

official and so by the time we had even got to the crash

site there was just quite a bit of media attention around it.

There were fragments,

pieces of aircraft miles away from the wreckage.

So my idea was to get as much information or

collect as much artifacts and physical evidence as I could.

Right from the start,

the investigation team is at a disadvantage.

They discover that there is no cockpit voice recorder or

flight data recorder on the plane.

What is standard for passenger jets is not

required in the Air Force.

I had assumed that that the Air Force

and these VIP flights had higher safety

standards than commercial flights

and so I was really shocked to learn that the standards

were generally lower than those for commercial aviation.

Without the standard tools,

investigators can't afford to overlook anything.

The wreck is almost 3 kilometres from the airport.

How did a trained crew get so far off course?

As Swancy examines the wreckage,

Nelson Spohnheimer is brought to look at other evidence.

An expert in aerial navigation,

he plots the plane's doomed final minutes.

To trace the last moments of the flight he turns to the sky--

and the US Air Force radar plane

which had been patrolling the region.

IFO-21, this is MAGIC-51.

Be advised you're leaving an approved corridor -

please reroute immediately.

Rerouting now to proper corridor. Over.

Apart from heading out of approved airspace,

Spohnheimer finds nothing unusual

about the plane's flight-- until the end.

The radar track that I was given

was from an AWACS aircraft and showed that the en route

portions of the flight from about a hundred miles

prior to the airport were entirely nominal.

The last segment of the flight however -

beginning twenty kilometres from the airport - is different.

On their final approach, the plane begins to head off course.

They start flying in a straight line -

which heads right into the mountains.

My initial look at the flight

track of the aircraft showed a seven degree bearing

error in the final segment of the approach.

A small error--

when traveling at hundreds of kilometers an hour--

could quickly lead to an enormous problem.

But why would the plane get off course at the end of the trip

if the rest of the flight showed no major navigational problems?

Even in bad weather, how had the crew become so lost?

Sponheimer examines the out-dated navigational

equipment at the airport.

Badly damaged during the recent war,

perhaps it had malfunctioned.

Two separate navigational beacons are used

for landing in Dubrovnik.

One guides planes TO the runway, the other lets them know

if they've gone too far.

The first is located on near-by Kolocep Island.

It transmits a specific Morse Code signal

to make it easily identifiable.

When they hear it, all Davis and his crew need to do is fly

a heading specified on their landing charts.

If they do-- they should eventually

arrive at the airport.

The second beacon is located at the airport itself.

It's a fail-safe device.

If the crew hears the beacon before they see the airport,

they have to declare a missed approach,

and circle around to try landing again.

In fact, the plane that brought Peter Galbraith to Dubrovnik

just minutes before IFO-21 only landed on its second attempt.

IFO-21. I read you 9A-CRO. Over.

Suggesting diverting to Split

if you have to execute the missed approach. Over.

Roger 9A-CRO. We read you. Out.

But after studying the equipment,

Spohnheimer doesn't believe it played a role in the crash.

Both the non-directional beacons were found to be

operating normally by flight tests

within a few days after the accident.

There are bizarre rumours

of an even more sinister theory.

Perhaps Davis was following a decoy beacon,

put in the mountains on purpose.

In a troubled region, was this an attack on the trade mission?

To get a signal that is strong enough to be heard you

have to have a very large ground system which is difficult to

establish in rocky, sandy soil so it would be very expensive

and very time consuming to set up an NDB in the mountains.

Such an elaborate scheme

would be nearly impossible to pull off.

No evidence is ever found of a decoy beacon.

The investigation continues.

In the wreckage of the Air Force flight,

investigators discover an important piece of the puzzle.

The plane's ADF-- or Automatic Direction Finder--

is recovered. It appears to be working--

but only one of the units had been installed on this jet.

To perform a proper landing in Dubrovnik

a plane requires two ADFs.

The device listens to the signals put

out by the land-based beacons.

But it can only listen to one at a time.

