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Friday, June 7, 1996 - 12:30 p.m.
Dr. Sheila E. Widnall, Secretary of the Air Force, et al.
General Sconyers: Good afternoon. Today we will brief you on the results and subsequent corrective actions of the Accident Investigation of the CT-43 crash April 3rd, in Croatia which tragically killed 35 people including Secretary of Commerce Ron Brown. There are press kits available which you've already had issued to you. There will be three complete sets of the 22 volume report in the conference room directly across the hall from this press briefing room. If you want your own copy of the report it's available in Room 4D922 immediately following.
Secretary of the Air Force Sheila E. Widnall and Chief of Staff of the Air Force, Ronald R. Fogleman, will first make some preliminary remarks and then General Charles H. Coolidge, Jr., the Accident Investigation Board president, will brief you on the details of the results of the investigation. General Fogleman will then brief you on the corrective actions at all levels. Because of the detail of the report, we would ask that you hold your questions until General Fogleman has completed his briefing on corrective actions. Before I introduce Secretary Widnall, I would like to read a statement on behalf of Secretary of Defense William J. Perry.
The Air Force Accident Investigation Board report of the CT-43 crash is detailed and thorough. It shows that there was no single cause of the crash but concludes that several mistakes occurred simultaneously. Following the accident, the Department of Defense and the Air Force began making changes in equipment, training, procedures and personnel.
We will consider additional changes based on a complete evaluation of the investigation board's findings. Nothing we do will ease the pain and loss from the accident which cost families and the nation so much, but we will use lessons from the accident to make military aviation as safe as possible. Secretary Widnall.
Secretary Widnall: Let me open by expressing on behalf of all members of the Air Force my condolences to the families and friends of those lost in the tragedy. Those who perished were on a noble mission to restore hope and a normal life to the people of the Balkans. Their work and their vision for that war-ravaged land represent the best of America.
The briefing you will see in a moment represents the work of a great many people all of them focused on determining the causes of this tragedy, leaning what lessons we can from this experience, and ensuring that the Air Force sustains the standards of performance and responsibility that we have established over many years. The briefing represents as well the collaborative efforts of investigators from the Air Force, the NTSB, and the FAA, all working together towards those goals. All contributing their unique expertise towards building a comprehensive picture of this tragic accident.
The thorough and professional report that Major General Coolidge will present is an excellent example of cooperative work among government agencies. As with any such mishap, the investigation uncovered a chain of events and decisions which if broken, would have prevented this tragedy. The Air Force has already begun to take actions necessary to minimize the chance of another tragedy, to ensure that our commanders perform to the standards we have long established and upheld and to give the family members of those lost in this mishap a full report on what went wrong. The next step is to inform the American people fully and openly and that process begins here.
General Fogleman, our chief of staff, will now provide the operational context and introduce the Board President who will brief the Board results.
General Fogleman: The United States Air Force was given the mission to provide operational support airlift for Secretary of Commerce, Ron Brown and his party of American industrialists while they conducted various visits to sites throughout the Balkans. The purpose of the visit was to help with the restoration and the rehabilitation of the economies of those nations.
We failed to execute that mission. As a result of that failure, 35 lives were lost, 29 civilians to include Secretary Brown, some of the most distinguished business leaders in America, dedicated members of the Commerce Department, six members of the United States Air Force in addition to two Croatian nationals. Additionally, we destroyed a CT-43 Boeing 737 aircraft. Following the accident, we convened an accident investigation board.
The purpose of that board was to determine the relative facts and circumstances surrounding the accident and if possible, to determine the cause or causes of the accident. We made a very deliberate decision to conduct an accident investigation board vice a mishap investigation board. The reason was that we wanted all of the facts and circumstances to be releasable to the public and under the mishap board concept, it would have been privileged information that could not have been released.
We were prepared to provide both transactional and testimonial immunity if required to get the full cooperation and candid testimony of witnesses and participants. This investigation board was comprised of military and civilian aviation experts to include as was pointed out earlier, representatives of the Federal Aviation Administration, the National Transportation Safety Board, and Croatian Civil Aviation authorities.
The Air Force specifically asked the FAA and the NTSB to be part of this investigation because they brought expertise in Air Traffic Control, in approach procedures, air worthiness issues, and unique experience in investigating the 737 accidents that had occurred at Colorado Springs, and in Pittsburgh. The President of the Board was Major General Charlie Coolidge. General Coolidge will now present a briefing that outlines the facts and circumstances surrounding the accident and he will share the board's statement of opinion on the causes of the accident.
Following his briefing, I will present the corrective action that has been taken, that is currently underway, and that will be taken in the future, not only at the major command level as represented by Headquarters, United States Air Forces, Europe, but here at Headquarters, U.S. Air Force and within the Department of Defense in Washington. General Coolidge.
General Coolidge: Good afternoon. As General Fogleman has indicated, I'll be giving you a brief background on what we looked at in the course of the investigation. The Air Force's mission to provide airlift support to Secretary Brown and a sequence of events for the flight of the day of the accident. I will then discuss the results of our investigation and describe the causes of that accident. A contributing factor and other reported facts the 10-member board together with 30 technical and legal advisors thoroughly investigated the following areas: together they constitute the principle avenues of inquiry to determine the cause and circumstances of this accident. We were able to rule out many of them and ultimately narrow our focus to the areas relevant to this accident. I would like to point them out.
The weather at Dubrovnik worsened throughout the day and required the air crew to use an instrument approach procedure. Although it seriously hampered search and rescue efforts, the weather was not a substantially contributing factor or a cause of this mishap.
This table summarizes the weather during the day. By way of explanation, a ceiling is the altitude at which a layer of clouds blocks 5/8 or more of the sky. Visibility is the horizontal distance that can be seen below the ceiling. On the day of the accident, the weather remained good enough to allow the aircraft to land at Dubrovnik using an instrument approach. The times noted on the table and throughout this briefing, refer to local or central European time.
Other areas of investigation, included the following: while investigating all aspects of this mishap the Board discovered the mishap co-pilot's crew rest was interrupted on the night prior to April 3rd. While this was technically a violation of crew rest, the Board determined it was not a substantially contributing factor. No other member of the crew had his or her crew rest interrupted.
