oversight

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)

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  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
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