[APPENDIX 3]{.underline}

Narrative Summary of CT-43 Tragedy Lessons Learned

Issue 1: Initial Recovery Actions (3 - 6 April 1996)

Findings:

A. The Air Force Operations Center promptly acquired and disseminated
information required by the national leadership to respond to inquiries
and direct recovery actions.

1\. Information flow was complicated by inaccurate and/or incomplete
data in the early stages of the mishap response. For example, the first
reports of the mishap aircraft type and location were erroneous and
delayed recovery efforts by the Operations Center and search and rescue
units. The lack of a passenger manifest delayed notification of the next
of kin.

2\. Liaison officers assigned by the Air Force Operations Center to the
Commerce Department facilitated interagency coordination in the early
phases of the mishap response.

B. Croatian authorities located the wreckage on a steep mountainside
after receiving information from a citizen. A US Army Field Morgue,
prepositioned in the region as part of the Implementation Force, made a
timely and professional response that resulted in the recovery of all
remains by 5 April 1996. Some remains could only be identified after
comparison with medical and dental records or through DNA testing. In a
few instances, the identification process was delayed approximately 24
hours because samples were not collected for testing at the earliest
opportunity.

C. The responsibility for notifying the next of kin that the deaths of
their loved ones had been confirmed was divided among five Federal
agencies and the Croatian government. The method of notifying the next
of kin and maintaining contact with the next of kin was not uniform
among the Federal agencies. In some cases, notice that some families did
not want contact from the United States Air Force (USAF) was not
provided by an agency's casualty notification officer to the Department
of Defense (DoD). In other cases, families were confused by information
provided by an agency's notification officer which conflicted with
information later provided by the USAF.

D. A C-17 returned the remains and some personal effects to the Dover
Air Force Base (AFB) port mortuary. Air Mobility Command procedures to
dedicate airlift for this mission resulted in timely repatriation on 6
April 1996.

Considerations:

A. All leaders will require timely and accurate data to direct recovery
actions and to maintain credibility with the victims' families and the
public at large. The accessibility of the crash site to the media will
largely determine the time frame in which a service component or agency
can ascertain the facts of the mishap, notify victims' families, and
prepare its response to inquiries.

1\. Confusion and factual inaccuracies are frequent products of major
tragedies.

2\. Employees of Federal agencies may have no knowledge of the initial
recovery actions that the military components will take after a major
tragedy. While other employees may have substantial understanding of
military recovery actions, they are unlikely to know the points of
contact in the DoD who could best coordinate the DoD's efforts with
those of an interested agency. The assignment of Air Force Operations
Center staff officers to provide liaison could fill the knowledge gap in
most instances.

B. Forces of nature are a factor in all recovery efforts. Country
clearances can be a factor for mishaps occurring outside the territorial
limits of the US. Aircraft crashes are generally violent events that can
make the identification of remains a time-consuming aspect of recovery
efforts; prior specialized training of Mortuary Affairs personnel is
necessary in expediting the identification of remains while minimizing
the trauma families experience when asked for their loved ones' medical
and dental records and biological samples for genetic testing.

C. Casualty notification is a critical process to every tragedy victim's
family. It is highly stressful to both the family and the individual
whose duty it is to inform the family that a loved one has met a tragic
death. As they adjust to the initial shock, the families will likely
have questions that are important to arrangements they must make for the
near- and long-term future. The families will likely need a Service
component point of contact who is familiar with the mishap, the Service
component's initial recovery actions, and other points of contact, both
in and out of the Service component, to provide guidance.

D. Remains of victims of tragedies occurring within the territorial
limits of the US may be transported by various methods to different
locations as directed by the next of kin. Remains of victims of military
tragedies occurring outside the US will generally be repatriated to the
US through either the Dover AFB, Delaware, or Travis AFB, California,
port mortuaries. A prompt repatriation will likely be important to the
next of kin; Air Mobility Command's Tanker Airlift Control Center (TACC)
can dedicate an aircraft to transport the remains of mass casualties,
but early tasking is key to mission success.

Conclusions:

A. The Operations Center concept is sound, and the "quick reaction"
checklists were effective in enabling senior leadership to undertake
appropriate recovery actions.

B. Assigning liaison officers to work with other interested agencies is
effective and should be continued as a process in future tragedies that
impact more than one agency.