The Accident Board found the following areas to be relevant to this accident: mission planning, aircrew performance, policy and guidance, instrument approach, air crew training, search and rescue, and aircraft systems. I would like to acknowledge the help of the government of Croatia, the National Transportation Safety Board, and the Federal Aviation Administration. Their cooperation greatly assisted us in completing this investigation. As you know, the United States as part of NATO has been conducting a mission in Bosnia, Herzegovina.
On April 3rd, Secretary Brown and his party were on a mission to support these objectives. The Air Force provided Secretary Brown's party airlift from the 76th Airlift Squadron based at Ramstein Air Base in Germany. The 76th provides special mission Airlift Support to distinguished visitors from the White House, Congress, the Department of Defense, and other U.S. and foreign dignitaries. The 76th Airlift Squadron is one of three flying squadrons belonging to Ramstein Air Base's 86th Airlift Wing.
The commander, U.S. Air Forces in Europe or USAFE, has operational control of all airlift operational support airlift in the European Theater in the 86th Airlift wing. Requirements come directly from Headquarters United States Air Force Special Air Mission's Office at the Pentagon or from U.S. European command Stuttgart, Germany, and they go directly to the 76th Airlift Squadron through the USAFE Air Operations Squadron. Command is exercised by USAFE though the 17th Air Force, Sembach Air Base, Germany, the 86th Airlift Wing and the 86th Operations Group both at Ramstein Air Base in Germany.
On March the 27th, the 76th Airlift Squadron was tasked from Headquarters Air Force through the United States Air Forces in Europe to support Secretary Brown and his party. At the time of the accident, the 76th Airlift Squadron flew three types of aircraft: one CT-43 Boeing 737 200, the mishap aircraft, nine C-21 Lear Jet 35's and three C-20 Gulfstream 3's. The CT-43 was the only aircraft large enough to accommodate the size of Secretary Brown's party.
On April 2nd, the mishap crew was flown from Ramstein to Zagreb in a 76th Airlift Squadron C-21 to arrive in time to begin their crew rest and to wait for the mishap aircraft which was completing a mission in Egypt. Secretary Brown was flown from Paris to Zagreb by another 76th Airlift Squadron C-21. Other members of his party arrived by commercial air. The mishap aircraft was flown to Zagreb late that evening from Cairo, Egypt, having just completed a mission supporting the Secretary of Defense.
On April 3rd, the mission called for the Brown party to travel from Zagreb to Tuzla, then to Dubrovnik on the CT-43 to meet with the U.S. Ambassador to Croatia and the Croatian Prime Minister. Due to the length of Secretary Brown's visit in Tuzla, the crew would take the plane to Split , refuel, and return. At Dubrovnik, the flight crew would return to Zagreb and Secretary's Brown's party would return to Zagreb by commercial air.
Because of ongoing military operations and to provide safety of flight for NATO aircraft operating in Bosnia, Herzegovina, the Dayton Peace Accord calls for NATO to use a series of corridors to travel in and out of the country. NATO's special instructions require airlift aircraft to remain in the predetermined corridors. Each of the CT-43's flights for the day would require them to use the northern or southern corridor through Bosnia, Herzegovina.
On April 3rd, the CT-43 using the call sign IFO-21 short for implementation force departed Zagreb enroute to Tuzla at 6:24 a.m. At Tuzla, the secretary's delegation got off the aircraft to visit with U.S. troops. The aircraft and crew departed for Split, Croatia, because there was not sufficient ramp space to park the aircraft at Tuzla during the Secretary's 7-hour visit. After refueling at Split, the aircraft returned to Tuzla where Secretary Brown's party re-boarded for the flight to Dubrovnik.
IFO-21 departed Tuzla at 1:55 p.m. approximately five minutes ahead of schedule. Nine minutes after take-off in accordance with normal operating procedures, the crew contacted the U.S. Air Forces in Europe, European Operations Center at Ramstein and asked if there were any mission changes. They were told there were no mission changes from the current mission but were cautioned about the reports of fog at Dubrovnik. Approximately, two minutes later, IFO-21 contacted Air Force weather service and asked for Dubrovnik weather for the planned arrival time.
The weather report was 500 feet broken, 2,000 feet overcast, 5 miles visibility and rain. Sixteen minutes into the flight, following the route they had planned IFO-21 started a turn to the south towards Split. This route was not in one of the authorized corridors. After being reminded they were going out of the approved corridor, IFO- 21 requested routing through the southern corridor. Zagreb said that the corridor was closed in accordance with the special instructions for navigation within the country. IFO- 21 was then re-routed and provided a vector to join the northern corridor.
This flight planning error by the aircrew increased their flying time to Dubrovnik by about 15 minutes and put the Secretary's party behind schedule. Approaching the Croatian border, IFO-21 was transferred from NATO's controllers to Croatian civilian air traffic control. Twenty-one minutes into the flight, and 40 minutes before impact, IFO-21 was cleared for a left turn to Split. After crossing over Split, IFO-21 was cleared for and began a normal descent toward the Dubrovnik airport. As they neared Dubrovnik, IFO-21 was transferred to the Dubrovnik tower, a non-radar approach facility. The tower cleared IFO-21 to proceed directly to Kolocep or KLP non-directional beacon. They also cleared them to descend to 5,000 feet.
The weather at the time of the approach was reported as 400 feet broken, 2,000 feet overcast, 8 km or about 5 miles visibility, rain, surface winds for 120, 12 knots, because of the weather, the crew is required to fly an instrument approach procedure into Dubrovnik.
Instrument approach procedures are used when there are clouds or when visibility is limited. They enable the pilots to fly to a fixed point from whence they can see the air field. The only instrument approach procedures to the Dubrovnik airport available to the crew was a Croatian designed and commercially published non-directional approach, non-directional beacon approach or NDB. This commercial company publishes approach procedures by extracting the relevant information from the host country's approach chart.
The Dubrovnik NDB approach to runway 12 required the pilot to tune to the frequency of a beacon emitting an AM radio signal. Course guidance from the signal is displayed in the CT-43 radio -- on a radio magnetic indicator located on the pilot and co-pilot's instrument panel. The procedure required the pilot to overfly this beacon KLP to begin the final approach. After crossing the KLP beacon, on the final approach fix, the pilot would be then allowed to descend to 2,150 feet on the minimum descent altitude. The Dubrovnik approach requires that the pilot fly a 119 course from the KLP beacon until the pilot either sees the airfield and lands or reaches the missed approach point and executes a missed approach. In this case, the missed approach point is a second non-directional beacon called a locator and is identified as CV (Cavtat).
