All language subtitles for Mayday.S04E08.Fog.of.War.1080p.AMZN.WEB-DL.DD+2.0.H.264-playWEB_track3_[eng]

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.