Green Ramp Disaster Re-Investigation

On March 23rd of 1994, a terrible mid-air collision took place between an Air Force F-16 and C-130 on final approach to a runway at Pope Air Force Base near Fayetteville, North Carolina.  The F-16 pilot and his passenger ejected safely, but the F-16 crashed into the adjacent aircraft parking ramp and collided with a parked C-141.  This collision caused a huge fireball which traveled along with the remnants of the F-16 to end of the ramp where 500 army paratroopers were staging for a practice para drop.   Twenty four paratroopers eventually died and over eighty were injured.  The damaged C-130 landed safely.  The disaster made national news and was recognized by President Clinton who visited the disaster site two days later.  I was involved with both the original accident investigation and a re-investigation conducted a few years later.  (Green Ramp Disaster on Wikipedia)

Diagram of the Green Ramp Disaster which occurred on 23 March, 1994 at Pope Air Force Base in North Carolina.

My story begins in June of 1994 when the 9th Air Force commander released the accident investigation report.  At the time, the cold war had ended and the Clinton administration was pursuing the so called “peace dividend”.  Vice President Gore was in charge of the “Re-inventing Government” program which was reducing the defense budget.   The Pentagon was downsizing and closing bases as a consequence.  A base closure is a highly charged political process.  No congressman wants a military base to close in his or her district.  These base closings resulted in forced dissimilar aircraft operations at the remaining bases  and the creation of a new organization called a composite wing.   A composite wing  was in place at Pope Air Force Base on the fateful day of the accident.

Dissimilar aircraft operations put aircraft with different operating characteristics like that of an F-16 and C-130 in the landing pattern of the runway at the same time.  This makes the air traffic control climate much more complex which increases risk.  Certain politicians seized on this issue as a way to impede a base closure.  The Armed Services Committees of both houses of Congress requested the investigating officer of the Pope accident appear to explain his report.

Like so often happened while serving on the air staff in the Pentagon, I was working at my desk one morning when out of the blue I was called to the head office (AF/XOO) to review the Pope accident report and then accompany the investigating officer to the Hill for committee hearings on the accident.  I had never seen the report before and only had one hour to review the one inch thick document.  I read the executive summary and conclusions and then closely read the attached control tower audio tape transcript.  I had insufficient time to review the full report.

I finished my review and learned I would be the only air traffic control expert on the briefing team.  The tape transcript did give me an overview of what had transpired in the control tower at the time of the accident.  There was no doubt in my mind that the Pope control tower had failed in its primary job of air safety by creating a confusing environment in the landing pattern.  I noted the report had also completely exonerated the F-16 pilot.

During good weather conditions, as was the case on the day of the accident at Pope, the control tower sets up the landing sequence of arriving aircraft (who’s first and who’s second etc..)  and advises pilots where other aircraft are in the pattern.  It’s the pilot’s responsibility to separate his or her aircraft from other aircraft in the pattern by visual means.  The F16 pilot had been adivsed by the tower of the C-130 in front of him on final approach and proceeded ahead until colliding with the C-130.  This fact stuck out in my mind.  But I hadn’t had time to adequately review the report to be sure there weren’t extenuating circumstances mitigating the pilot’s decision to proceed.

I met the investigation officer, Colonel Vincent J. Santillo. Jr., an F-16 pilot, as well as other members of the team.  We proceeded to Capitol Hill to brief the House and Senate Armed Services committees.  Colonel Santillo briefed the House first with the team sitting behind him.  During this first briefing, he made factual errors concerning internal control tower procedures.  As we walked to the Senate committee room for the next briefing, I advised him of the errors.  I found it strange that he did not have an understanding of basic control tower operational procedures when he had cited the tower operators as the sole cause of the accident in the report.