Due to rapidly rising terrain north of the airport, the missed approach procedure requires an immediate climbing right turn to the south. Even though the mishap aircraft did not have a cockpit voice recorder, or a flight data recorder, the accident investigation board was able to obtain critical information from several sources, including NATO E-3 airborne early warning radar tapes and the Dubrovnik tower voice tapes. From this data we were able to reconstruct the final approach sequence.
At seven minutes prior to impact, a pilot on the ground at Dubrovnik made a radio call to IFO-21 and told them he had landed about an hour earlier and the weather was near minimums for the approach. This same pilot who had flown the U.S. Ambassador and the Croatian Prime Minister to Dubrovnik testified that the crew acknowledged his radio call. Five minutes before impact, IFO-21 reported to the Dubrovnik tower they were sixteen miles from the airport.
The Dubrovnik tower cleared IFO-21 to descend to 4,000 feet and told them to report the KLP beacon. The radar data showed IFO-21 crossed the KLP beacon four minutes before impact at 4,100 feet. At one minute later, IFO-21 called the tower and reported they were inside the locator inbound and were then cleared for the approach and landing. We determined IFO-21's indicated airspeed when he crossed KLP was approximately 220 knots, or 80 knots faster than the computed approach speed for the aircraft's weight and configuration.
During an instrument approach, technical orders require the aircraft be properly configured and stabilized before starting the final approach. Having the aircraft configured properly at this point is necessary so that the pilot's attention is devoted to course, altitude, and the missed approach requirement. The CT-43 flight manual indicates that at this speed, IFO-21 could not have been properly configured when crossing the final approach fix.
Although the published final approach indicates a course of 119, IFO-21 tracked outbound from the KLP beacon on approximately 110 course until impact. To fly a course of 119 they would have had to correct for wind drift by flying a 125 heading. The winds were from the south at altitude. The radio magnetic indicator and horizontal situation indicator here depict what the co-pilot should have seen on the instruments in their cockpit. However, the pilot's selected heading approximately 10 degrees in error. Here is a depiction of the actual course the pilots flew. Instead of the proper heading, they selected a heading of 116 or 116 which resulted in the 110 or 110 course. Later data analysis also shows IFO-21 descended to 2,200 feet which is consistent with the published minimum descent altitude of 2,150 feet and they slowed to a normal final approach airspeed.
The pilots failed to identify the missed approach point and IFO-21 impacted a rocky mountain side at 2:57 p.m., more than one nautical mile beyond the missed approach point and 1.7 nautical miles to the left of the Dubrovnik runway. Ground speed at the time of impact was 140 knots. The aircraft was configured for landing and all aircraft systems were operating properly at the time of accident.
The following were causes of the accident: failure of command, aircrew error, and an improperly designed instrument approach procedure. Prior to 1994, non-DoD approved approaches were routinely flown by the Air Force. A change in the Air Force directive in 1994 required major commands to review non-DoD approaches such as the procedure for Dubrovnik for their accuracy and reliability prior to their use. The 86th Airlift Wing routinely operated into many air fields in Eastern Europe that do not have the DoD approved approaches.
In November, 1995, after a publication from the major command USAFE, supplement to the directive the wing realized the impact the directive would have on their operations. They requested a waiver to fly these approaches without review. They forwarded their request to the Air Force Flight Standards Agency through the USAFE Director of Operations and were told by USAFE they could continue to fly the approaches while awaiting a formal reply to their waiver request. However, on January 2nd, 1996, the waiver request to fly non-DoD approaches without a major command review was disapproved by Headquarters, Air Force because non-DoD approaches for some countries may be unreliable and need review to ensure safety.
After the USAFE staff told the 86th Airlift Wing the waiver had been denied and they had withdrawn their permission for crews to use the approach, the Wing chose to continue using non-DoD approaches. Based on a history of using the approaches for years, the Wing leaders erroneously believed the approach procedures to be safe. The day after the accident, the Wing rescinded the aircrew authorization to fly non-DoD approaches. Had the 86th Airlift Wing rescinded the aircrew authorization when directed, the mishap crew would not have been authorized to fly an approach into Dubrovnik and the accident would not have occurred. As we noted in the description of events, the aircrew made errors prior to and during the flight.
The aircrew improperly flight-planned their route by failing to comply with the special instructions for navigation which identified corridor air space and the closed corridor. The error added 15 minutes to the planned flight time and may have caused the crew to rush the approach. The crew also failed to properly review the Dubrovnik approach requirements. Had the aircrew properly reviewed the approach they would have recognized the need for two automatic direction finders (ADF), one to provide final course guidance and one to identify the missed approach point. The mishap aircraft had only one automatic direction finder. As equipped, they were not authorized to fly the Dubrovnik instrument approach.
The aircrew also made a series of errors in flight during the final approach sequence leading up to the mishap. First, the aircrew crossed the final approach fix before properly configuring the aircraft and were approximately 80 knots too fast. Second, the aircrew began their final approach before receiving specific clearance from the Dubrovnik tower. Finally, they selected a heading which placed the aircraft on an incorrect course, 9 left of the published course.
Most significantly, the pilots failed to identify the missed approach point and consequently failed to execute the missed approach procedure. The aircraft impacted the mountain one nautical mile or about 30 seconds past the missed approach point. These aircrew errors when combined were a cause of the accident. Had the missed approach procedure been executed in a timely manner, the accident would not have occurred. The final cause of this accident was an improperly designed approach procedure.
The procedure was flawed because the designer did not provide sufficient obstacle clearance in accordance with international civil aviation organizations or ICAO criteria. ICAO is made up of nations including Croatia, that agree on international standards to ensure safe flying practices.
The host country made two errors in designing the approach. First, they applied design criteria which applied only to the missed approach segment in developing the final approach segment. Because of this, they failed to identify the correct controlling obstacle. This caused the computation of the minimum descent altitude to be too low. Second, the Croatian designer failed to increase the minimum descent altitude to account for the excessive length of final approach from KLP to the runway.
According to ICAO criteria, when the final approach fix is longer than six nautical miles from the runway threshold, the minimum descent altitude must be increased in direct proportion to the increased length. The Dubrovnik approach from final approach to landing surface is 11.8 nautical miles. The designer identified the minimum descent altitude as 2,150 feet. The minimum descent altitude should have been 2,822 feet, based on the approach as it's depicted in the charts.