C. Each Service component should review its procedures for reacting to
mass casualties with emphasis on responding to difficult terrain, under
adverse weather conditions, in cooperation with a nation which may
require country clearance prior to permitting entry of US military
personnel, and under circumstances requiring expedited identification of
remains. Further, each Service component should review its procedures
for communicating requests for records and biological samples so as to
minimize the trauma to be experienced by the next of kin while awaiting
notification of their loved one's survival or death.

D. When agencies outside the Service component are involved with
casualty notification, one agency should take responsibility to assure
the notifications are comparable, and to assure that next of kin have a
single point of contact to provide appropriate and consistent
information, advice, and guidance.

E. Dedicated airlift to repatriate the remains was sound, and was timely
in large part due to early tasking by the Tanker Airlift Control Center
(TACC).

Issue 2: Short Term Support of Families (6 April -30 June 1996)

Findings:

A. On 6 April 1996, the Air Force returned the remains of the 33 US
citizen to the port mortuary at Dover AFB, Delaware. The President, Vice
President, cabinet members, other senior government officials, senior
military officers, and the families of the victims came to Dover to
attend the memorial ceremony that accompanied the repatriation.

1\. The ceremony was planned and conducted by the Army Honor Guard
(Military District of Washington). Air Force funded the travel for
surviving family members, and travel was arranged cooperatively by the
Air Force Deputy Chief of Staff for Personnel and the Department of
Commerce, the agency that sponsored the mishap mission.

2\. Although the Air Force generally transports remains to its port
mortuaries without news media involvement, this ceremony was deemed
newsworthy and was open to the media. Public Affairs briefed media
representatives prior to the ceremony on ground rules necessary to
respect the privacy of the families and to maintain the dignity of the
occasion.

3\. The Air Force provided an escort officer for each family, and
provided the privacy of the base chapel to each family prior to the
memorial ceremony.

B. Following the memorial ceremony, the Air Force arranged and funded
common air carrier transport of the remains from Dover port mortuary to
the locations designated by the families. Escort officers accompanied
the remains of military personnel as is generally the military custom.
The Air Force did not provide escort officers to accompany the remains
of civilians.

C. The Air Force also returned the personal effects to the families in
accordance with their directions. However, USAF personnel could not
identify the owners of certain personal property. Accordingly, the Air
Force provided photographs of the property in question to each family
with directions explaining how the property could be identified by the
rightful owners. Some families expressed their dissatisfaction with this
method of property identification.

D. The Air Force chose to forego the ordinary practice of first
conducting a privileged safety investigation of the mishap followed by a
fully releasable accident investigation. Because the desire to fully
release all the facts of the accident as quickly as possible was
paramount, Air Force leaders directed the Commander of United States Air
Forces in Europe (COMUSAFE) to convene a single, fully releasable
accident investigation. USAF Safety personnel assisted the General
Officer accident investigator as part of his investigating team.
National Transportation Safety Board (NTSB) and Federal Aviation
Administration (FAA) investigators also assisted due to the potential
that findings of this investigation would be applicable to the Boeing
737 civilian fleet.

E. After the Dover ceremony and while the accident investigation was
underway, a few families complained that they wanted information from
the USAF but did not know who to contact. The Air Force Chief of Staff
appointed the Assistant Vice Chief of Staff (CVA) as the single Air
Force point of contact for CT-43 family concerns. CVA sent personal
letters of introduction to all families, personally accepted their
telephone calls, and personally answered their questions within 24 hours
of receiving them. CVA remained their point of contact as subsequent
arrangements were made to brief the report of the accident investigation
to each family, to answer family questions about the report, and to
bring the families together for a meeting at Andrews AFB, Maryland.

F. The Air Force offered each family a private briefing on the results
of the accident investigation prior to public release of the report.
Most, but not all, of the families accepted this offer and received
their briefings on 7 June 1996, shortly before the Accident Investigator
briefed his report publicly in the Pentagon press room.

1\. The family briefing teams were composed of a senior pilot in the
grade of colonel and, in most cases, the officer who acted as the
family's escort at the Dover ceremony. The teams received two full days
of training in advance of meeting their families -- the training
included briefings and handouts covering grief counseling, government
benefits, government claims procedures, and experiences of officers who
had performed this duty after the Black Hawk shootdown and Pope AFB
tragedy. The CT-43 Accident Investigator and his staff briefed their
findings to the teams and provided copies of their briefing to each
team. The training concluded with two mock family briefings by team
members.