Colonel Santillo finished the second briefing to the Senate.  Based on the questions the committee members asked in both briefings, I realized they were not really interested the accident itself, but rather how it could be used to further political agendas.  Walking outside, I was approached by the 9th Air Force Commander who had observed the briefings.   The general asked me if I had any comments about the report and I replied that I hadn’t had enough time to review the report to be able to form any valid opinions.  At the time, I found his question strange since the report had been approved by him before its publication.  It was a little late to be asking a senior air traffic control officer his opinion about the report.  As I was to find out later, his apparent misgivings were well founded. (Green Ramp Disaster Original and Follow-up Accident Report)

But that was not to be the end of it.  The control tower watch supervisor on duty the day of the accident was forced to retrain and transferred to a menial job in base operations.  He felt he was treated unfairly and that the F-16 pilot shared the blame, yet was exonerated.  He filed a complaint with the Air Force Inspector General (IG) but the claim was dismissed.  Not satisfied, he filed the claim with the Department of Defense Inspector General (DoD IG).  The DoD IG, being in a position to be more objective, saw merit in the claim.  He sent the accident report to the Federal Aviation Administration (FAA) for an unbiased 3rd party assessment.  The FAA reviewed the report and concluded the pilot was partially culpable and recommended a further look.  Based on this, the DoD IG recommended a re-investigation to the Secretary of the Air Force, Dr. Sheila Widnall.   She ordered the re-investigation.  After more than two years of bureaucratic grinding, the re-investigation was to take place.  (Associated Press article dated 18 January 1997)

By this time I had left the air staff and been reassigned to Nellis AFB in Las Vegas, Nevada, as the Operations Officer of the 57th Operations Support Squadron.   I was at home one weekend in February, 1997 when I received a call from the Operations Group Commander, Colonel “Hime” Oram.  He told me that I had been tasked by the commander of Air Combat Command to join a team re-investigating the Pope accident.  I wondered who had recommended me for this accident board.  While on the air staff, I had met Dr. Widnall, the Secretary of the Air Force.  I had also worked with DoD IG on several occasions.  It also might have been someone from my old office.

Lieutenant Colonel Tim Hammon and Secretary of the Air Force, Dr. Sheila Widnall in the Pentagon, December 1995.   Dr. Widnall was the first female service secretary in the nation’s history.  She was appointed by President Clinton in response to the Navy “tailhook” scandal.

At 10:00 Tuesday morning, 18 Feburary 1997, I left Las Vegas in my truck and headed for Davis Monthan AFB near Tucson, Arizona.  I checked into the Davis Monthan Inn that night.  The next morning the team assembled  in a conference room for introductions.  The team included an Air Force lawyer, a C-130 pilot, an F-16 pilot, a psychologist, and a human factors specialist from the Biomedical Service Corps.  We were all seated around the conference room table and the investigating officer, Colonel Michael S. Brake introduced himself.  And then something happened that I will never forget.  He looked at me and with a touch of anger in his voice let me know he was not happy that I was on the team.  I had never met him before so I was dumbfounded.  Everyone in the room had a “what just happened” look on their faces.

Throughout my time as an Air Force air traffic control officer, I had experienced this attitude in Air Force fighter pilots time and time again.  The FAA entrusts stewardship of parts of the national airspace system to the military.  In return, the military is required to follow the rules the FAA sets for all air traffic controllers.  These rules put air safety paramount over all other considerations.  The Air Force fighter pilot culture encouraged “pushing the envelope”.  This created a natural conflict between fighter pilot and controller.  To Colonel Brake, the re-investigation of the Pope accident was nothing more than an attempt to ruin the career of a good F-16 pilot.  I believe he projected his contempt with air traffic control on me.  Welcome to the team.

We spent a week in Tuscon going over the first accident report.  Having more time to review the report this time around, something else stuck out in my mind.  The investigating officer, Colonel Santillo, was the 6th Operations Group commander based at McDill AFB, Florida.  When appointed as the investigation officer, he had taken two of his own air traffic control non-commissioned officers (NCOs) with him as his air traffic control advisors.   Normally, accident investigation teams are made up of officers not NCOs.   He  must have known this accident investigation would put him in a position to judge controller and pilot actions.  These NCOs were not going to tell him something he didn’t want to hear since they worked for him.

