Table Of Content---
YRATILIM TFiLRIA
Information on Gander
Crash and Improved
Controls revO Military
Charters
t9
II llI
142194
RELEASED
toN--DE’ICIRTSER ot eb desaeler edistuo eht
lareneG gnitnuoccA OfPlce sselnu specifically
devorppa yb ebt OffIce of lanoissergnoC
.snoitaleR
OAG
detinU setatS
lareneG gnitnuoccA eciffO
,notgnihsaW .C.D 84602
lanoitaN ytiruceS dna
lanoitanretnI sriaffA noisiviD
690322-B
rebmetpeS 0991,11
ehT elbaronoII nhoJ ,sreynoC .rJ
,namriahC noitalsigeL dna
lanoitaN ytiruceS eettimmocbuS
Committee no Government
snoitarepO
esuoH of sevitatneserpeR
ehT elbaronoH C.W. Bill gnuoY
esuoH of sevitatneserpeR
nI esnopser ot ruoy ,stseuqer ew have depoleved information no eht .S.J1
s’tnemnrevog noitapicitrap in eht naidanaC investigation of eht 5891
hsarc of na worrA Air aircraft in ,rednaG .dnaldnuofweN Specifically,
this troper sesserdda )1( eht selor of eht .S.U laredef seicnega taht
detsissa eht naidanaC Aviation Safety draoB in its investigation, )2( eht
ograc taht saw dedaol draoba eht ,enalp dna )3( eht snoitca nekat ot
erusne eht safety dna ytiruces of .S.U military airlift sretrahc in
esnopser ot ruo ,troper Military Airlift: tnemeganaM slortnoC Over
retrahC Airlift deeN ot eB denehtgnertS ,76-78-DAISN/OAG( .raM ,6 .)7’891
Results in Brief Several .S.U laredef seicnega erew involved in gnipleh eht naidanaC Avi-
noita Safety draoB htiw eht hsarc investigation. lanoitaN -atropsnarT
noit Safety draoB officials detapicitrap in all stcepsa of eht
investigation. A laredeF Aviation noitartsinimdA official saw trap of a
maet taht detcudnoc investigations in ,tpygE Italy, dna West .ynamreG
ehT demrA secroF etutitsnI of ygolohtaP dna eht laredeF uaeruB of
Investigation depleh identify hsarc victims, dna eht etutitsnI osla -rep
formed .seispotua nI ,noitidda eht laredeF uaeruB of Investigation
detsissa in gniniatbo sliated no eht noitidnoc of eht aircraft erofeb it
detraped for rednaG from srebmem of eht flight werc taht dah nwolf eh,t
aircraft from ,oriaC ,tpygE ot ,engoloC West .ynamreG
gnidroccA ot eht manifest, ograc hcus sa loot ,sexob a ,aremac a riaper
strap kit, ,srekcoltoof noitacinummoc ,eannetna medical ,sdrocer ,skoob
’ dna strahc erew no eht aircraft. ehT manifest seod ton etacidni taht
explosives erew no eht aircraft.
ruO weiver detacidni taht most of eht snoitadnemmocer in ruo hcraM
7891 troper have neeb implemented, dna slortnoc over eht safety of mil-
itary airlift retrahc aircraft have improved. roF example, ew dnuof taht
egaP 1 BB242-OMIAISN/OAG yratiliM tfilriA
eht Military Airlift dnammoC dna eht Military Traffic tnemeganaM
dnammoC have improved flight safety dna ytilauq yb improving eht
yaw yeht eganam dna rotinom retrahc aircraft.