2\. The teams carried copies of the 7,000 page report of investigation
to each family along with binders containing materials relating to the
accident investigation, answers to frequently asked questions, tailored
information sheets pertaining to benefits and claims, and points of
contact for future reference.

G. The public release plan included arranging transportation of 35
briefing teams from their bases of assignment to the training in
Washington, DC, to briefing locations from Croatia to California, and
back to their home bases. It required reproduction of hundreds of copies
of the 7,000 page report, training materials, and family briefing
binders. It also involved briefing the President, agency Secretaries,
and members of Congress prior to the public release. The participation
of the senior Accident Investigator was essential.

1\. The Air Force honored the requests of several families to conduct
additional briefings for the benefit of family members who could not be
present for the initial briefing. The Air Force also honored the
requests of most families to provide one or more additional copies of
the report of investigation for family members and other interested
parties, e.g., employers and attorneys.

2\. Although the timeline for the public release plan was flexible
through the last week of May 1996, scheduling briefings for 35 families
and the national leadership required the plan to become fixed
approximately 10 days before the public release date.

H. On 7 June 1996, the Air Force activated toll free 1-800 telephone
lines into the Air Force Operations Center to receive any questions the
families had after the briefing teams departed. The telephones were
manned by personnel who had attended the same training and received the
same reference materials provided to the briefing teams.

I. The toll free lines remained open for five days, after which the
personnel who took the calls transitioned into "Tiger Teams" the Chief
of Staff created to review the entire report of investigation. The
"Tiger Teams" provided written responses to over 700 questions raised by
the families either during or after the briefings they received on the
accident report of investigation.

Considerations:

A. Memorial ceremonies often accompany the repatriation of remains of
military personnel following a tragedy or acts of war. The magnitude of
the Dover CT-43 ceremony was atypical and compounded the support
required of the Base Commander.

1\. A ceremony of this kind can help the families through the grieving
process. Protecting their privacy and maintaining the dignity of the
ceremony are essential. Such an event will be newsworthy, and Public
Affairs planning and execution of a media control plan are key elements
for success.

2\. The Army Honor Guard provides outstanding support to ceremonies of
this kind.

3\. Family members can observe subtle differences in the treatment one
family receives compared to another family. These differences, even if
unintended, can lead to complaints of inequitable treatment at a future
date, and may complicate future relationships, e.g., claims or
subsequent support.

4\. Ceremonies of this type may require substantial expenditures of
funds for transportation and lodging. It is arguable whether the Joint
Federal Travel Regulation authorizes payment under these circumstances
for the families that traveled to the ceremony. As a result, the Air
Force chose to use Secretary of the Air Force (SECAF) "emergency and
extraordinary" (E&E) funds to pay for family travel.

B. Escort officers accompanying the remains can be seen as a gesture of
goodwill and, in some cases, can prevent or solve problems associated
with common air carrier transport of remains. Providing escorts for one
category of victim but not others can lead to complaints of inequitable
treatment.

C. Family members will be sensitive to the methods chosen by the Service
components to communicate information or questions. Communication of
more personal information or questions, such as the request to identify
personal property, although well intended, can bring unnecessary stress
to the families.

D. Safety investigations have the primary purpose of preventing future
aircraft mishaps by determining the cause of an aircraft accident. To do
this quickly and with the greatest degree of accuracy, Safety
investigators offer witnesses confidentiality and do not release certain
portions of the Safety report of investigation, including witness
statements, to the public. Accident investigations have the primary
purpose of preserving evidence for all purposes other than mishap
prevention. Accident investigators generally do not offer witnesses
confidentiality and make their entire report of investigation available
to the public. Ordinarily, the Safety investigation precedes the
Accident investigation.

E. Providing families a single point of contact within an agency can
provide numerous advantages to both the families and the agency. The
families have a single face and voice within the agency to answer their
questions consistently and without conflicting information. The agency
has better control of information flow and is not plagued by the need to
recover from conflicting advice or guidance. Providing a competent
single point of contact early in the process can prevent problems from
arising.

