Original subtitles

A 737 is in trouble.

The pilots are blinded by rain.

In the cabin are 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.

Ladies and gentlemen...

We've lost both engines.

Put the mask over your nose.

Emergency descent.

Mayday! Mayday!

Brace for impact!

I think I lost one.

It's gonna crash!

Wednesday, April 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 hurries 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

33,000 feet in the sky.

Today, the cabin is filled with what the military calls

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.

I obviously will do everything that is proper...

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

and business leaders,

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.

On approach to Dubrovnik is IFO-21.

Its pilot is Captain Ashley J. Davis.

His colleagues call him AJ.

Departure, IFO-21.

From the cockpit, Davis can see some clouds

ahead that he wants to avoid.

Come left here,

just a couple of miles from build-up.

IFO-21, this is approved as requested.

Climb and maintain flight level 160.

Up to 160 now.

IFO-21.

It's 2:00 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 in the front line

of American military efforts.

In the past, he flew mid-air 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,

Shelly Kelly is a technical sergeant.

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

have everything they need.

Mr. Secretary, something to eat?

No, no. Thank you.

I was wondering how our time is looking.

The diplomats are expected

to arrive in Dubrovnik by mid-afternoon,

but they've been running late all day.

But 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, have a copy?

Over.

IFO-21, copy loud and clear.

Weather for Lima Delta Uniform as follows.

Rain, sky conditions 500, broken.

That would be ceiling.

How well do you copy?

Metro, IFO-21 copies.

Yeah.

We've been in it all day.

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 reroute 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 airspace.

They're flying into potentially dangerous territory.

Repeat.

You're leaving an approved corridor.

Reroute.

Roger, Magic.

Our error.

Rerouting now to proper corridor.

Over.

The 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 15 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.

DVs aren't going to be happy at all.

That weather 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.

As IFO-21 approaches the airport,

the rain isn't letting up.

But the crew is dealing with more

than just bad weather.

A 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.

And 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.

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 Ambasaddor Galbraith, had touched

down earlier in Dubrovnik.

The pilot of that plane is an experienced flier 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 minimum.

Suggesting diverting to Split if you have to execute

the 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, 5,000.

IFO-21, roger. Descend to 4,000.

Report Kilo Lima Papa.

Down to 4,000, IFO-21.

Sir. Thank you.

Flying above the storm, the crew

finally hears the radio signal from the first beacon.

Hey, AJ. At Kilo Lima Papa, we're tracking

outbound at 119 degrees.

119 confirmed.

Mr. Secretary, we're landing.

We'll take this up later, Adam.

It sounds 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, please go on.

IFO-21.

AJ Davis flies blind through heavy rain and

cloud cover.

He expects to see the airport any second.

Pull up! Pull up!

IFO-21, do you read?

Just before 3:00 in the afternoon,

Dubrovnik tower loses all contact with IFO-21 .

IFO-21, Dubrovnik approach, do you read?

IFO-21, do you read?

Without an 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, and he said,

we've lost radio contact with Ron Brown's plane.

I got the State Department Operations Center

on the phone.

And he 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 100 miles away.

I was in Brindisi, Italy.

We launched two of our MH-53 helicopters

with Special Tactics Air Force personnel

on board, 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, Dubrovnik approach, do you read?

IFO-21, do you read?

IFO-21, do you read?

As the hours pass, poor visibility

frustrates the searchers.

They arrived off the coast,

and 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,

4 and 1/2 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.

Then almost miraculously, police

make a heartening discovery.

Inside the tail section, they find a survivor.

It's Technical Sergeant Shelly Kelly.

As we arrived at the tail section,

one policemen 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.

Enormous rocks and treacherous conditions

make the wreck site difficult to reach.

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 several 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.

AJ 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 Shelly Kelly is

pronounced dead in the ambulance en route

to the hospital.

No one has survived the crash of IFO-21.

Once we realized there were no survivors,

the mission changes.

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,

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.

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 the 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.

Hillary 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 redesigned 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?

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, rumors

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 or physical evidence as I could.

Right from the start, the investigation team

is at a disadvantage.

They discover that there was 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 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 two miles from the airport.

How did a trained crew get so far off course?

As Swancy examines the wreckage,

Nelson Sponheimer is brought in 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,

Sponheimer finds nothing unusual about the plane's

flight, until the end.

The last segment of the flight, beginning

almost 12 and 1/2 miles 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 7-degree bearing error in the final segment of the approach.

A small error when traveling

at hundreds of miles 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?

Experts question whether the airport's

outdated navigational equipment may be partly to blame.

Two separate navigational beacons are

used for landing in Dubrovnik.

The first is located on nearby 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 the inner marker,

which lets pilots know that they

need to be able to see the runway

to continue the approach.

Otherwise, they must 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 approach, over.

Roger.

9A-CRO, we read you.

Out.

But after studying the equipment,

Sponheimer 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 rumors of an even

more sinister theory.

Perhaps Davis was following a decoy beacon put

in the mountains on purpose, but

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 in 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 KOP.

Flying with only one ADF, the crew

can listen either to the outer beacon at Kolocep

or the inner beacon at the airport,

but both beacons are needed for a proper approach.

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 got CV.

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

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.

The Air Force jet wasn't adequately equipped to land

at this airport.

They're talking in a very short time span

of making the approach.

It's going to 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's Sponheimer 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 2 or 3 miles

inside the final approach fix.

For the next 7 or 8, 9 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 Sponheimer thinks he knows why.

Fighting heavy rain and hampered by a single direction finder,

Sponheimer believes the crew

turned to a newer technology called INS,

or Inertial Navigation System, to find the runway.

But INS is an en route navigational system

and should not be used for airport approach.

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 sounds 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 Jeppesen 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

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 over 2,800 feet,

but the chart the crew was using

showed it was just over 2,100 feet.

It means that the crew could have flown almost 700 feet

lower than experts in the US thought

was safe without having to abort the landing.

Combined with the other problems

the crew is 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 this difficult flight safer?

To discover why the crew was attempting

to land in such difficult circumstances,

the investigators questioned 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 times for budgets.

Mazurowski has been told to do more with less.

Investigators focus on the Jeppesen landing charts

the crew is 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 chart said and what the Department of Defense

considered safe.

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, and safety

didn't seem to be in question.

But the Department of Defense 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 100.

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 have been approved in this time frame.

Not to my knowledge, sir.

No.

In the end, a fatal combination of factors

came together to cause the crash of IFO-21.

Dubrovnik approach, IFO-21, level 100.

Dubrovnik approach, good afternoon.

Maintain 10,000 feet for beacon approach.

Runway 812.

IFO-21.

The crew was fighting bad weather.

They were landing at an unfamiliar airport,

which was hampered by outdated technology.

The unapproved charts made a bad situation much worse.

After an investigation involving nearly 150 interviews,

the final report on the crash of IFO-21

exceeds 7,000 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

faults 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 in 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 AJ 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.

13 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 inside the locator, inbound.

IFO-21, roger.

Cleared for beacon approach.

Runway, please go on.

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.