We're still not past it. I'm tuning back to KLP.

Flying with one ADF, the crew can listen to either

the beacon, which is telling them how to get to the airport,

or the beacon, which is telling them they've gone too far.

They can't do both at the same time.

That would have required

two ADF receivers in the aircraft

which the accident aircraft had only one,

and only having one ADF restricted their ability

to follow the approach accurately.

I've got CV. We're still not past it though.

I'm tuning back to KLP.

69 By quickly tuning back and forth between the two

beacons, the crew can use one ADF to listen to two signals.

But it would have added stress to an already difficult landing.

And it's another surprise-- the Air Force jet wasn't

adequately equipped to land at this airport.

You're talking in a very short time span

of making the approach.

It's gonna become rather difficult in trying to dial

both to keep listening to the code

if you're also trying to search for your course and headings.

As he continues to study the path

that IFO-21 took, Nelson Spohnheimer

focuses on an S-shaped curve in the plane's flight.

It's the sort of path a plane would take

when looking for a signal from a non-directional beacon.

But just when the crew

should be looking for the beacon signal,

the S-turns disappear.

About two or three miles

inside the final approach fix,

for the next seven or eight, nine miles,

the flight track is perfectly straight.

Instead of trusting the navigational system

that was in place, even though it was primitive,

the crew suddenly seems to give up.

And Spohnheimer thinks he knows why.

Fighting heavy rain and hampered by a single direction finder,

Spohnheimer believes the crew resorted to another even

older piece of technology to find the runway,

something called INS, or Inertial navigation system.

An INS system uses gyroscopes to maintain

an awareness of how much the airplane turns and banks.

After entering a specific geographical

position at the beginning of a flight, an inertial

navigation system tracks all the turns a plane makes.

It's a self-contained system on the aircraft.

But there is a potentially enormous problem.

If the gyroscopes don't perfectly calculate every

single maneuver of the plane, a pilot can be off course.

It's not very broken up down there.

I can't see through it. Tim?

The crew might have thought that

switching to this system would help them find their way.

But in this case,

it might have put the plane dangerously off course.

INS drift in this case was probably, in my view,

the primary reason the aircraft ended up where it was.

Investigator Howard Swancy examines the Jeppeson

approach chart the crew was using as they attempted to land.

Hampered by poor visibility and relying on the inertial

navigation system, their charts would have been a key aid.

But when he takes a closer look at it,

he notices something peculiar.

A key figure - the minimum descent altitude -

isn't accurate.

The minimum descent altitude is the height where pilots

must be able to see the airport.

If you can't see it at that height--

you have to abort the landing.

Each country has a responsibility of developing

these procedures and then publishing the information

so that other nationalities as well as their own aircrews

can fly those approach procedures.

Swancy discovers that the minimum descent altitude

on the chart doesn't meet American aviation standards.

Given the mountainous terrain it

should have been more than 28-hundred feet.

But the chart the crew was using said it

was just over 21-hundred feet.

It means that the crew could have flown

almost 7-hundred feet lower than experts in the US thought

was safe without having to abort the landing.

Combined with the other problems the crew was dealing with,

the non-standard chart sealed their fate.

Struggling to find the airport,

they were straining to see through the clouds,

assuming they were still safely above the mountains.

Pull up! Pull up! Pull up!

But why wasn't an Air Force jet properly

equipped to land in Dubrovnik?

And why didn't the crew have the right landing charts that

would have made even a difficult flight safer?

The answers are found

at an American military base in Germany -

with some of the most senior members of the Air Force.

In the spring of 1996, a US Air Force jet crashed

just outside the airport in Dubrovnik Croatia.

Pull up! Pull up! Pull up!

None of the 35 people on board IFO-21 survived.

The plane was a specially re-designed 737.

But investigators have found that the crew

didn't have the equipment it needed to safely land

in the war-ravaged airport and that the charts

they were using weren't up to American aviation standards.

