--- MILITARY AIRLiFT Information on Gander Crash and Improved Controls Over Military Charters t9 II142194 Ill RELEASED RESTRICI’ED--Not to be released outside the General Accounting OfPlce unless specifically approved by tbe OffIce of Congressional Relations. United States GAO General Accounting Office Washington, D.C. 20648 National Security and International Affairs Division B-223096 September 11,1990 The IIonorable John Conyers, Jr. Chairman, Legislation and National Security Subcommittee Committee on Government Operations House of Representatives The Honorable C.W. Bill Young House of Representatives In response to your requests, we have developed information on the 1J.S. government’s participation in the Canadian investigation of the 1985 crash of an Arrow Air aircraft in Gander, Newfoundland. Specifically, this report addresses (1) the roles of the U.S. federal agencies that assisted the Canadian Aviation Safety Board in its investigation, (2) the cargo that was loaded aboard the plane, and (3) the actions taken to ensure the safety and security of U.S. military airlift charters in response to our report, Military Airlift: Management Controls Over Charter Airlift Need to Be Strengthened (GAO/NSIAD-87-67,Mar. 6, 198’7). Several U.S. federal agencies were involved in helping the Canadian Avi- Results in Brief ation Safety Board with the crash investigation. National Transporta- tion Safety Board officials participated in all aspects of the investigation. A Federal Aviation Administration official was part of a team that conducted investigations in Egypt, Italy, and West Germany. The Armed Forces Institute of Pathology and the Federal Bureau of Investigation helped identify crash victims, and the Institute also per- formed autopsies. In addition, the Federal Bureau of Investigation assisted in obtaining details on the condition of the aircraft before it departed for Gander from members of the flight crew that had flown t,he aircraft from Cairo, Egypt, to Cologne, West Germany. According to the manifest, cargo such as tool boxes, a camera, a repair parts kit, footlockers, communication antennae, medical records, books, ’ and charts were on the aircraft. The manifest does not indicate that explosives were on the aircraft. Our review indicated that most of the recommendations in our March 1987 report have been implemented, and controls over the safety of mil- itary airlift charter aircraft have improved. For example, we found that Page 1 GAO/NSIAIMO-242BB Military Airlift the Military Airlift Command and the Military Traffic Management Command have improved flight safety and quality by improving the way they manage and monitor charter aircraft. On December 12, 1986, a DC-8 aircraft chartered from Arrow Air Background crashed and burned at Gander, Newfoundland, Canada. The crash killed 248 military personnel from the 1Olst Airborne Division, Fort Campbell, Kentucky, and 8 crew members from Arrow Air. The aircraft was en route from Cairo, Egypt, to Fort Campbell, Kentucky, with stops in Cologne, West Germany, and Gander, Newfoundland. The aircraft had been chartered by the Multinational Force and Observers, an indepen- dent international organization established to supervise the implementa- tion of the security arrangements established by the Egyptian-Israeli Treaty of Peace. The United States and several other countries agreed to send troops to the Middle East to help enforce this treaty. The nine-member Canadian Aviation Safety Board investigated the crash under provisions outlined in International Civil Aviation Organiza- tion procedures. Although the Board was unable to determine the exact sequence of events that led to this accident, the majority of the Board’s members believed that most of the evidence supported the conclusion that shortly after liftoff, the aircraft experienced an increase in drag and reduction in lift, which resulted in a stall at low altitude from which recovery was not possible. They determined that the most probable cause of the stall was ice contamination on the leading edge and upper surface of the wing. Other possible factors, such as a loss of thrust from an engine and inappropriate takeoff speeds, may have compounded the effects of the contamination. The other members of the Board concluded that the wings of the air- craft were not contaminated by enough ice for ice contamination to be a factor in the accident. They believed that an on-board fire and a loss of power caused the aircraft to crash. A former Canadian Supreme Court Justice also reviewed the case. He concluded that nothing in the material the Board reviewed indicated the cause of the accident. To accomplish our objectives, we interviewed officials and reviewed Scopeand” available documents at Headquarters, Military Airlift Command, Scott Methodology Air Force Base, Illinois; Headquarters, Military Traffic Management Page 2 GAO/NSIAD90-243BR lWMary Airlift lb223033 Command, and Criminal Investigation Division, Department of the Army, Falls Church, Virginia; and the Federal Aviation Administration, National Transportation Safety Board, Federal Bureau of Investigation, Department of State, and Armed Forces Institute of Pathology, Wash- ington, D.C. We also contacted other agencies, such as the Central Intelligence Agency, Defense Intelligence Agency, U.S. Customs Service, and the Air Force Inspection and Safety Center to determine what role they had, if any, in the investigation. Our review indicated that none of these agen- cies had any involvement in the investigation. Appendix