Background nO rebmeceD ,21 ,6891 a 8-CD aircraft deretrahc from worrA Air
dehsarc dna denrub ta ,rednaG ,dnaldnuofweN .adanaC ehT hsarc killed
842 military lennosrep from eht 1Olst enrobriA Division, troF ,llebpmaC
,ykcutneK dna 8 werc srebmem from worrA Air. ehT aircraft saw
ne etuor from ,oriaC ,tpygE ot troF ,llebpmaC ,ykcutneK htiw spots in
,engoloC West ,ynamreG dna ,rednaG .dnaldnuofweN ehT aircraft dah
neeb deretrahc yb eht lanoitanitluM ecroF dna Observers, na -nepedni
tned lanoitanretni noitazinagro dehsilbatse ot esivrepus eht implementa-
noit of eht ytiruces stnemegnarra dehsilbatse yb eht ilearsI-naitpygE
ytaerT of .ecaeP ehT detinU setatS dna several rehto seirtnuoc deerga ot
dnes spoort ot eht elddiM tsaE ot pleh ecrofne this .ytaert
ehT rebmem-enin naidanaC Aviation Safety draoB investigated eht
hsarc rednu provisions deniltuo in lanoitanretnI Civil Aviation -azinagrO
noit .serudecorp hguohtlA eht draoB saw elbanu ot enimreted eht tcaxe
ecneuqes of events taht del ot this ,tnedicca eht majority of eht s’draoB
srebmem believed taht most of eht ecnedive detroppus eht noisulcnoc
taht yltrohs after liftoff, eht aircraft decneirepxe na esaercni in gard
dna noitcuder in lift, hcihw detluser in a stall ta wol edutitla from hcihw
yrevocer saw ton .elbissop yehT denimreted taht eht most elbaborp
esuac of eht stall saw eci noitanimatnoc no eht gnidael egde dna reppu
ecafrus of eht .gniw rehtO elbissop factors, hcus sa a ssol of tsurht from
na enigne dna etairporppani takeoff ,sdeeps may have dednuopmoc eht
effects of eht .noitanimatnoc
ehT rehto srebmem of eht draoB dedulcnoc taht eht sgniw of eht -ria
craft erew ton detanimatnoc yb hguone eci for eci noitanimatnoc ot eb a
factor in eht .tnedicca yehT believed taht na draob-no fire dna a ssol of
rewop desuac eht aircraft ot .hsarc
A former naidanaC emerpuS truoC ecitsuJ osla deweiver eht .esac eH
dedulcnoc taht gnihton in eht material eht draoB deweiver detacidni eht
esuac of eht .tnedicca
Scope ”dna oT hsilpmocca ruo objectives, ew deweivretni officials dna deweiver
available stnemucod ta ,sretrauqdaeH Military Airlift ,dnammoC ttocS
ygolodohteM
Air ecroF ,esaB Illinois; ,sretrauqdaeH Military Traffic tnemeganaM
egaP 2 RB342-09DAISN/OAG yraMWl tfilriA
330322bl
,dnammoC dna Criminal Investigation Division, tnemtrapeD of eht
Army, Falls ,hcruhC Virginia; dna eht laredeF Aviation Administration,
lanoitaN noitatropsnarT Safety ,draoB laredeF uaeruB of Investigation,
tnemtrapeD of ,etatS dna demrA secroF etutitsnI of ,ygolohtaP Wash-
,notgni .C.D
We osla detcatnoc rehto ,seicnega hcus sa eht lartneC ecnegilletnI
,ycnegA esnefeD ecnegilletnI ,ycnegA .S.U smotsuC Service, dna eht Air
ecroF noitcepsnI dna Safety retneC ot enimreted tahw elor yeht ,dah if
,yna in eht investigation. ruO weiver detacidni taht enon of eseht -nega
seic dah yna involvement in eht investigation. xidneppA I provides -idda
lanoit information no ruo .weiver
We detcudnoc ruo weiver from rebmeceD 9891 hguorht yaM 0991 in
ecnadrocca htiw yllareneg detpecca tnemnrevog gnitidua .sdradnats sA
,detseuqer ew did ton niatbo ycnega stnemmoc no this .troper ,revewoH
eht views of elbisnopser ycnega officials erew thguos gnirud eht esruoc
of ruo ,krow dna yeht yllareneg deerga htiw eht facts sa .detneserp
sselnU uoy ylcilbup ecnuonna its stnetnoc ,reilrae ew nalp on rehtruf
noitubirtsid of this troper until 03 syad after its eussi .etad At taht time
ew will dnes seipoc ot eht ,rotceriD Office of tnemeganaM dna ;tegduB
eht seiraterceS of ,esnefeD ,noitatropsnarT eht Army, eht Navy, dna eht
Air ;ecroF eht ,rotceriD laredeF uaeruB of Investigation; eht Adminis-
,rotart laredeF Aviation Administration; eht ,namriahC lanoitaN -snarT
noitatrop Safety ;draoB dna etairporppa lanoissergnoc committees. We
will osla ekam seipoc available ot .srehto
This troper saw deraperp rednu eht noitcerid of ycnaN .R ,yrubsgniK
,rotceriD Air ecroF ,seussI ohw may eb dehcaer ta )202( 8624-572 if uoy
ro ruoy staff have yna snoitseuq gninrecnoc this .troper rehtO major
srotubirtnoc ot this troper era listed in xidneppa II.