Under ICAO criteria, the minimum descent altitude, would have been approximately 500 feet above the mountain. A properly designed minimum descent altitude would have placed the aircraft well above the terrain even though the aircrew flew 9 off course and this accident would not have occurred.
A substantially contributing factor to this mishap was the failure of commanders to provide theater specific training to aircrew flying non-DoD approaches, although he 86th Airlift Wing routinely flew into many airfields in Europe without DoD approved approaches, commanders failed to provide adequate training for using commercially published instrument approach procedures. Aircrews relied primarily on familiarization training and experience gained during training flights and scheduled missions. Proper training would have enabled the aircrew to recognize they could not fly the Dubrovnik approach with the navigational equipment onboard the aircraft. Had the commanders provided adequate training, the accident probably would not have occurred.
Other reported facts in the investigation are search and rescue, the crash position indicator and ground proximity warning system, pressure on the aircrew, and procedures used to maintain passenger manifests. Croatian authorities were responsible for search and rescue in their country. However, because they did not have helicopter support in the Dubrovnik area, they requested assistance from NATO. The search and rescue efforts combined Croatian and NATO implementation forces capabilities.
Under Croatian search and rescue procedures, the Dubrovnik tower served as the coordinator and the local police served as the primary search and rescue party. The Croatians requested NATO assistance because in this area they had only ground transportation and boats with which to conduct the search. NATO assisted by requesting French helicopters stationed in nearby Ploce to begin an aerial search.
Zagreb Center, a civilian air traffic control center and NATO ATC in Zagreb worked together with the combined air operations center located in the Vincenza , Italy to control NATO search and rescue efforts. The E-3 Airborne Early Warning Aircraft and later an EC-130 with a mission commander onboard provided primary communication links between NATO and Croatian search and rescue assets. U.S. helicopters would join the search later after flying one hour from Brindisi, Italy.
Progressively deteriorating weather and erroneous information concerning the crash location severely slowed down the Croatian and NATO search and rescue efforts. They were also hampered by dense fog and low visibility. The Croatian search began around 4 p.m. after numerous radio and land communication efforts to locate IFO-21. French helicopters arrived in the area around 5:15 p.m. Their initial search efforts began at the last known location of the aircraft at KLP and proceeded along the coastline between the KLP beacon and the airport. At approximately 6 p.m., when the clouds briefly lifted a Croatian civilian living in the remote village of Veljido. Because there was no phone in his village he traveled 45 minutes to the next village where he notified the local police. The police responded to the reported site and confirmed the accident location at 7:20 p.m. Meanwhile, U.S. helicopters from Brindisi, Italy, had also joined the search and French helicopters now low on fuel departed.
Unaware that a Croatian civilian had located the crash site, U.S. helicopters continued to search until they, too, ran low on fuel. At 7:48 p.m., they landed at the Dubrovnik airport. At the site, the police began looking for survivors. By this time, it was dark at the site and low clouds had dropped visibility to less than 30 feet. Low visibility created extremely hazardous flying conditions and the helicopters could not reach the site. At around 10:30 p.m., Croatian police informed rescuers they had found a survivor with serious injury. Because the Croatians feared causing additional injury they requested NATO helicopter support to evacuate the Air Force crew member from the mountain.
Learning of a possible survivor, one U.S. MH-53 helicopter launched at 10:36 p.m. and made repeated attempts to reach the site, but again, weather prohibited them from reaching the area. Upon receiving word that the U.S. helicopter was unable to reach the site, the police began moving the crew member down the mountain by litter at 11:15 p.m. At that time, the crew member showed no signs of life. The police reached the bottom of the mountain and transferred the crew member to a waiting ambulance. An accompanying Croatian physician pronounced her dead on the way to the hospital.
The board also investigated the operation of aircraft systems including the crash position indicator and the ground proximity warning systems. The crash position indicator is used by rescuers to locate a downed aircraft by emitting an internationally recognized distress signal. Because of the steep mountain and the crash position indicator's location by the aircraft, it's signal was blocked in every direction to the northwest and southeast. Rescuers initially detected a weak signal that could not provide direction to the downed aircraft. When they got close enough to receive a direction finding signal, the weather prevented them from reaching the site.
Although the beacon was heard the day of the accident, helicopters that arrived the following day were unable to hear it even though the beacon was designed to transmit for 48 hours or more. In examining the system for this investigation, we found moisture had entered the crash position indicator causing its battery power to drain faster than normal.
The mishap aircraft was also equipped with a ground proximity warning system. This system provides visual and aural warning if the aircraft exceeds predetermined parameters when approaching the ground. However, the system did not activate because of design limitations. It was not designed to respond to this combination of sharply rising terrain, the aircraft configuration, and its flight path. Had any one of these factors been different, the system may have provided crew aural and visual warnings to avoid this crash. Newer models may have activated under similar conditions.
We also examined whether Secretary Brown or his staff placed pressure on the aircrew to complete this mission. We initially examined this issue during the course of the investigation and found no evidence that Secretary Brown or his staff pressured the crew to fly any of the legs of this particular mission. Later, after recent media reports, we re-examined this issue. We collected new testimony and found no reason to change our original assessment. Throughout Secretary Brown's stop at Tuzla, no one expressed any concerns about the weather before they left for Dubrovnik.
Another issue, the board examined was passenger manifesting procedures. Aircrews are directed to prepare a passenger manifest prior to each take-off to account for passengers onboard. These manifests are then maintained by the European Operations Center. No passenger manifest was found after this accident. A passenger list had to be reconstructed by the U.S. Embassy in Zagreb.
In summary, our investigation found this aircraft accident had multiple causes, failure of command, aircrew error, and an improperly designed instrument approach procedure. We identified inadequate theater specific training as a substantially contributing factor. Like most accidents, multiple causes resulted in the tragedy any one of which had it not existed would have prevented this accident. This concludes my briefing.
General Fogleman: What I would like to do now is go through the corrective actions that have, as I said earlier taken place, are taking place and are planned. They run three levels as you can see. The first is at the major command level, U.S. Air Forces in Europe. Next slide. Immediately following this accident, General Mike Ryan the commander of U.S. Forces in Europe directed a command-wide safety stand-down. The primary purpose behind this stand- down was to just take a general look at the operations and the OP tempo. Today, the 86th Wing conducted an additional stand-down day because this was the first day that the results of this accident investigation could be shared with all the members of the Wing and so that's what they have been doing this day, reviewing that accident investigation and the findings.