I provides addi- tional information on our review. We conducted our review from December 1989 through May 1990 in accordance with generally accepted government auditing standards. As requested, we did not obtain agency comments on this report. However, the views of responsible agency officials were sought during the course of our work, and they generally agreed with the facts as presented. Unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its issue date. At that time we will send copies to the Director, Office of Management and Budget; the Secretaries of Defense, Transportation, the Army, the Navy, and the Air Force; the Director, Federal Bureau of Investigation; the Adminis- trator, Federal Aviation Administration; the Chairman, National Trans- portation Safety Board; and appropriate congressional committees. We will also make copies available to others. This report was prepared under the direction of Nancy R. Kingsbury, Director, Air Force Issues, who may be reached at (202) 275-4268 if you or your staff have any questions concerning this report. Other major contributors to this report are listed in appendix II. Frank C. Conahan Assistant Comptroller General Page 3 GAO/NSIAD-30.243BB Military Airlift Contents Letter 1 Appendix I 6 The Gander Crash and Canadian Aviation Safety Board Investigated the 6 Accident Investigation US. Agencies Were Involved in the Crash Investigation 7 Manifest Details Cargo Aboard the Aircraft 8 Improvements Made in Safety and Security of U.S. 9 Military Airlift Charters Appendix II 12 Major Contributors to This Report Abbreviations DOD FAA Department of Defense Federal Aviation Administration FBI Federal Bureau of Investigation MTMC NTSB Military Airlift Command Military Traffic Management Command National Transportation Safety Board Page 4 GAO/NSIAD-BO-248BR Military Airlift Page 6 GAO/NSIADgO-243BR Military Airlift ~A>pndix -_ I The Gander Crash and Investigation Standards and recommended practices for aircraft accident inquiries were first adopted in 1951 at the Convention on International Civil Avi- ation and were designated as Annex 13 to the Convention. Annex 13 states that “the State in which the accident occurs will institute an inquiry, the State in which the aircraft is registered shall be given the opportunity to appoint observers to be present at the inquiry and the State holding the inquiry shall communicate the report and findings in the matter to that State.” The Canadian Aviation Safety Board is an independent federal govern- Canadian Aviation ment body that reports annually to the Canadian Parliament. At the Safety Board time of the accident, the Board consisted of nine members that set Investigated the overall policy, adjudicated accident and incident reports and their asso- ciated findings and recommendations, and determined when all reports Accident were to be released. The Board’s regulations stated that decisions were to be made by majority vote of the members present. Most Members Concluded Five members of the Board concluded that most of the evidence sup- That Ice Contamination on ported the conclusion that shortly after lift-off, the aircraft experienced an increase in drag and reduction in lift, which resulted in a stall at low the Wing Probably Caused altitude from which recovery was not possible. The most probable cause the Accident of the stall was determined to be ice contamination on the leading edge and upper surface of the wing. Other possible factors, such as a loss of thrust from an engine and inappropriate takeoff speeds, may have com- pounded the effects of the ice contamination. Other Members Concluded The other members of the Board believed that the wings of the aircraft That an On-Board Fire were not contaminated by enough ice for ice contamination to be a factor in the accident. They concluded that an on-board fire and a loss of Caused the Accident power caused the aircraft to crash. Justice Believes That The Canadian Minister of Transport asked Justice Willard Estey, for- merly of the Supreme Court of Canada, to conduct a review of the entire Neither Conclusion Was record of the Gander accident investigation and provide a report on Supported whether any further investigation or inquiry was warranted. Justice F&ey concluded that nothing in the material the Board reviewed indi- Y cated the cause of the accident. Justice Estey also concluded that “no investigation or inquiry conducted five years after the accident is going to contribute to the public interest in the safety of aviation.” Page 6 GAO/NSIAtMO-MBR INWary Airlift Appendix I The Gander Crash and Investigation Several U.S. federal agencies were involved in the crash investigation U.S. Agencies Were because of the provisions outlined in Annex 13 to the International Civil Involved in the Crash Aviation Organization and because the Canadian Aviation Safety Board Investigation requested their assistance. These agencies included the National Trans- portation Safety Board (NTSB), the Federal Bureau of Investigation (FBI), the Federal Aviation Administration (FAA) and the Armed Forces Insti- tute of Pathology. NTSB Participated NTSB appointed a representative that was responsible for overseeing all Extensively in U.S. personnel involved in the investigation. The representative appointed a team that consisted of technical advisors from NTSB, FAA, Investigation McDonnell Douglas (the manufacturer of the aircraft), Pratt & Whitney (the manufacturer of the aircraft’s engine), Arrow Air, and the U.S. Army. The team investigated the crash