During this week, I kept quiet and did not offer any opinions which would have probably evoked another confrontation with Colonel Brake.  Throughout my time in the Air Force, I had always enjoyed better interactions with airlift pilots. They seemed to better appreciate the job of air traffic controllers.   Major Mitch Gerber, the team’s C-130 pilot, was no exception and we hit it off immediately.  We spent time together and went on cross-country runs after work every day.  He was down-to-earth and I liked him.

On February 25th, we left for the Tucson airport on our way to Fayetteville and eventually Pope AFB.  We were able to keep our rooms back at Davis Montham while we simultaneously checked into billeting at Pope.  This is the only time in my Air Force career that I was able to “double billet”, one of the perks of being on an accident investigation team.  We checked into Pope billeting that night at 8:15.

At our first meeting at Pope the next day, Colonel Brake told me he had no interest in talking to the control tower watch supervisor who had caused this re-investigation and was still working at Pope in base operations.  Our purpose at Pope was to simply re-create the accident.  The flight recorder of the F-16 had been destroyed in the crash and the C-130 flight recorder had malfunctioned.  Colonel Brake would fly the same pattern the accident F-16 had flown with the same configuration and weather conditions.  At a different time, a local C-130 pilot would do the same.  We would take this newly captured data and re-create the accident in a computer simulation with the original control tower audio tape recordings providing the sound track.

On the day of the accident, the F-16 pilot was performing a maneuver called a simulated flameout (SFO) approach.  This emergency F-16 approach has the pilot throttle back the single engine and glide to a landing from a high position near the runway.  Since the approach was initiated outside the control tower airspace, Fayetteville Approach, an FAA radar facility, would have to give approval.  A minor error made by the FAA the day of accident was cited in the original investigation  report as a contributing factor.  I would have to coordinate Colonel Brake’s planned SFO maneuver with them since they had prohibited SFOs at Pope after the accident.

I contacted the local air traffic control officer and he made an appointment that day with the FAA facility chief at Fayetteville Approach Control.  We met with the facility chief and his assistant and I explained who I was and what we intended to do while at Pope.  When he realized we intended to fly an SFO approach, the chief emphatically denied authorization.  I was a little amused since he apparently did not realize the high level interest this accident re-investigation had.  I was on a “mission from God”.  I asked him if he was sure he wanted to deny the maneuver.  He wouldn’t budge.

We went back to the air traffic control office at Pope.  I still had contacts back in Washington DC from my time on the air staff.  I called the Air Force liaison office located in the FAA headquarters building in Washington.  I talked to a friend and explained the situation.  She said she would take care of it.  The next day, we got a call from the Fayetteville FAA facility chief who wanted to meet with us in his office.  We met with the the FAA chief and his assistant once again.  This time there was a huge change in attitude.  They were falling all over themselves to help us get the SFO procedure done.   We were able to complete both the C-130 and F-16 flights while we filmed them from the Pope control tower.

While we were at Pope, another deficiency from the original investigation became apparent.  When the accident occurred, there were other C-130s in the vicinity of the airport whose crew members were witnesses to the catastrophe.  The original investigator, Colonel Santillo, never interviewed these C-130 crew members.  By now one had left the Air Force and was flying for a commercial airline.  We were able to contact him between flights and interviewed him over the phone.  One other C-130 crew member in the same plane as well as a crew member whose aircraft was on a nearby taxiway were also telephonically interviewed.  But, none of these interviews added anything new to the investigation.

We successfully captured data from the flights of an F-16 and C-130.   We also located the original control tower audio recordings and made copies as well as a written transcript.  With data collection complete, our time at Pope ended.  On 3 March, after spending a week at Pope, we flew back to Tuscon.  We spent the night at Davis Montham and the next afternoon flew to Tinker AFB located in Oklahoma City.

For the next four days we used Tinker’s  Mishap Analysis Animation Facility (MAAF) to re-create the accident in a computer animation.  Combined with the control tower recordings, we were able to witness the whole accident in real time.  Hearing the original control tower tape recordings gave me a new perspective on the attitude and state-of-mind of the F-16 pilot.  He seemed to be overly relaxed in his communications with the tower almost to the point of being flippant.  Putting all the pieces together, I was convinced he was partially responsible for the accident.  The control tower had set the stage but had he acted in a careful manner, the accident might have been prevented.  We flew back to Tucson on March 8th and spent the next 6 days at Davis Montham finishing up the analysis of the accident.