Additionally, a standardization evaluation team from Headquarters U.S. Air Forces, Europe, augmented by members from other major commands, was directed to go in and do a thorough standardization evaluation of the 86th Wing. As a result of that evaluation and the corrective actions, the Wing has been given a clean bill of health. Additionally, General Ryan put into effect a requirement that all operational support airlift crew members be required to attend a refresher instrument training course prior to the 31st of May. Any member who was unable to do that because of TDY or leave is grounded until they complete that.
Additionally, all operational support airlift aircrew members are required to get an in-flight evaluation before they are cleared to fly with passengers, again. As of two days ago, out of approximately 180 crew members, all but 20 had completed the new instrument refresher training and out of approximately 77 crew members, all but six had completed the in-flight evaluation. Additionally, there were some corrective actions that were taken to address the issue of the mal-designed approach. As soon as that was identified, the Croatians and the FAA were notified. The commercial publisher who takes the [host nation] approved approach and publishes them as a commercial venture, was also notified of the design defects. Additionally, as you can see, to ensure that all DoD aviation elements were aware of the danger involved, a notice to airmen was published and disseminated. To make sure that our U.S. civil aviation was warned of the danger, the Federal Aviation Administration [issued an advisory to civil aviation.]
Additionally, General Ryan requested augmentation so that within his command, they could accelerate the review of these non-DoD approaches that by their very nature of the operational area, the aircrews in Europe must use. Other actions that were not directly related to the accident but as one of these accident investigations occur and as you can see here the result of this accident investigation is a report that is some 7,100 pages long that there will be items surfaced and so I would say that this corrective action that you see here, generally falls into the category of command and control and training issues that were identified within the command that are also being reviewed for applicability across our other commands.
Finally, here are -- not finally, but, next, here at the Headquarters, what you see is we have come to the realization and we had come to this realization back in 1994, the purpose of the new Air Force guidance was that with the end of the Cold War, suddenly hundreds of airfields with literally thousands of approaches in the former Warsaw Pact were opened up and this Squadron in Europe began to fly into those airfields. And, what they discovered is perhaps they would go in during daylight, fly an approach, and they would say, gee, something about that didn't seem right. And, I would not want to do this in weather. So, as a result of the feedback we were getting, we had a feeling that all of these approaches may not be safe and that's why we put the guidance out that said we're going to do these reviews before we use these approaches. It was based on evidence that we accumulated after the end of the Cold War. And, so, what we now are trying to do is take a survey of all the commands and determine how many of these airfields we use on a frequent basis and try to get these airfields into the Department of Defense flight information publication. The Air Force is the executive agent for that.
Within one of our major air commands, the United States Air Force operates on the principle of centralized direction and control but decentralized execution and so each major air command has a certain amount of latitude about publications that they publish that are applicable to their aircrews. One of our major air commands, the Air Mobility Command, has world-wide operations as a result of its mission and they had published what is known as an airfield suitability report and a summary of airfield restrictions that applied to their aircrews. It was not applicable to the crews in Europe although those crews had it available. In that document, the Dubrovnik airfield was listed as an airfield that Air Mobility Command crews could only fly into under VMC [visual meteorological conditions.]
Since this command does this for a living and they are involved with world-wide operations, we are going to take this document and make applicable to Air Force-wide operations. Additionally, we are doing a top to bottom review of all of our operational support airlift aircraft and we are establishing what is known as a MESL minimum essential equipment list to make sure that all of those aircraft are equipped with the type of equipment required to operate safely in all environments. The review of pipeline training while General Ryan is focusing on his theater training, we want to go back and see if in our schoolhouses, we should not be doing more of this kind of training to make sure our crews are prepared.
And, finally, we are chagrined by the fact that there was an Air Force instruction in the field, it went out in November of 1994, and it took until November of 1995 for the Headquarters to be approached for a waiver to this instruction. So, clearly we need to go and make sure that everybody understands that when an Air Force instruction is issued, it takes priority over all lower Headquarters' instructions and nobody can issue an instruction at a lower Headquarters that is less restrictive than one that comes of the Headquarters. We thought that this was clearly understood. It has been clearly articulated over the years. We want to go back and make sure that this is a fact.
Now, here, within Washington, you all know that back in April when the events started to unfold from this accident, Secretary Perry directed the Services to do a review for the safety and navigation equipment of all of our aircraft. Out of that, the Air Force has reprogrammed, as you can see, some $264 million to accelerate the installation of the kinds of equipment that you see here. As a result of this action and brief, the Secretary has also directed the Chairman of the Joint Chiefs of Staff to ensure that the lessons learned by the Air Force are cross-flowed to all of the Services.
Now, in addition to the corrective actions, General Ryan has taken some command actions. These have been reported in the media and what I would like to do is clearly delineate between the command actions which have been taken which are administrative in nature. They were the result of the 17th Air Force Commander losing confidence in the three individuals what you see listed by duty title. In addition, General Ryan has appointed an independent flag officer in accordance with the Uniform Code of Military Justice to do an inquiry to take all the evidence that has been uncovered by this investigation and any other evidence that he may uncover in the course of his investigation and that inquiry officer is charged then with recommending to General Ryan what disciplinary action may in fact occur.
That concludes my briefing. We will be prepared to take questions. General Coolidge will join me at the podium.
Q: Generals, unless things have changed markedly the aircraft commander in the case the pilot flying the left- hand seat of this aircraft, has the final authority to go, no-go, land, or not land. Secretary said there are multiple reasons for the crash, the accident board states three prime reasons, and yet some say there was no apparent major mechanical difficulty aboard the aircraft and since there's no apparent evidence of wind-shear or some other so-called act of God, then, by elimination, isn't the prime underlying prime reason for this crash pilot error?
General Coolidge: Sir, there were three causes of this accident, any one of which would have precluded the accident. So we cannot determine that there is a prime among the causes. We are not charged to do that and therefore, we have not done that.
Q: Well, I mean, if you look at the report of the preponderance of things listed, even here on the slide show, a prima facie problem missing the missed approached, the air speed which doesn't to me seem overly important but obviously being left of course without adjusting for drift, by trying to land without two ADFs, all of these things were the pilot's responsibility. So, if you look and just add the numbers, there were far more cases of pilot error here that led to this than the other two causes. I mean, we know, the command responsibilities of the aircraft probably should not have been allowed to go in and land in the airport at Croatia. And, we also know that the approach procedures were not adequate, ILS, no GCA, and I'm not trying to pin you down, but it does seem that certainly pilot error overwhelms the other two causes?