F. Preparation for the public release of a report explaining a tragedy
that has had intense public interest will likely require substantial
staff coordination. Because the families rightfully should learn about
the mishap's causes from the Service component rather than the news
media, the components must consider means to complete the staffing
process while maintaining the security of the report.

G. Unfortunately, each Service has substantial experience in responding
to tragedies. This experience is useful when preparing and releasing
investigation reports to the public.

H. Installation of toll free telephone lines can be an economical means
of maintaining personal contact with the family members of victims of
tragedies. Agency representatives who answer these telephones can
provide an important service to the families while developing goodwill
for the agency. The agency representatives will best provide this
service if they have been provided adequate instruction and have the
appropriate attitude.

Conclusions:

A. Senior leadership should consider conducting initial memorial
ceremonies at the time and place best suited to the particular tragedy.

1\. The authority to fund travel costs for family members to attend
memorial ceremonies should be ascertained by executive order or
legislation.

2\. Agencies should protect family member privacy and the dignity of the
ceremony through active Public Affairs involvement, assignment of escort
officers, and coordinated efforts of family support organizations.

3\. Agencies should guard against the appearance of preferential
treatment, but may wish to separate the families of aircrew personnel
from families of passengers if the mishap is perceived to be due to
aircrew error.

B. Senior leadership should consider providing escorts to accompany the
remains of non-military passengers to the location designated by the
next of kin.

C. The authority to fund transportation of remains of non-military
victims via common air carrier should be ascertained by executive order
or legislation.

D. Prior to mailing communications involving sensitive matters to the
families, e.g., identification of unmatched personal property, the
(single) point of contact should first contact the families to ask for
direction and permission to proceed.

E. Senior leadership should consider and exercise mishap investigation
options based on the facts of the particular mishap.

F. Agencies should appoint a single point of contact for family
concerns. If more than one agency is involved, each point of contact
should coordinate that role with other interested agency POCs. One
agency POC should assume the overall leadership role.

G. Agencies should develop public release plans for reports of
investigation explaining major tragedies. The plans should be flexible
while recognizing that certain actions, e.g., scheduling a delivery date
to the families or briefings for officials with inflexible calendars,
will require fixed execution of the plan.

1\. Service components should anticipate and honor the requests of
families for secondary briefings and additional copies of the report of
investigation.

2\. Briefing teams should receive extensive training, including lessons
learned from briefing previous tragedies to families. These teams should
be composed of mature officers including, whenever possible, personnel
who have had previous contact with the family, e.g., an escort officer
who assisted the family on an earlier occasion.

H. Service components should activate toll free telephone service to
benefit families. The telephone number should be reserved for these
families and not be advertised to the news media or the public at large.
The service should continue as long as the families make regular use of
it.

I. Agency representatives answering family questions should receive the
same training and reference materials provided to the briefing teams.

Issue 3: Long Term Support of Families (1 July 1996 - Present)

Findings:

A. A few families asked AF/CVA to arrange a meeting for surviving family
members to attend. Their intention was to again meet the other families,
receive the accident investigation briefing as a group, and to ask
questions of Air Force officials. AF/CVA polled the remaining families
and found that a majority of the families wanted to participate.
Accordingly, the Air Force arranged and funded travel for 22 of the 35
families to come to Andrews AFB, Maryland, for a family briefing.

1\. The meeting occurred on 12 July 1996. AF/CVA acted as moderator and
introduced the senior Accident Investigator. The Accident Investigator
briefed his report in the same manner that he previously used when
presenting it to the national leadership. There was some understandable
hostility from the audience, but the AF/CVA kept the meeting focused on
the issues at hand.

2\. Letters of appreciation that followed this meeting indicated that
several of the families appreciated the Air Force's effort in hosting
this meeting, and that the meeting was useful in coming to terms with
the loss of their loved ones.

B. Among the hundreds of NOK questions answered by the USAF "Tiger Team"
there were approximately five that specifically asked for information
about how the military disciplinary system works in cases like this one,
and whether the NOK would be informed of the results of that process.

1\. The Tiger Team response (in all cases, personally approved by
AF/CVA) informed the NOK that the Commander, United States Air Force in
Europe (COMUSAFE) had directed an inquiry under Rule of Court Martial
(RCM) 303 to find facts and make recommendations upon which the
Commander would act. It concluded by stating that the families and the
public would "have access to all information consistent with legal
restrictions." The legal restrictions include the Privacy Act and
privilege applying to intra-agency communications within the USAFE
staff.