On the final day at Davis Montham, Colonel Brake had the whole board vote on the F-16 pilot’s culpability in the accident.  The vote was unanimous in favor of  the culpability of the F-16 pilot.  I’m sure Colonel Brake wished otherwise, but the board consisted of pilots, controllers, and human factor specialists.  He had no choice but to concede.  Colonel Brake dismissed the board and proceeded to write the report alone.   I drove back home to Las Vegas on 14 March.

In June of that year, the final report was released.  (Associated Press Article in the Valdosta Daily Times (Georgia) dated 22 June 1997).  Originally, the controllers involved in the crash were fined, demoted, and relieved of duty.  And for all his trouble after the release of the second report, the watch supervisor who had made the DoD IG complaint was given an article 15 (non-judicial punishment).  Three months later, on September 3rd, the F-16 pilot, Captain Joseph R. Jacyno, was promoted to Major (Congressional Record) and continued on flying status.   As far as I know, no action was taken against Colonel Santillo, the original accident investigation officer, for his biased report.

The accident was a terrible event and like most accidents of this sort had multiple causes.  The initial accident investigation and its follow-up investigation reaffirmed to me how corrupt the culture of the Air Force had become by the 1990’s.  I have been retired now for over twenty years and this corruption was one of the many reasons I chose not to continue on in the Air Force at the 21 year point.  As a lieutenant colonel, I could have stayed for 28 years.  Some events which have taken place over the last twenty years have given me hope the culture has changed and the Air Force is a better functioning organization.  But in this case, the corrupt fighter pilot culture successfully protected its own.

 

The First Defense Ministerial of the Americas

In December 1994, President Clinton hosted 33  democratically elected leaders from the Western Hemisphere at the Summit of the Americas in Miami in order to affirm commitments to democracy and develop a new architecture for ongoing relationships.  In that spirit, Secretary of Defense William J. Perry followed up with a summit of defense representatives from all thirty-four democratically elected governments of our Hemisphere (Cuba excluded) in July 1995 (State Department Background on the First Defense Ministerial of the Americas).  I was lucky enough to attend this historic summit as the leader of a liaison team to the Trinidad and Tobago delegation.  The following is my recollection of that three day summit.

This is the logo developed for the first Defense Ministerial of the Americas. It shows the American continent superimposed over a drawing of the Governor’s Palace located in Colonial Williamsburg which was where this historic event took place.

Secretary Perry selected Air Force Colonel Raymond C. Gagnon, Jr. as the Director of the task force organizing the event.  It was planned for 3 days starting on July 24th, 1995.  Colonel Gagnon had an air weapons controller background and apparently had the trust of the secretary to put this very important event together.  Colonel Gagnon was given the Colonial Williamsburg location to stage the event.  This is a very popular tourist destination which was closed to the public for three days in order to ensure tight security for the attendees.

One of the many problems to be solved was the various languages the attendees spoke:  English, French, Spanish, and Portuguese.  A call went out for bilingual military officers to act as liaisons to the attendees.  My boss was bilingual in French and was picked for the Canadian delegation.  After becoming involved with the planning, he recommended me for the Trinidad and Tobago delegation.    Trinidad is an English speaking nation but a Spanish speaker was needed for possible interactions with the majority Spanish speaking delegates.  I had graduated from the Defense Language Institute seven month Castilian Spanish course and had lived and worked for three years in Zaragoza, Spain.  I had also spent time in Central America having been deployed to work military exercises several times.

I am pictured here sitting at my cubicle  in our secure office called a “vault” inside the Pentagon in 1995. Notice the window in the background. This was a luxury for the rank and file. In my previous office, there were no windows. There were times when I would go to work in the dark and return home in the dark never seeing the sunlight all day.

I was working in my office on Wednesday, July 19th when my boss called and told me to drive down to Williamsburg, Virginia that evening for in-processing and training the next day.   After a two and a half hour drive from my home in Fairfax Station, Virginia, I arrived at Williamsburg and checked into the Williamsburg Lodge at nine o’clock that night.  Since I was a team leader, I was given a private room.