General Fogleman: I think the way I would respond to that is clearly it is ultimately the aircrew's responsibility to flight plan, and execute the mission and so people who wear these wings know that from the first day that they have them pinned on their chest. It goes with the turf.
Q: General Coolidge, on the issue of the missed approach point, had they had the equipment that could have been tuned into the two beacons, the two signals at once, and had it been tuned, would they have gotten a warning buzzer, a warning signal or simply a light? What would they have seen to alert them that they've missed the approach point?
General Coolidge: This aircraft is not equipped with a buzzer or a light as you describe it. They would have however, have seen the other needle swing or the needle pointing to CV, the locator beacon, and therefore would have been able to identify the missed approach point.
Q: Can you just on the question of the search and rescue and the one lone survivor, can you tell us, first of all is she identified in the report as to who she is and is there any way to determine whether or not she might have been able to survive had search and rescue been able to reach her earlier?
A: She is not specifically identified in the report. However, I will tell you that the judgment of medical authorities was that she sustained blunt force injuries, the same as every other member the exception of one who died from an inhalation injury and those injuries were of such a nature that they were -- would not have been survivable.
Q: General, you point a lot of fingers at a lot of different people in this one. I want to know was there a perception that someone had to be a fall guy in this whole accident report?
A: Sir, let me state unequivocally, the objective is uncover all the facts and circumstances of the case and if possible, the causes. It was not our objective, nor our intention to identify people or point fingers as -- as you described.
Q: Do we expect other -- others to be relieved of command in addition to the three who have already been relieved?
General Fogleman: That will only be determined by the outcome of the inquiry done by the officer that has been appointed by General Ryan. General Ryan is the appointing authority and he will also be the one who will make the decision about what actions will be taken as a result of the recommendations that come from that inquiry officer.
Q: General, can you describe the -- what was apparently going on in the cockpit in the accident report it certainly sounded like there some confusion, there was some pressure, a cockpit crew that was as well-trained as this and had as high marks wasn't performing the way that it should of. Can you kind of walk us through what you think was happening in those minutes?
A: If I were to do that, I would be speculating. But, what I would really like to do is perhaps take a minute and let's go back over the briefing that -- that General Coolidge gave.
For instance, at the point of the flight, when the crew called into the weather station and they were advised of the weather conditions at Dubrovnik, that was approximately 40 minutes before the scheduled arrival at the fix. At that point, that crew knew they were going to have to fly an instrument approach. And, that's the point at which most crews would get out the instrument approach. Now, they are -- they are required to have those approaches as part of their flight planning and should have done study of it as part of their flight planing, but at that point, and it was not really clearly pointed out, when they received their weather briefing at Zagreb on the morning before they started this series of flights. The weather forecast that was given to them for Dubrovnik at that time was essentially visual weather conditions and so when they got this information, they had at least 40 minutes to be thinking about what they were going to do. When they're mission planning error of trying to go direct rather than fly the corridors compounded the situation and got them 15 minutes behind, then, I believe that while they were -- this is a crew, these kinds of crews put great stock on arriving on- time at a location. So, conceivably what you begin to see was a series of events that forced the crew to rush in an attempt to get on the ground. In addition to being behind as a result of their flight planning error, they were held at altitude, at 10,000 feet, for a period of time before they were cleared to descend to that final approach fix.
allowed to proceed beyond that final approach fix unless you are specifically cleared and so what should have happened is that crew should have leveled at 4,000 feet and they should have entered holding which would have allowed them then to get the airspeed stabilized, the configuration stabilized and as General Coolidge, said, would then have allowed them to concentrate on flying the approach as they proceeded from the final approach fix inbound.
Q: You mentioned that some -- there's some of element of speculation here. Are there some questions about this that will never be answered because there was no cockpit voice and flight data recorders on this plane?
A: The answer to that is yes, a cockpit voice recorder would have been very helpful to the Board. It would not have prevented this accident, but it would help explain these apparently inexplicable actions such as flying the wrong course. I would point out that because of the kind of data that was available from the NATO E-3 radar tapes, from the Zagreb air traffic control tapes, from the tear down of the instruments that were found at the crash scene, I believe and you can ask General Coolidge, that the data that was available to the board is very fidelity data and probably little could have been aided by a data recorder. It would have been nice to have it, but clearly, again, it would not have prevented the accident.
Q: General, have you -- have either generals or the board spoken personally with Nolanda B. Hill quoted in the New York Times article on Sunday by Syble Shannon as saying that Ron Brown should have been in contact with Ron Brown several times that day and was a good friend of his said Ron Brown over-ruled staff members who were worried that it was dangerous to fly into Croatia because of the treacherous weather at that time. She said, I begged him not to go but he said no. Sir, and secondly following up John's question, what -- did they ever break into the clear on their approach into Dubrovnik and were they always in the clouds?
A: Let me answer the last question first, we believe that they were always in the clouds. General Coolidge's board talked to different witnesses who said they heard an aircraft go over. There was one indication that one person might have seen an airplane going in and out of clouds but every indication is they were in the clouds.
Now to the second question. Even though this board had completed its investigation, when the New York Times article appeared on Saturday, I directed General Coolidge to reopen the investigation and to go gather whatever evidence he could upon this issue. We took two approaches on this. We contacted Ms. Hill directly and we contact Brigadier General Cherry who was Secretary Brown's escort officer the entire time that he was on the ground at Tuzla.
General Cherry was with Secretary Brown throughout his visit -- says that he was never more than 10 or 20 feet away from him except for a 10-minute period when Secretary Brown was in some sort of a hydroelectric plant where there were no telephones. General Cherry never saw Secretary Brown use a telephone, never saw him receive a telephone call. He never saw Secretary Brown talk to the aircrew or any member of the aircrew. General Cherry was at the bottom of the steps as Secretary Brown went into the airplane and he saw him turn right and go the rear of the aircraft. He did not talk to the people in the cockpit.
In addition, Ms. Hill chose not to provide direct testimony to the board but she did give us a sworn affidavit in which much of the information that appeared in the Saturday New York Times was [inaccurate]. That information by the way is all available in the report in Volume 22.
Q: General, requesting the ADS issue, ADF -- was this a failure to note that the -- that he didn't have the two- channel capability at that date, there were two beacons that were going to be required to make this instrument land? That that was an error that occurred before take-off if I read the report correctly?