knarF .C nahanoC
tnatsissA rellortpmoC lareneG
egaP 3 BB342.03-DAISN/OAG yratiliM tfilriA
stnetnoC
retteL
1
Appendix I
6
ehT rednaG hsarC dna naidanaC Aviation Safety draoB detagitsevnI eht 6
Investigation tnediccA
.SU seicnegA Were Involved in eht hsarC Investigation 7
Manifest sliateD ograC draobA eht Aircraft 8
Improvements edaM in Safety dna ytiruceS of .S.U 9
Military Airlift sretrahC
Appendix II
21
rojaM srotubirtnoC ot
This Report
snoitaiverbbA
DOD
AAF
tnemtrapeD of esnefeD
laredeF Aviation noitartsinimdA
CMTMFBI laredeF uaeruB of Investigation
BSTN Military Airlift dnammoC
Military Traffic tnemeganaM dnammoC
lanoitaN noitatropsnarT Safety draoB
egaP 4 RB842-OB-DAISN/OAG yratiliM tfilriA
egaP 6 RB342-OgDAISN/OAG yratiliM tfilriA
~A>pndix I
_-
The rednaG hsarC dna noitagitsevnI
sdradnatS dna dednemmocer secitcarp for aircraft tnedicca seiriuqni
erew first detpoda in 1591 ta eht noitnevnoC no lanoitanretnI Civil Avi-
noita dna erew detangised sa xennA 31 ot eht .noitnevnoC xennA 31
setats taht eht“ etatS in hcihw eht tnedicca srucco will institute na
,yriuqni eht etatS in hcihw eht aircraft is deretsiger shall eb given eht
ytinutroppo ot tnioppa srevresbo ot eb tneserp ta eht yriuqni dna eht
etatS gnidloh eht yriuqni shall etacinummoc eht troper dna findings in
eht matter ot taht ”.etatS
Canadian Aviation ehT naidanaC Aviation Safety draoB is na tnednepedni laredef -nrevog
tnem ydob taht stroper yllaunna ot eht naidanaC Parliament. At eht
ytefaS Board
time of eht ,tnedicca eht draoB detsisnoc of enin srebmem taht tes
detagitsevnI eht
overall policy, detacidujda tnedicca dna tnedicni stroper dna rieht -ossa
Accident detaic findings dna ,snoitadnemmocer dna denimreted nehw all stroper
erew ot eb .desaeler ehT s’draoB snoitaluger detats taht snoisiced erew
ot eb edam yb majority vote of eht srebmem .tneserp
tsoM Members Concluded Five srebmem of eht draoB dedulcnoc taht most of eht ecnedive -pus
tahT Ice Contamination on detrop eht noisulcnoc taht yltrohs after lift-off, eht aircraft decneirepxe
na esaercni in gard dna noitcuder in lift, hcihw detluser in a stall ta wol
the Wing Probably Caused
edutitla from hcihw yrevocer saw ton .elbissop ehT most elbaborp esuac
the Accident
of eht stall saw denimreted ot eb eci noitanimatnoc no eht gnidael egde
dna reppu ecafrus of eht .gniw rehtO elbissop factors, hcus sa a ssol of