The next day, I met my team which consisted of a marine major and an air force captain who were both bilingual in Spanish.  We spent  two days in-processing and receiving an overview of the summit.  We also received training in protocol as well as what our duties would be.  I learned my team would be assigned to the Trinidad and Tobago delegation which would consist of their foreign minister, an assistant, and a Trinidad army colonel.  The Trinidad Defense Minister was not able to attend so the Foreign Minister, Mr. Gordon Draper, would be sent in his place.  As part of the in-processing, we were issued special badges for the event.  Security of the attendees was of paramount importance.

This is the badge I was given for the summit. We were instructed not to wear our uniforms during the event which is why I am pictured here in civilian clothes. Also, notice the Trinidad and Tobago national flag was part of the badge. Each Trinidad delegate and my team members wore identical badges during our stay in Colonial Williamsburg.

On July 22nd at 8:30 am, all 34 liaison teams boarded government buses bound for Langley Air Force Base near Virginia Beach, Virginia where we boarded a military transport bound for Miami International Airport.  The arrival plan for all the delegates had them arrive in Miami and then be transported to Colonial Williamsburg as a group.  We arrived at Miami International Airport at 12:45 pm and then shortly after checked in at the Miami Hilton located near the airport.  The delegates would all arrive at different times the next day.

The next day, July 23rd, we were instructed that each team leader would travel to the airport in a limousine and personally meet our assigned delegation.  A special line through customs was set up to quickly usher our VIPs through the airport.  I met the limousine at the hotel and rode in the back to the airport by myself.  I must admit that I was somewhat apprehensive on the ride there and hoped I would not be the cause of an international incident if something should go wrong.

I arrived at the airport and proceeded to the arrival gate of my delegation.  These were the pre-911 days when you could still meet arriving parties at the gate.  I connected with my delegation as they entered the airport and ushered them through customs.  We picked up their baggage and proceeded to the limousine  which now had a police escort provided by the city of Miami.  We got in the limousine and were off immediately.  The two car police escort turned on their lights and sirens and we were whisked through the city to the hotel.  I found it to be quite an interesting experience.  During the ride, I gave the group a security briefing and gave each member of the delegation a badge to be worn while in Colonial Williamsburg.

Arriving at the hotel, my team met the limousine and were introduced to the individuals they had been assigned as liaisons.  The major would take care of the army colonel and the captain was matched with Mr. Draper’s assistant.  I accompanied Mr. Draper to his room and helped him with his baggage.  Once inside, we continued the conversation we had as we rode in the limousine and became acquainted with each other.  At the end of the conversation, he asked me to call him Gordon.  I explained I probably shouldn’t in public but I would be happy to in private.  I realized I was lucky to have been matched with an important but approachable man.  I liked him right away.

Mr. Gordon Draper, Foreign Minister of Trinidad and Tobago in 1995 is pictured here as he appeared in 2000.

We left the Miami Hilton at 10:00 am the next day on a government contracted bus and boarded an Air Force transport at the Miami airport for the flight back to Langley Air Force Base.  We arrived at 12:45 pm and spent a few hours at Langley and then proceeded to Colonial Williamsburg.  Along with the summit’s support staff, I checked in to the Williamsburg Lodge while the delegates stayed at the Willimasburg Inn.

My job was to accompany Gordon to most events during the next two days of the summit to help him with interactions with other delegates if needed.  I was issued a hand held radio which we called a “brick” in the military.  In 1995, cell phones were still essentially a novelty.  The brick would give me instant contact with the summit’s support headquarters should any problems arise.

At the end of the first day, a catered dinner in a large tent set up on the grounds of the Governor’s Palace was planned.  I met the Trinidad delegation there during a cocktail hour before the dinner.  The delegation chose to stay together in light conversation.  It was a pleasant summer evening and the mood was light.  After a while, the protocol people began to encourage the delegations to find their tables under the tent.  After a short while, most the people in attendance had found their seats, but my three delegates continued to remain outside engaged in light conversation.