General Coolidge: If you're going to fly this instrument approach, that's a mission planning error.
Q: Now, how flagrant an error is this? Is this a basic check box that pilots do for every flight or is this a fairly unusual problem that arises and therefore it's not necessarily as --
Major General Coolidge: This is a fairly complicated approach as far as approaches go. Even particularly non-DoD approaches. DoD approaches don't usually use two ADFs or NDBs in order to fly the approach. That's the normal. But, it's a fairly complicated approach, but it's one they should have been trained and could have recognized as needing a second ADF onboard the aircraft.
General Fogleman: Let me expand on that if I could. These commercially available charts that we use for our operations, have a different legend but are in many ways similar they have some very subtle nuances and so if you were to go get a package of these charts in the beginning or in the front of that package are several pages of legends and instructions on how to read that chart and what it precisely means. We had --- we did not have in place a training program to train our aircrews in that specific detail. So, this is what General Coolidge was talking about in his briefing when he said, we depended upon them to learn through experience, through normal training, picking this thing up, reading through it itself. What we have now put in place is a formal training program that says, this is what this index really means. We have had for years and it's part of our annual instrument exam questions having to do with the DoD legends, that had to do with our Department of Defense approaches.
Q: Do you disagree that they messed up the approach plate? There's a specific flaw in the program you recommend instead. But do they concur that there's a problem in their approach procedures?
A: No. They do not. In fact, with the publication of this report, we are in receipt today of a letter. However, we in concert with FAA stand by our position and our finding.
Q: But, General, if in fact you established the MDA listed in the report, this airplane couldn't have landed there under these conditions, correct? If you went over CV and you correctly identified CV you can't conduct a stabilized approach in 1.9 miles from the altitude that you list as having been proper? You'd have been knocked out of that airport for a different reason?
A: Immaterial to the issue at hand.
Q: Well, no transport category jet could land under the MDA you recommend there?
A: It's immaterial to the issue. No, in fact, it's directly relevant to the issue in that had the correct MDA been published, that would have been hopefully, clearly evident to the crew, they would have looked when they knew they had to make an instrument approach, they did not have an instrument approach compatible with the airfield. They would have gone to an alternate.
Q: There's been accidents a great number of mishaps involving Air Force fighters, etc., over the past few months. Do you think the Pentagon, the Department should be looking into some sort of systemic problem within the Air Force, concerning training perhaps, or the experience of pilots?
A: No, I reject your assertion to start with. In fact, I have a couple of backup slides I would like to bring up. Would you bring up back-up slide #1. I think we have an excellent safety program. I can show you that not only has our safety program improved over the years, but most notably, when you go back and look at that period of time when we were operating during the Cold War, whenever our safety program and crews were out there in a relatively stable environment, in the Cold War environment, operating out of the same airfields, etc., we had the kind of accident rate per 1,000 flying hours that you see there. Since the breakup, or since the end of the Cold War, when our operation tempo has increased four-fold -- and not only has it increased but we're operating in to more strange locations -- you see a very positive trend in that accident rate. And now, you say in recent months -- what I would like to do if you would bring up the chart which shows our 1996 versus 1995 and if you will look, 1995, was a pretty darn good year and we have a very good year going in 1996.
Next. What this shows you back up to the one you just had. We've got computer over-shoot here. Keep going. I want the other slide. There we go. This is a chart that I get briefed on in my staff meeting on a regular basis. And, what we do is we compare the accident rate at the end of 1995 which as you can see we had 32 accidents at a 1.44 per 100,000 flying hours, that's all classes of aircraft. If you go look at 95 at this point, in FY'95, we had an accident rate of 1.36. In 96, we're at 17 or 1.17. I would like to also add that out of those 17 aircraft if you notice, only 11 of them have been destroyed. We are being penalized in our accident rate right now by the fact that by definition, if an aircraft receives $1 million of damage or more, it's categorized as a major aircraft accident. With the cost of engines today, and costs of some of our components, you can lose an engine due to foreign object damage or some other means, and it will be listed as a major aircraft accident. If this was normalized over time, for inflation, etc., you would see a dramatic improvement in our safety record. But as it is I will stand behind the United States Air Force's safety record any day before anybody, anywhere.
Q: If these aircrews put so much stock in being able to make their arrival time on time, what are you doing now to kind of reduce some of that stress in your training programs. That is not a big deal if you're over 15 minutes late, I mean, don't push the envelope?
A: Yes. There's two things that you do here. One, is hopefully, that's one of the outcomes of these safety stand-downs. You talk about it. The second thing, is that you go back and you make the point that -- and this has been -- this is the last line of virtually every flight briefing I've ever been in -- never compromise safety.
And, so, we've just got to -- what you have though are people who are self-motivated, take great pride in what they do. But here is a case -- we don't know, we're speculating -- we don't know whether that was really the thing that was driving them but circumstantial evidence indicates that this was -- by the way, this was a highly experience aircrew, and this was a crew that was widely respected among the squadron and the wing.
Q: But, in your judgment, did the aircrew overdrive the safety of this flight?
A: Again, I would be speculating but I would -- I think that the circumstantial evidence and the cumulative effect of what had happened to them, may have been responsible for why procedures were not followed.
Q: Knowing what you know, now, General, at what point should that aircrew have called off the approach to Dubrovnik?
A: Again, if you go back in this chain of events, and had they been required to have that approach reviewed before they left -- in other words at the time they got the tasking, from the Pentagon, back down to that squadron, and they went in and they said, Dubrovnik, Ah, no DoD approaches. That approach should have been sent to the people who do the compatibility review.
So, right there was a point at which it should have been and at that point, what they would have had to tell the people who were tasking them is that we can only go into Dubrovnik under visual conditions. And, everybody would have known that right up front.
possibly restricting instrument approaches to airfields worldwide that have more sophisticated landing systems such as ILS or GCA?
A: Well, we have given thought to that. We are looking at it but the fact of the matter is, you can safely do approaches with these less sophisticated landing systems and to unduly restrict that is to say that you can not do visual approaches, I think, would unduly restrict our operations. But we, this is part of this ongoing review.
Q: Even though you said the plane remained in the clouds probably until impact, based on cockpit settings and engine power settings, can you say the pilot took any action in the final moments?
A: I think General Coolidge, could answer that question better than I, but I have my own view on it.