tsurht from na enigne dna etairporppani takeoff ,sdeeps may have -moc
dednuop eht effects of eht eci .noitanimatnoc
Other Members Concluded ehT rehto srebmem of eht draoB believed taht eht sgniw of eht aircraft
tahT an On-Board Fire erew ton detanimatnoc yb hguone eci for eci noitanimatnoc ot eb a
factor in eht .tnedicca yehT dedulcnoc taht na draob-no fire dna a ssol of
Caused the Accident
rewop desuac eht aircraft ot .hsarc
Justice Believes tahT ehT naidanaC retsiniM of tropsnarT deksa ecitsuJ Willard ,yetsE for-
Neither Conclusion Was merly of eht emerpuS truoC of ,adanaC ot tcudnoc a weiver of eht eritne
drocer of eht rednaG tnedicca investigation dna provide a troper no
Supported
rehtehw yna rehtruf investigation ro yriuqni saw .detnarraw ecitsuJ
ye&F dedulcnoc taht gnihton in eht material eht draoB deweiver indi-
Y detac eht esuac of eht .tnedicca ecitsuJ yetsE osla dedulcnoc taht on“
investigation ro yriuqni detcudnoc five sraey after eht tnedicca is gniog
ot etubirtnoc ot eht cilbup tseretni in eht safety of aviation.”
egaP 6 RBM-OMtAISN/OAG yraWNI tfilriA
xidneppA I
ehT rednaG hsarC dna noitagitsevnI
.S.U Agencies Were Several .S.U laredef seicnega erew involved in eht hsarc investigation
esuaceb of eht provisions deniltuo in xennA 31 ot eht lanoitanretnI Civil
Involved in eht Crash
Aviation noitazinagrO dna esuaceb eht naidanaC Aviation Safety draoB
Investigation
detseuqer rieht .ecnatsissa esehT seicnega dedulcni eht lanoitaN -snarT
noitatrop Safety draoB ,)BSTN( eht laredeF uaeruB of Investigation ,)IBF(
eht laredeF Aviation noitartsinimdA )AAF( dna eht demrA secroF Insti-
etut of .ygolohtaP
NTSB Participated BSTN detnioppa a evitatneserper taht saw elbisnopser for gnieesrevo all
Extensively in .S.U lennosrep involved in eht investigation. ehT evitatneserper
Investigation detnioppa a maet taht detsisnoc of lacinhcet advisors from ,BSTN ,AAF
llennoDcM salguoD eht( rerutcafunam of eht aircraft), ttarP & Whitney
eht( rerutcafunam of eht aircraft’s ,)enigne worrA Air, dna eht .S.U
Army. ehT maet investigated eht hsarc site, denimaxe ,sdrocer dna
deweivretni lennosrep ta worrA Air. yehT osla detsissa in examining eht
senigne dna rehto aircraft .erawdrah gniruD eht s’draoB yad-8 cilbup
gniraeh no eht investigation, BSTN saw dettimrep ot examine sessentiw
dna dah full ssecca ot all factual atad detcelloc yb eht team.