2\. Several families, fewer than ten, wrote personal letters to the
USAFE Commander and other officials (including the White House) in which
some NOK asked for leniency, while others sought the most severe
disciplinary actions possible.

3\. The Victim and Witness Protection Act requires all Federal law
enforcers, including those in the DoD, to give appropriate deference to
"victims of crime" in reaching prosecutorial decisions and to maintain a
liaison with victims to keep them informed about the progress of
investigations, prosecutions, incarcerations and releases of prisoners.

4\. While the Act applies specifically to victims of crimes leading to
prosecutions in criminal trials, to include courts-martial, USAF/JA has
historically encouraged its application to victims of crimes where
lesser disciplinary actions (Article 15, administrative discharges,
reprimands) result.

5\. Following the RCM 303 inquiry, COMUSAFE directed actions against 16
Air Force officers ranging from punishment under Article 15 to
counseling. He signed the documents initiating the adverse actions on 12
Jul 96; the officers were informed of these actions on 15 Jul 96, and
given opportunity to respond. The Commander made his final decision*s*
on these actions on 1 Aug 96, and on that date advised HQ USAF of his
decisions and intention to serve the actions on the individuals on 6 Aug
96. The officers were informed of the Commander's decision on 6 Aug 96.

6\. Immediately after the officers were informed of the decisions, USAFE
Public Affairs (PA) and OSD/PA made news releases of the corrective
actions taken; the families did not receive advance notice. The release
identified the specific actions taken against certain named senior
officials. It gave *only* grades (no names) of other officers and the
actions taken. The limitations on the information released were
consistent with the provisions of the Privacy Act.

C. The Air Force provided other long-term support to the families in a
variety of ways. Families continued to request and receive additional
accident investigation briefings and copies of the 7,000 page report of
investigation. The Air Force reproduced and distributed video tapes of
the Dover ceremony and still photographs of various scenes, including
photographs taken by the passengers in Tuzla, Bosnia, immediately prior
to the mishap flight to Dubrovnik. Air Force also distributed copies of
the book commissioned by Congress to commemorate the death of Commerce
Secretary Brown and those on his mission. Air Force lawyers assisted the
families of government employees pursuing life insurance benefits
(further described below), and advised families and their legal
representatives on filing their claims against the USAF.

Considerations:

A. Although a few families would have preferred to receive their primary
accident investigation briefing in a group setting, as was done at the
meeting at Andrews, others did not. There is no universal solution.

B. Meetings of this type may require substantial expenditures of funds
for transportation and lodging. It is arguable whether the Joint Federal
Travel Regulation authorizes payment under these circumstances for the
families that traveled to the meeting. As a result, the Air Force chose
to use SECAF "emergency and extraordinary" (E&E) funds to pay for family
travel.

C. It is appropriate for Commanders to consider the interests of the NOK
in reaching decisions on disciplinary actions.

1\. There were several reasons USAF decided not to provide the families
advance notice of the disciplinary actions.

\- 35 NOK families were dispersed from Croatia to California

\- USAF had already made numerous contacts with the NOK, and sensed that
some were tiring of the continued reminder of the tragedy and wanted to
move on with their lives

\- USAF timed the public news release to occur immediately after
informing the officers of the actions taken in their cases to prevent
piecemeal public release of the corrective actions

\- At the "corrective action" stage, USAF saw its accountability to the
US public at large to be paramount

2\. The news release explained the disciplinary process and the
importance of the sanctions to the recipients. This explanation was the
main message USAF wanted to convey to the families and the public.

3\. Furthermore, because of USAF experience to that date with the NOK --
some of whom did not want to be contacted by USAF, some appeared to be
tiring of USAF attention, some wanted leniency for the officers, and
some wanted the most severe sanctions -- USAF reasoned there would be
little advantage to the families in receiving notification prior to the
press release. USAF was also concerned that the limited information USAF
could provide under the Privacy Act would frustrate the families rather
than make them feel more fully informed.

D. The families' need for assistance on various matters and to various
degrees will continue for months and, in some cases, years.

Conclusions:

A. Senior leadership should consider a mass accident investigation
briefing for family members as an alternative to individual family
briefings, recognizing there is no universal solution.