To discover why the crew were attempting to land

in such difficult circumstances,

the investigators question Colonel John Mazurowski.

He's the operations Group Commander

for the airlift wing in charge of the flight.

His job is to provide transportation

for a growing number of distinguished visitors.

But these are tight budget times.

Mazurowski has been told to do more with less.

What I'd like to talk about now

is the Jeppeson approach subject.

One of the major focuses of the investigators

is the Jeppeson landing charts the crew were using.

The charts-- drawn up for most major airports--

give crews a vast amount of information,

including what to do in the case of a missed approach.

But Investigator Howard Swancy has already

found that these charts were not up to US standards.

The Air Force had a directive that required all

procedures in foreign countries to have gone through a US

or their evaluation process prior to an air force crew

being able to fly that approach.

Landing at the Dubrovnik airport

had not been approved.

The Jeppesen landing charts that did exist for the airport

had not been reviewed.

It's the reason that Howard Swancy found

a difference between what the charts said--

and what was considered safe by the defense department.

Mazurowski believed that restricting his planes to

approved airports would severely limit some of his missions.

It takes time to check all the airports out.

He had asked for the review to be waived

for some airports including Dubrovnik.

This Jeppesen approach waiver.

What caused you to initiate this?

It just seemed like we had been

using these approaches for years.

Safety didn't seem to be in question.

But the Defense Department waiver

was never granted.

The approach for Dubrovnik was never approved.

Yet even without the safety clearance,

the Air Force continued to land there.

Dubrovnik Approach. IFO-21 level one zero zero.

Dubrovnik Approach. Good afternoon.

The airport in Dubrovnik

was far below modern standards.

The charts used to land there hadn't been checked

by the Department of Defense.

Nevertheless, senior Air Force officials had decided to permit

landing at Dubrovnik and other airports they were flying into.

In fact none of them had been approved

in this time frame.

Not to my knowledge sir, no.

In the end, a fatal combination of factors

had come together to cause the crash of IFO-21.

Dubrovnik Approach. IFO-21 level one zero zero.

Dubrovnik Approach. Good afternoon.

Maintain ten thousand feet for beacon approach runway one two.

IFO-21.

The crew were fighting bad weather.

They were landing in an unfamiliar airport,

which was hobbled by old technology.

The unapproved charts made a bad situation much worse.

After an investigation involving

nearly 1-hundred and 50 interviews,

the final report on the crash of IFO 21 exceeds 7-thousand pages.

How much of the weeping we have done

this last week because there were

so many brilliant young people on that plane with him

from different backgrounds and different racial groups.

Why? Because Ron Brown could see in them

the promise of a new tomorrow.

The results of the investigation fault

several individuals and institutions.

Dubrovnik Airport is singled out for an improperly designed

instrument approach procedure.

Today, Automatic Direction Finders are no longer

needed to land at Dubrovnik.

The airport has replaced its approach

equipment with the Instrument Landing System which was

being delivered at the time of the accident.

I got CV.

The final report says A.J. Davis

and his cockpit crew are responsible for flight errors.

And - like a bullet piercing the heart of Air Force operations

leading military figures are blamed for a failure of command.

In the aftermath of the report, two senior

members of the Air Force are relieved of their posts.

The Air Force severely reprimands

Colonel John Mazurowski for dereliction of duty.

He is demoted and eventually retires as a Major.

Thirteen other officers are also singled

out for their roles in connection with the crash.

The Air Force also changed the way it did business.

All military aircraft were ordered to carry

Flight Data Recorders and Cockpit Voice Recorders.

No aircraft is allowed to fly into an airport

without approval from the Department of Defense,

not even for high-ranking diplomats.

IFO-21. Sir, we are in sight of the locator inbound.

IFO-21, roger. Prepare for beacon approach.

Runway two one.

IFO-21.

The Air Force Command

was held accountable for the accident.

But it is the pilots,

the crew and the passengers of IFO-21 who paid the ultimate

price for oversights made by the 86th Airlift command.