staff deweiver dna detnemmoc no eht draft troper of eht investiga-
BSTN
noit erofeb eht final troper saw .deussi BSTN staff dlot su yeht did ton
find yna smelborp htiw eht draft ro final .stroper
FBI Helped yfitnedI ehT IBF detsissa eht naidanaC Aviation Safety draoB yb gniweivretni
Remains and Interviewed srebmem of eht flight werc taht dah nwolf eht aircraft from ,oriaC
,tpygE ot ,engoloC West .ynamreG ehT esoprup of eht sweivretni saw ot
Previous Flight werC
niatbo sliated no eht noitidnoc of eht aircraft erofeb it detraped for
.rednaG ,oslA a evitatneserper of eht S'IBF identification division
devresbo eht removal of emos of eht seidob ot eht yraropmet eugrom
facilities ta rednaG .tropriA nI ,noitidda eht IBF detsissa in eht ydob
identification efforts yb providing tnirpregnif snosirapmoc no all
.sniamer After eht tnirpregnif snosirapmoc erew ,detelpmoc eht IBF -noc
deunit ot pleh identify eht seidob yb gnirehtag stnirpregnif from -rep
lanos items dna gnizylana riah .selpmas
FAA Was traP of nA AAF official saw trap of eht investigation team. This maet detcudnoc
Investigation Team sweivretni htiw )1( ecnanetniam dna dnuorg werc lennosrep in ,emoR
Y Italy; ;engoloC dna ;oriaC )2( lortnoc rewot officials in ;engoloC dna )3(
lanoitanitluM ecroF dna srevresbO officials in .oriaC ehT maet osla
7egaP RB342-09-DAISN/OAG yratiliM tfilriA
ehT rednaG hsarC dne noitaglteevnI
deweivretni military lennosrep taht erew nwolf from troF ,llebpmaC
,ykcutneK ot oriaC no eht emas aircraft taht yltneuqesbus .dehsarc
Armed Forces Institute of enO of eht prime missions of eht demrA secroF etutitsnI of ygolohtaP is
Pathology Led the Body ot provide ecnatsissa in eht medical investigation of all fatal military
aircraft .stnedicca gniruD eht investigation, eht etutitsnI demrofrep
Identification stroffE
seispotua dna del eht efforts ot identify eht .seidob
Other Federal Agencies sA trap of ruo ,weiver ew detcatnoc several rehto .S.U tnemnrevog -nega
Were Not Involved in the ties ot enimreted tahw selor yeht ,dah if ,yna in eht investigation of eht
.hsarc esehT seicnega dedulcni eht lartneC ecnegilletnI ,ycnegA esnefeD
Investigation
ecnegilletnI ,ycnegA .S.U smotsuC Service, dna eht Air ecroF noitcepsnI
dna Safety .retneC ,revewoH officials ta esoht seicnega dias yeht erew
ton involved. We osla deksa eht lanoitaN ytiruceS licnuoC rehtehw it
saw involved, tub ew dah ton received a esnopser yb eht time ew deussi
this .troper
tsefinaM Details Cargo We erew deksa ot yrt ot enimreted tahw ograc saw dedaol no eht .enalp
We detacol a ypoc of eht manifest of ograc no eht aircraft. ehT manifest
Aboard eht Aircraft
detacidni ,taht in noitidda ot poort duffel ,sgab 84 seceip of ograc erew
no eht aircraft. esehT items detsisnoc of loot ,sexob a ,aremac a riaper
strap kit, ,srekcoltoof noitacinummoc ,eannetna medical ,sdrocer ,skoob
,strahc gniniart ,sdia lagel forms, dna a erutcip in a frame.
ehT AAF official taht saw trap of eht investigation maet dlot su taht eh
confirmed hguorht sweivretni taht emos of eht egaggab dedaol draoba
eht aircraft deniatnoc eht ’spoort krowrepap latned( sdrocer dna rehto
tnenitrep information). ehT manifest deton taht 14 duffel sgab erew ton
no eht aircraft esuaceb eht aircraft’s ograc dloh saw filled. ehT manifest
did ton etacidni taht explosives ro yna rehto volatile material erew no
eht aircraft. ,rehtruF various officials dlot su yeht believe taht -olpxe
sives ro yna rehto volatile material erew ton no eht aircraft.
egaP 8 RB342W-DAWIjOAG yratiliM tfUrlA
Description:MILITARY AIRLiFT Information on Gander Crash and Improved Controls Over Military Charters II Ill t9 142194 Military Airlift: Management Controls Over
