[FWD] The T-43A Accident in Dubrovnik

From:         Alain.Deckers@man.ac.uk (Alain Deckers)
Organization: I speak for nobody but myself
Date:         02 Jun 96 23:01:52 
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Since it might be of interest to the readership of this group, I am
forwarding the following item published in RISKS Digest 18.08 (on

[A courtesy copy of this message has been sent to the original author.]

--------------- Begin forwarded message ---------------

RISKS-LIST: Risks-Forum Digest  Monday 29 April 1996  Volume 18 : Issue 08

ACM Committee on Computers and Public Policy, Peter G. Neumann, moderator


Date: Mon, 29 Apr 1996 21:56:27 +0200
From: ladkin@TechFak.Uni-Bielefeld.DE
Subject: The T-43A Accident in Dubrovnik

There are many articles in RISKS wondering about various aspects of the
safety of increasing automation in aircraft. We should remember that
increased automation can also help to avoid accidents.

Nancy Leveson (RISKS-17.21) pointed out some incidents in which TCAS (the
Traffic Avoidance and Collision Alert System) seems to have helped avoid
collision accidents. In RISKS-17.89, I referred to a report that the US
Navy was speeding up acquisition of digital flight control systems for
F-14s to help avoid loss-of-control accidents.

There is another example in recent news.  From newspaper reports, it seems
as if the safety of flight IFOR 21, a US Air Force T-43A (a type of
B737-200) which crashed on approach to Dubrovnik, Croatia, could have been
enhanced by more modern navigation equipment. This flight carried US
Secretary of Commerce Ron Brown.

The USAF does not normally release results of its investigations to the
public. So I have summarised facts from a short *Washington Post* article,
two articles from *Flight International*, and a *New York Times Service*
feature article that appeared in the *International Herald Tribune* on
Monday 29 Apr 1996. I also include some of my own observations and (a link
to) the approach plate (map) for the Dubrovnik NDB Runway 12 approach that
the aircraft was in course of executing. This summary is available in the
Compendium `Computer-Related Incidents and Accidents...'  under my WWW home
page at http://www.techfak.uni-bielefeld.de/~ladkin/

Peter Ladkin

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