-   The authority to fund travel costs for family members to attend
    agency sponsored meetings of this type should be ascertained by
    executive order or legislation.

    B. This area is probably not subject to a best practice. In cases
    where the Victim & Witness Protection Act clearly applies, the
    decision to keep surviving family members informed will be automatic
    and not complicated by Privacy Act protections of information found
    only in administrative records (as opposed to public judicial
    records).

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-   Nevertheless, senior officials should always consider notifying
    families of disciplinary actions ahead of making a public news
    release, and provide prior notice when appropriate.

C. Agencies should anticipate the need for secondary briefings and
additional copies of reports of investigation and plan to make them
readily available.

D. Agency personnel should be mindful that each reply to a family
request and each offer of additional assistance must be carefully
prepared and dispatched. Responses must be complete, timely, accurate
and appropriate.

Issue 4: Value of Combined Safety / Legal Investigation

Findings:

A. The Air Force chose to forego the ordinary practice of first
conducting a privileged Safety investigation of the mishap followed by a
fully releasable accident (legal) investigation. Because the desire to
fully release all the facts of the accident as quickly as possible was
paramount, Air Force leaders directed the Commander of United States Air
Forces in Europe to convene a single, fully releasable accident (legal)
investigation.

B. USAF Safety personnel assisted the General Officer accident
investigator as part of his investigating team. NTSB and FAA
investigators also assisted due to the potential that findings of this
investigation would be applicable to the Boeing 737 civilian fleet. The
accident investigators' findings were reviewed by a unique "technical
review board" (TRB) comprised of experienced aviators and aircraft
maintenance personnel; the TRB was responsible for assuring that each
statement of fact reported by the investigators was supported by the
evidence contained in the report.

C. The accident investigation commenced immediately on 3 April 1996 and
became a public record on 7 June 1996. Although the 7,000 page report of
investigation generally received compliments as being frank and
thorough, some observers criticized the Air Force for deviating from the
standard practice of conducting two separate investigations. Others
speculated that leadership pressured the investigators into concluding
the investigation prematurely, comparing this two month investigation to
the nearly one year process that is common to the NTSB.

Considerations:

A. Safety investigations have the primary purpose of preventing future
aircraft mishaps by determining the cause of an aircraft accident. To do
this quickly and with the greatest degree of accuracy, Safety
investigators offer witnesses confidentiality and do not release certain
portions of the Safety report of investigation, including witness
statements, to the public.

B. Accident (legal) investigations have the primary purpose of
preserving evidence for all purposes other than mishap prevention.
Accident investigators generally do not offer witnesses confidentiality
and make their entire report of investigation available to the public.
Ordinarily, the Safety investigation precedes the accident
investigation.

C. DoDI 6055.7 requires the Service components to conduct both
investigations after every Class A mishap (fatalities, \$1 million or
more in damage, or destruction of an aircraft). The instruction also
requires that Safety investigations be completed within 30 days of a
mishap so as to maximize the prevention impact of the investigation.

Conclusion:

Senior leadership should consider and exercise mishap investigation
options based on the facts of the particular mishap. In the interest of
flight safety, leadership should ordinarily follow established
procedures of conducting both Safety and legal investigations whenever
appropriate.

Issue 5: Successes and difficulties addressing insurance and claims
issues

Findings:

A. Twelve Federal employees charged the commercial transportation
portion of this mission on their "U.S. Government Travel Only" charge
cards. This card provides automatic, no charge "door to door" accidental
death and dismemberment coverage in the amount of \$200,000.00 during
periods of travel when transportation expenses have been charged to the
government card.

B. Policies of life insurance contain exclusions from coverage. The
Federal government charge card's business travel accident insurance
includes the following exclusion:

> "The policy does not cover any loss caused or contributed to by: . . .
>
> . . . 4. Travel into hazardous worksites (e.g., underwater, mines,
> construction sites, oil rigs, etc.); . . .
>
> . . . 7. Participation in any military, police or fire-fighting
> activity; . . .
>
> . . . 11. Flying in military aircraft (other than those operated by
> the Air Mobility Command) or . . . ."

C. DoD frequently transports civilian employees and invited guests in
all types of aircraft (not just those assigned to or operated by Air
Mobility Command), vehicles, and vessels.