site, examined records, and interviewed personnel at Arrow Air. They also assisted in examining the engines and other aircraft hardware. During the Board’s 8-day public hearing on the investigation, NTSB was permitted to examine witnesses and had full access to all factual data collected by the team. NTSB staff reviewed and commented on the draft report of the investiga- tion before the final report was issued. NTSB staff told us they did not find any problems with the draft or final reports. FBI Helped Identify The FBI assisted the Canadian Aviation Safety Board by interviewing Remains and Interviewed members of the flight crew that had flown the aircraft from Cairo, Egypt, to Cologne, West Germany. The purpose of the interviews was to Previous Flight Crew obtain details on the condition of the aircraft before it departed for Gander. Also, a representative of the FBI'S identification division observed the removal of some of the bodies to the temporary morgue facilities at Gander Airport. In addition, the FBI assisted in the body identification efforts by providing fingerprint comparisons on all remains. After the fingerprint comparisons were completed, the FBI con- tinued to help identify the bodies by gathering fingerprints from per- sonal items and analyzing hair samples. FAA Was Part of An FAA official was part of the investigation team. This team conducted Investigation Team interviews with (1) maintenance and ground crew personnel in Rome, Y Italy; Cologne; and Cairo; (2) control tower officials in Cologne; and (3) Multinational Force and Observers officials in Cairo. The team also Page7 GAO/NSIAD-90-243BR Military Airlift The Gander Crash end Inveetlgation interviewed military personnel that were flown from Fort Campbell, Kentucky, to Cairo on the same aircraft that subsequently crashed. Armed Forces Institute of One of the prime missions of the Armed Forces Institute of Pathology is Pathology Led the Body to provide assistance in the medical investigation of all fatal military aircraft accidents. During the investigation, the Institute performed Identification Efforts autopsies and led the efforts to identify the bodies. Other Federal Agencies As part of our review, we contacted several other U.S. government agen- Were Not Involved in the ties to determine what roles they had, if any, in the investigation of the crash. These agencies included the Central Intelligence Agency, Defense Investigation Intelligence Agency, U.S. Customs Service, and the Air Force Inspection and Safety Center. However, officials at those agencies said they were not involved. We also asked the National Security Council whether it was involved, but we had not received a response by the time we issued this report. We were asked to try to determine what cargo was loaded on the plane. Manifest Details Cargo We located a copy of the manifest of cargo on the aircraft. The manifest Aboard the Aircraft indicated that, in addition to troop duffel bags, 48 pieces of cargo were on the aircraft. These items consisted of tool boxes, a camera, a repair parts kit, footlockers, communication antennae, medical records, books, charts, training aids, legal forms, and a picture in a frame. The FAA official that was part of the investigation team told us that he confirmed through interviews that some of the baggage loaded aboard the aircraft contained the troops’ paperwork (dental records and other pertinent information). The manifest noted that 41 duffel bags were not on the aircraft because the aircraft’s cargo hold was filled. The manifest did not indicate that explosives or any other volatile material were on the aircraft. Further, various officials told us they believe that explo- sives or any other volatile material were not on the aircraft. Page 8 GAOjIWAD-W243BR Military AlrUft In December 1986 we were asked to evaluate the Department of Improvements Mad’= Defense’s (MID) policies and procedures for chartering commercial air- Safety and Security of craft and monitoring their performance, including whether they comply U.S. Military Airlift with FAA safety regulations. We issued a report on our findings in March 1987. Charters The two DOD transportation agencies responsible for charter operations are the Military Airlift Command (MAC) and the Military Traffic Manage- ment Command (MTMC). MAC,an Air Force command, negotiates annual contracts for long- and short-range international passenger and cargo airlift as well as domestic and Alaskan operations expected to last 90 days or more. MTMC, an Army command, arranges domestic passenger airlift and air taxi operations expected to last less than 90 days through air transportation agreements with several airlines and air taxi operators. We found that both MAC and MTMC needed to improve procurement and oversight procedures to ensure flight safety and enhance the quality of charter airlift. Specifically, the commands needed to make improve- ments in the following areas. . Airlift capability surveys1 were not as thorough and not performed as frequently as they should have been and did not include foreign airlines. . Specific safety clauses were not included in contract agreements with foreign air carriers. . MAC’sramp inspection2 program did not cover MTMC’S charter airlines and air taxi operators. . Waivers of seat-row spacing criteria were being granted but not prop- erly controlled. l The process of providing feedback on passengers’ comments needed to be improved to address specific safety concerns raised during a flight. . FAA and DCD were not communicating effectively. l FAA’s security classification assessments3 were not being provided to WD. ‘Airlift capability surveys are reviews of contractor and FAA records of operations, training, insur- ance, maintenance, safety, and other items. The surveys also provide for discussions between MAC survey personnel and FAA officials responsible for the airline beii surveyed. 