Mayday (2013) s04e08 Episode Script

Wednesday, April 3, 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 cancelled 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 10,000m 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.
I obviously will do everything 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.
As Commerce Secretary, Brown is helping to rebuild the local economy.
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 'AJ'.
- Departure, IFO 21.
- IFO 21 From the cockpit, Davis can see some clouds ahead that he wants to avoid.
On the 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 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.
It means a lot of travelling, 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's looking.
The diplomats are expecting to arrive in Dubrovnik by mid-afternoon, but they've been running late all day.
I'll check to find out for sure, if you'd like.
Yeah, thank you.
Early would be good.
(Laughs) 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's aware that 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.
MAN: 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.
You're leaving an approved corridor.
Re-route.
Roger, Magic.
Our error.
Re-routing now to proper corridor.
Over.
(Mutters) For 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.
Ladies and gentlemen, could I have your attention, please? Unfortunately there will be a slight delay on our arrival into Dubrovnik.
Our DVs aren't gonna be happy at all.
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.
Dubrovnik Approach, IFO 21, level 100.
Dubrovnik Approach.
Good afternoon.
Maintain 10,000 feet for beacon approach.
Runway 12.
OK, descending to 10,000 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 'nondirectional beacons' to guide planes towards the runway.
In the aviation world, it's ancient technology.
There are many nondirectional 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's very familiar with the area.
He wants to let the crew know what to expect.
IFO 21, we landed about an hour ago.
Um, the weather wasn't minimum.
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.
5,000.
IFO 21, roger.
Descend to 4,000.
Report, Kilo Lima Papa.
Down to 4,000.
IFO 21.
Sir, madam, 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.
OK.
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 12.
IFO 21.
AJ Davis flies blind through heavy rain and cloud cover.
He expects to see the airport any second.
ALARM BEEPS No! - Ahhh! - Pull up! Pull up! BOOM! IFO 21.
Do you read? Just before three o'clock in the afternoon, Dubrovnik Tower loses all contact with IFO 21.
IFO 21, Dubrovnik Approach.
Do you read? IFO 21.
Do you read? 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.
(Man speaks Croatian) TRANSLATION: 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'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 centres.
(Speaks Croatian) But no-one has had any contact with IFO 21.
The search and rescue efforts focuses on the approach to the airport.
Perhaps the plane had ditched into the Adriatic.
MAN: At the time I was about 100 miles away.
I was in Brindisi, Italy.
We launched two of our MA53 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.
CANAVAN: 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 a 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.
SIRENS WAIL 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.
(Bajac speaks Croatian) TRANSLATION: 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.
5 hours after the crew called for clearance to land.
The crash of IFO 21 is finally confirmed.
The news races from Dubrovnik to America.
MAN: The crash site has been reached by Croatian police, and I've, uh I've just received word that there is 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.
(Bajac speaks Croatian) TRANSLATION: These were hard moments as we were walking over the boulders, not knowing if we were 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 Shelly Kelly.
(Bajac speaks Croatian) TRANSLATION: 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 realise that Kelly needs immediate medical attention if she's going to survive.
(Bajac speaks Croatian) TRANSLATION: When I realised 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.
Mike Canavan is in charge of the US crash recovery operation.
CANAVAN: I met a Croatian major.
He told me that he was going to 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.
HELICOPTER WHIRRS 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.
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 hospital.
No-one has survived the crash of IFO 21.
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, 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.
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? 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.
And there were fragments and pieces of aircraft miles away from the wreckage.
So my idea was to get as much information, or collect as much artefacts or physical evidence as I could.
Right from the start, the investigation team is at a disadvantage.
They discover that there's no cockpit voice recorder or flight data recorder on the plane.
What's standard for passenger jets is not required in the air force.
I had assumed, er .
.
er, 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 3km from the airport.
How did a trained crew get so far off course? As Swancy examines the wreckage .
.
Nelson Spohnheimer 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 are leaving an approved corridor.
Please re-route immediately.
Re-routing 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 100 miles prior to the airport were entirely nominal.
The last segment of the flight, however, beginning 20km 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 travelling at hundreds of kilometres 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? Spohnheimer examines the outdated 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 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 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.
Adjust and divert into 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 nondirectional 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.
SWANCY: That would've 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.
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.
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 nondirectional beacon.
But just when the crew should be looking for the beacon's signal, the S-turns disappear.
SPOHNHEIMER: At about two or three miles inside their 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 manoeuvre 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 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, um has the responsibility of developing these procedures and then publishing information, so that other nationalities, as well as their own air crews, 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 2,800 feet, but the chart the crew was using said 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 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.
- ALARM BEEPS - Pull up! Whoa! Pull up! Pull up! No! BOOM! 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.
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 Jeppesen approach subject.
One of the major focuses of the investigators is the Jeppesen 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, um, 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 and 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.
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 timeframe.
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 100.
Dubrovnik Approach.
Good afternoon.
Maintain 10,000 feet for beacon approach.
Runway 1-2.
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 150 interviews, the final report on the crash of IFO 21 exceeds 7,000 pages.
BILL CLINTON: 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 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 is 12.
IFO 21.
The air force command was held accountable for the accident, but it's the pilots, the crew and the passengers of IFO 21 who paid the ultimate price for oversights made by the 86th Airlift Command.
Supertext Captions by Red Bee Media Australia