The protocol people began to give me visual signals indicating my delegation needed to move to the tent.  I tried succinctly to get them to move.  Gordon apparently realized my discomfort and offered, “We are going to lime just a bit longer”  (In Trinidad, liming is a slang term meaning the art of doing nothing).  After seeing the quizzical look on my face, he offered an explanation, “a man in Trinidad was once sent by his wife to get a chicken for dinner.  He returned the next day slightly drunk and instead of giving his wife a chicken, he gave her a lime instead.”  Much to the relief of the protocol people, my delegation eventually took their seats under the tent and we enjoyed a pleasant dinner.

Delegates to the first Defense Ministerial of the Americas are pictured here in the Colonial Williamsburg conference center in July 1995.

During the summit, only two minor problems arose with the delegation.  The first concerned the Trinidad army colonel.  He did not agree with the arrangements the Trinidad government had made for the summit.  He felt that he, as the delegation’s military representative, should be its head.  He asked that I make a request to have him be recognized as the lead.  I passed his request to the protocol people and they contacted the Trinidad government.  Trinidad replied there would be no changes and I informed the colonel who accepted the answer.

The next problem concerned security.  I had told the members of the delegation that they had to wear their badges at all times while at the summit.  One afternoon, one of the Trinidad delegation members decided to take a walk around the grounds without his badge and was challenged by security.  They tried to reach me on my brick but I must have been out of range and never got the call.  In the end, security identified him and let him go on his way.

Highlights of the summit included speeches by Secretary of Defense Perry and Vice President Al Gore. Terry McAuliffe, now Governor of Virginia (2018) introduced the Vice President.  I was in attendance at all of these events.

I accompanied Gordon to most events during the summit.  On the second evening of the summit, we attended a cocktail party in the Governor’s Palace where Secretary Perry was in attendance.  Gordon indicated he wanted to meet the secretary so we walked over to him and I found myself introducing the Foreign Minister of Trinidad to the US Secretary of Defense.  As we approached the Secretary, I was reviewing proper protocol procedures in my mind.  I was nervous but I managed to get through the introductions without making a mistake.  This definitely was not my area of expertise.

On the last day of the summit, all the delegates were gathered to have a group photo taken in front of the Governor’s Palace. I was standing next to the photographer when this photo was taken.

The summit ended on July 26th and we left Colonial Williamsburg at 2:00 pm for the bus ride back to Langley.  Upon arriving at Langley, we immediately boarded an Air Force transport and flew back to Miami.  We checked back into the Miami Hilton at 5:30 pm that evening.  Later that evening, we socialized in a suite reserved for us on the top floor of the Hilton.  I spent a pleasant evening with the delegation in conversation and drinks.  Gordon was a pleasant and warm man and we enjoyed a pleasant evening together.

The next morning, July 27th, the delegation checked out of the Hilton and Gordon and I said goodbye.  He was going to spend a few days in Miami as a tourist.  I breathed a sigh of relief as this special assignment ended without any serious problems arising.

At 1:30 that afternoon, I flew back to Langley and was bused back to Colonial Williamsburg to reunite with my vehicle.  I arrived back home at Fairfax Station, Virginia at 8:00 pm and went back to work in the Pentagon the next day.  A few months later, my contribution to the summit was recognized by Colonel Gagnon.

This is a letter sent to the Air Force Director of Current Operations by Colonel Gagnon a few months after the summit was over. A very nice certificate signed by the Secretary of Defense, William Perry and a personal letter to me were attached. That certificate proudly hangs on my wall to this very day.  In addition, we were all given the “T-shirt”, in this case a polo shirt with the Ministerial Logo imprinted.

Final Thoughts:

Sadly, Gordon Draper died of an aneurysm (sudden bleeding in the layer between the skull and the brain) in St. Mary’s Hospital in London, England in August of 2004.  Friday 13th August edition of the Trinidad and Tobago Newsday.

The Defense Ministerial became a biennial event.  The 2nd Ministerial was held two years later in Argentina.  Coincidentally, the 12th one was held in Port of Spain, Trinidad and Tobago in 2016.  The 13th is to be held in Mexico this year,  2018.