Investigation Summary
The accident occurred during a high-profile trade mission to the Balkans. The aircraft (MSN 20696/347, manufactured in 1974) was attempting a non-directional beacon (NDB) approach to Runway 12 at Dubrovnik Airport, a procedure that was not approved for Department of Defense aircraft because it had not been properly reviewed by U.S. military authorities. The approach required two Automatic Direction Finders (ADFs) to track the course and identify the missed approach point simultaneously, but the CT-43A was only equipped with one. Furthermore, the crew was flying significantly faster than the recommended approach speed and deviated 9 degrees from the published inbound course. The aircraft was not equipped with a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR); this absence forced investigators to reconstruct the flight path and sequence of events using ground-based radar data and wreckage distribution analysis. The crash site was located on a 2,300-foot hill, 1.8 nautical miles north of the approach end of runway 12.
Final Conclusions
The U.S. Air Force Accident Investigation Board concluded the crash was a result of controlled flight into terrain (CFIT). The primary causes were a failure of command to ensure the approach procedure met safety standards, aircrew errors in navigation and speed management, and an improperly designed instrument approach procedure. The board also noted that the crew was rushed and failed to execute a missed approach despite being off course and beyond the missed approach point.
Photographic Evidence (1)
Video Analysis
The Crash Of Flight IFO-21 That Shocked The World | Mayday — A detailed look at the 1996 crash of a USAF CT-43 carrying Secretary of Commerce Ron Brown, examining the navigational errors and regulatory failures that led to the disaster.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
Ashley Davis (Pilot)
Captain
Tim Shafer (Pilot)
Systems & Failure Modes
Automatic Direction Finder (ADF)
The primary navigation instrument used for NDB approaches; the aircraft lacked the second unit required to identify the missed approach point.
Non-Directional Beacon (NDB)
A ground-based radio transmitter used for navigation; the approach at Dubrovnik relied on two such beacons (KLP and CV).
Interesting Facts
- 01The aircraft was a Boeing 737-200 modified for executive transport and lacked both a CVR and an FDR.
- 02The Dubrovnik NDB approach required two ADFs, but the aircraft only had one installed.
- 03The crew flew a course of 110 degrees instead of the published 119 degrees.
- 04The minimum descent height on the Croatian chart was 2,150 feet, which was lower than the surrounding terrain.
- 05One flight attendant, Shelly Kelly, initially survived the impact but died of her injuries en route to the hospital.
Safety Actions & Advisories
CVR/FDR Retrofitting
The U.S. Air Force mandated the installation of flight data and cockpit voice recorders on all transport aircraft following the discovery that their absence hindered the investigation.
Approach Procedure Review
Strict enforcement of the requirement for U.S. military authorities to review and approve all non-U.S. instrument approach procedures before use by DoD aircraft.
GPS Implementation
Accelerated the adoption of GPS-based navigation to reduce reliance on obsolete and less precise NDB approaches.