REPORT CITES LAPSE IN COMMAND AS MAJOR CAUSE OF CROATIAN CRASH.

Byline: The New York Times

A sustained breakdown in the Air Force's chain of command was a leading factor in the plane crash that killed Commerce Secretary Ron Brown and 33 other people aboard a jet in Dubrovnik, Croatia, two months ago, the service said Friday in its official report on the accident.

It was as a result of this breakdown, the report said, that Air Force commanders in Europe had failed to make a safety inspection at the Dubrovnik airport that might have prevented the crash.

The report concluded, as previously published news accounts had suggested it would, that pilot error, insufficient on-board navigational equipment and poor airport design had also contributed to the accident.

The chain of causes began with erroneous Croatian landing guidelines and ended with a harried air crew, rushing fatally through its landing procedures, flying off course and almost 90 mph too fast.

In between, the Air Force said in its 21-volume crash report, top commanders of the jet's squadron had ignored Air Force orders that forbade landings at airports like Dubrovnik's in poor visibility.

``Safety is not compromised if we continue to fly . . .'' one commander wrote in rejecting the Air Force directives, the report said.

The report also said that while the jet, a military version of the Boeing 737, lacked on-board navigational aids needed to land in bad visibility at Dubrovnik, the crew was unaware of that.

It condemned Air Force training procedures for not having its pilots properly schooled on the difficulties of landing at poorly equipped airports of the former Soviet Bloc.

And, in wrenching detail, it described how Air Force Sgt. Shelly A. Kelly, 36, a flight attendant from Zanesville, Ohio, survived with a broken back for almost seven hours in the rain and wreckage before dying when rescue crews finally reached the site.

Kelly was the only one to survive the 50 to 100 G's exerted on the victim's bodies by the impact. Brown and 33 others on the jet were probably killed instantly, the Air Force said.

The report was blunt - as was a grim Air Force chief of staff Ronald Fogleman at an afternoon Pentagon briefing.

``The United States Air Force was given the mission to provide operational support airlift for Secretary of Commerce Ron Brown,'' Fogleman said.

``We failed to execute that mission.''

Three Air Force officers - including a veteran brigadier general - already have been relieved of duty because of the crash, and Fogleman said an investigation is under way to see if they or others will be court martialed.