2A ramp inspection is a visual check of the aircraft performed by an experienced Air Force represen- tative and an airline representative. 3Public Law 00&X3,8661 (a), codified at 49 U.S.C. App. I 1616 (axl), International Security and Development Cooperation Act of 1986, requires the Secretary of Transportation to conduct security assessmentsof the effectiveness of security measures maMained at foreign airports. Page 9 GAO~SLAD-88848Blt Military AIrlift Appendix I The Gander Crash and Investigation We recommended in our report that MAC and MTMC strengthen passenger charter procurement and oversight procedures. We also recommended that the Secretaries of Defense and Transportation work together to improve communication on air safety issues and coordination of foreign airport security evaluations and classifications. Many of our recommendations have been implemented, and other actions have been taken to improve procurement and oversight of mili- tary charter airlift. Some of these improvements are as follows. MAC and MTMC have strengthened their oversight of airlift contractor agreements by conducting surveys of potential foreign and domestic contractors. Safety clauses specifically making contractors responsible for flight safety have been added to MTMC'S airlift agreements. Detailed procedures have been established for approving waivers of the seat-row spacing criteria. Standard guidelines and permanent policies have been developed to inform contractors of passenger and baggage weight criteria. MAC and MTMC are periodically reminding personnel and contractors that hazardous substances are not allowed on passenger aircraft. MAC'S ramp inspection program has been expanded to over 150 commer- cial airports and now includes MTMC charter aircraft. The process of providing feedback on passengers’ comments has been improved by focusing passengers’ attention on various safety and quality of service issues. The DOD Inspector General conducted an independent follow-on assess- ment of military charter issues and found that the recommendations had been implemented with very few exceptions. In addition to implementing our specific recommendations on flight safety and security issues, DOD and FAA have made other improvements. DOD has established an Air Carrier Survey and Analysis Office to help ensure high standards of safety and airworthiness from commercial air carriers doing business with DOD. The office has five teams that survey the operation and maintenance of DOD charter aircraft, including over- sight over FAA certification, dispatch operations, facilities, marketing plans, training programs, aircraft inspection programs, quality assur- ance, weight and balance determinations, maintenance control, and en route support. The survey results are discussed with local FAA officials, Page 10 GAO/NUAMW43BR Military Airlift -1 The Gander crash and Inveatlgatlon communicated to DOD users, and input into the Air Carrier Analysis Sup port System.4 DOD and FAA have developed policies and procedures to improve commu- nications through interagency liaison arrangements between MAC and FAA. Also, MAC and FAA have established liaison officers to ensure a con- tinuing dialogue and exchange of information on areas such as equip- ment, certification methods, acquisition, research and development, training, personnel, international operations, and emergency actions. The results of FAA inspections and actions involving air carriers used by DOD are also shared with DOD. Public Law 99-83, International Security and Development Cooperation Act of 1986, requires the Secretary of Transportation to conduct assess- ments of the effectiveness of security measures maintained at foreign airports. These assessments are now coordinated with DOD. 4The Air Carrier Analysis Support System is an automated system that includes all information on DOD air carriers. The system’s objectives are to provide comprehensive and accurate information to DOD and FAA users in assessing a carrier’s capability to complete assigned transport missions safely. Page 11 GAO/NSIAMtO-WBR Military Airlift. Appendix II Major Contributors to This Report William Wright, Assistant Director National Security and Frank Bowen, Evaluator-in-Charge International Affairs John D. Sawyer, Staff Evaluator Division, Washington, DC. Richard E. Burrell, Senior Evaluator St. Louis Regional Lauri A. Bischof, Staff Evaluator Office (892848) Page 12 GAO/NSIAD-BO-242BR Military Airlift Ordt~ring Informatiou The first. five copies of each GAO report are free. Additional copies at-(* $2 t*ach. Orders should tie sent, to the following address, accom- panied IJY a check or money order made out to the Supt’rint.endt~nt of Ih~curut~n ts, whw necessary. Orders for 100 or more copies to be mailed to a single address are discount,ed 25 percent. I1.S. Gt~neral Accounting Office I’.(). Hex 0015 Gaithersburg, MI) 20877 Orders may also tie unlaced by calling (202) 275-6241.
Military Airlift: Information on Gander Crash and Improved Controls Over Military Charters
Published by the Government Accountability Office on 1990-09-11.
Below is a raw (and likely hideous) rendition of the original report. (PDF)