Considerations:

Decisions concerning insured risks and exclusions are appropriately in
the private domain. However, exclusions to coverage of travelers using
the government charge card should be rational and disclosed to the
travelers in advance. Insured risks and exclusions are proper matters
for negotiation when the government chooses its charge card contractor.

Conclusions:

A. A General Services Administration contracting officer should
ascertain whether the government charge card life insurer will amend its
policy to cover travelers being transported on DoD aircraft other than
those operated by the Air Mobility Command but that are designed and
used to provide passenger transportation services.

B. The Service components should develop procedures to disclose, in
advance of providing transportation on DoD aircraft, the possibility
that the travelers' life insurance coverage may not extend to flights on
DoD aircraft.

C. DoD General Counsel (GC) should inform life insurance industry trade
representatives that the exclusion in question may be based upon a
misunderstanding or lack of knowledge concerning the mission of DoD
aircraft other than those of the Air Mobility Command.

D. The General Services Administration contracting officer responsible
for the government charge card program should consider the exclusions to
life insurance coverage when negotiating the award of future government
charge card contracts.

Findings:

The Air Force assumed claims responsibility for the CT-43 crash, even
though the Army had been assigned jurisdiction for all claims in
Croatia.

1\. DoD Directive 5515.8 assigns each of the Services claims
responsibility in certain areas of the world. Since the Air Force
believed it had an overriding interest in handling claims from the
crash, it sought permission to do so.

2\. The Services may agree among themselves which Service will handle
claims under the Military Claims Act.

3\. DoD must provide permission to change claims responsibility for
foreign claims. In order to ensure consistency of claims adjudication in
Croatia, which are affected by an Agreement with Croatia, the Air Force
agreed to consult the Army before payment of any foreign claims.

Consideration:

Although foreign policy considerations dictate that DoD speak with one
voice in foreign countries, there are certain situations where it may be
prudent to shift claims responsibility. The key to shifting claims
assignment in such circumstances is the ability of the different Service
claims personnel to work together to achieve the best result for DoD.

Findings:

The next of kin of the Federal government civilian employees believed
compensation for death under the Federal Employees' Compensation Act
(FECA) was inadequate.

1\. At the time of the crash of the CT-43, FECA provided payment for
embalming, a casket, and transportation of the body to the deceased
employee's home, and up to \$800.00 in funeral expenses.

2\. A one-time payment to the personal representative of the decedent of
\$200.00 was available for the expenses associated with the termination
of the status as a Federal employee.

3\. Death Gratuity legislation was passed on 30 Sep 96, retroactive to 2
Aug 90, which allowed a \$10,000 payment (amount combined with the \$800
burial expenses and \$200 termination payment cannot exceed \$10,000).

Consideration:

The tragedies of the CT-43 crash and the Oklahoma City bombing
highlighted the lack of a death gratuity for Federal civilian employees,
although one is provided for military personnel. As a result, Congress
chose to enact legislation which would provide such a benefit to the
victims of the crash.

Summary of Conclusions Drawn from the CT-43 Tragedy "Lessons Learned"

[Funding:]{.underline}

The authority to fund travel costs for family members to attend memorial
ceremonies or accident investigation briefings, and fund transportation
of remains of non-military passengers via common air carrier should be
ascertained by executive order or legislation.

[Single Point of Contact:]{.underline}

When agencies outside the Service component are involved with casualty
notification, one agency should take responsibility to assure the
notifications are comparable, and to assure that next of kin have a
single point of contact to provide accurate information, and appropriate
and consistent guidance.

[Timely and Accurate Information:]{.underline}

Agencies should develop public release plans for reports of
investigation explaining major tragedies. The plans should be flexible
while recognizing that certain actions, e.g., scheduling a delivery date
to the families or briefings for officials with inflexible calendars,
will require fixed execution of the plan.

Senior officials should always consider notifying families of
disciplinary actions ahead of making a public news release, and provide
prior notice when the circumstances allow.

[Sustaining Mechanisms:]{.underline}

Senior leadership should consider providing escorts to accompany the
remains of non-military passengers to the location designated by the
next of kin.

Service components should activate toll free telephone service for the
benefit of surviving families. The telephone number should be reserved
for these families and not be advertised to the news media or the public
at large. The service should continue as long as the families make
regular use of it.