General Coolidge: We have no indication that they took any last minute avoidance actions or that they even knew that were running into the mountain. There is one note in the report; if you will read that. You find that that fuel control unit on engine #1 was dictating full power which means there could have been a warning of some sort, and they had advanced the power but again, they did not have time to make any change to the engine and therefore the performance of the aircraft was still on level flight. That's the only piece of evidence that's contrary to what I told you first.
Q: Would their radar have indicated there's a mountain coming?
A: They do have radar in the aircraft, but remember, the weather is such that's either a ground mapping feature or it's a weather radar. So, they most likely the weather radar was burned beyond repair, or beyond analysis, and therefore we believe it was probably in the weather feature.
Q: Were there any indications that the second beacon wasn't working properly?
A: No, sir. We had an FAA Hawker-Sydney Aircraft come and actually test the navigation aids, the ground-based navigation aids on the 8th of April and the procedure as depicted and the frequencies of the navigation aids were sufficient to shoot the approach and it passed an FAA certified check in terms of the ground based navigation aids.
Q: How hard would it have been to see that they should have had a second ADF? Should it have been right there for them to see or would it have taken a lot of searching through that manual to?
A: Can you bring up the approach plate again, please?
Q: And, your thoughts on the final moments, you said you had some thoughts on that?
A: As it turned out, General Coolidge cover that which was the fact that in the report as I read it, I was taken by the fact that the number one engine fuel control had spun up. What that could indicate there because the throttle quadrant was totally destroyed, there was no way to know where the throttle was, and so, when you find an engine with a fuel control that's spun up that's one piece of evidence, it doesn't tell where the throttle was relative to that. And, the thing that is unusual about that -- that would be different than what you would do to execute a missed approach is that to execute a missed approach you would not go to 100% power. You would command what, 80%? Roughly 80 or 90%. And, so, it's all why one was and the other wasn't, we don't know, this sort of thing.
Q: Is there one 'why' in the whole thing that will haunt you the rest of your days in uniform?
A: The biggest question that I have from my level is how could we have an Air Force instruction in the field that was not being complied with at the major air command level. I need to find the answer to that. Because, in my view, that's the start of this chain of events. We had evaluated a situation that is the use of these non-DoD approaches, and based on that evaluation -- which did not just occur here in the headquarters, we had inputs from out in the field -- we made a very deliberate decision to change the Air Force policy. We made it. We distributed that guidance to the field and it was not implemented. Now, I need to find out, and in fact we have already taken procedures or taken steps to make sure that this is not happening with other instructions and to make sure that everybody clearly understands the rules. So, that more than anything else, haunts me.
Yes, go back to the approach procedures. For the person who is properly trained on how to read this approach plate, what you do is you go up in here and you see this shade around this box. It's different from the shading around that box. So, what that shading tells you along with that course line with that arrow, says, that the course guidance for this approach comes off of this beacon. In our instrument procedures, we clearly state that you will not detune a station that is providing the course guidance on final approach. And, so, with only one ADF, they had to detune. I will tell you that 50 per cent of the crews when interviewed in the squadron and looked at the approach and that was two of four right turns, said that they thought that that was a legal approach to fly from that -- from the one ADF standpoint and that from a technique standpoint, they could describe to you how they would have flown it. The fact of the matter is they would have been violation of our instruments procedures had they done it. It is possible to do, but you would be in violation of our procedures if you did.
Q: How would they do it?
A: What you would do, is you would in fact, tune in that ADF. This distance is 9.9 miles and so over that distance, that's about four minutes. And, so, as you came off that fix if you had yourself stabilized and you had the wind drift killed and they should have had the wind drift killed because they had a dual INS on this airplane, a dual inertial navigation system, and that inertial navigation system was found with the control head in the position that told them what the wind drift was for the wind ahead at altitude, so there was no guess involved in this. And, once you were stabilized coming outbound, say for two minutes or so, and you were confident that you were on the course, you could then flown the heading, selected the missed approach point, and when you flew across it you would have known you were there. There is no evidence that they did that though because their ADF was found tuned to the final approach fix.
Q: So, they followed the procedure?
A: Say again?
Q: So, that was --
A: That course, they followed the procedure to the best we understand. Now that was -- they were approximately five minutes from the time they left the final approach fix until they hit the mountain. General Coolidge and the operational member of the board, trying to determine how long it takes to detune and tune this. This is a kind of control head in this particular aircraft that's very much like an old AM radio and so what they were doing was going from a frequency of 318, whatever it is up here, to a frequency 390. Not only do you have to physically look down, tune it, but you are required to identify it and while it's not clear up there each of those underneath here, this is Morse code and so once you have tuned that you have to listen until you get those dots to make sure you have positive identification. And, so, that was about, under ideal conditions on the ground, it took them 20-22 seconds. Now in a Lear jet, we have a digital switch, self-tuning and so, a flick of a switch and you have information. But, again, they did not have this.
Q: Back to the question that you answered on why, if the order to the 82nd -- 86th Air Wing had been obeyed with respect to the charts and related matters to that, could the operational tempo that has been sustained, be sustained and what effect would that have had on the overall missions in the 86th?
A: It would have clearly had an adverse impact on the operation tempo. And, let me put into context a couple of things. First of all the 76th Airlift Squadron is a mini 89th Wing in a sense if you think about it in terms of providing VIP support. That squadron with those aircraft and the resources you saw there are responsible for providing VIP airlift throughout all of Europe to include the former Eastern Bloc countries and all of Africa. So, they have a very wide area of responsibility in a lot of Third World kinds of places so, and they had for years operated using these non-DoD approaches and that's what sort of convinced them that they were safe.
The second thing is the 86th Airlift Wing during this period of time, November through February, November of 95 through February of 96, was probably the most heavily tasked wing in the United States Air Force. Think what was happening during that period of time. This was the period of time that we were putting the implementation force into Bosnia. This is the parent wing for all of the C-130's that are stationed in Europe and so it's not like there wasn't a lot things going on from an op tempo standpoint. Additionally, when you go look at the major command headquarters one of the things that happens when you have a crisis or a contingency that you're responding to is that your action officers that kind of do routine work, are no longer at their desks, because you go to 24 hour manning in your crisis action centers and in your command posts and so there's op tempo that impacts everybody.
That is not an excuse. It is a factor that I think General Ryan and I, as the Chief of Staff, must be concerned about. Thank you very much.