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Clipper Climax
George Terhune

"I was the first first Pan Am employee on the site, along with two US Army personnel from the Jakarta embassy, an Indonesian from their Dept of Aviation, and some Indonesian Army personnel, for a preliminary look at the wreckage about a week after the accident. At that time we determined the general layout, and that the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) were no longer attached to the structure where they should have been, and were probably buried pretty deep in a pile of wreckage at the bottom of a gully.
I took part in the official accident investigation on site, along with a Pan Am maintenance chief, some Indonesians from the Dept of Aviation, and of  course a good many Indonesian Army personnel as escorts. I was one of three Pan Am people, along with a half dozen Balinese workers and an Army
escort, who returned to the site almost three months later, when we took about 10 days to dig out the recorders. I later obtained readouts of the  recorders and did my own plot and analysis of the flight path and cockpit conversations at each point in the last part of the flight. Finally I attended the hearing in Jakarta the following March (I believe), where I first heard most of what eventually appeared in the accident report (and a > lot more).
 

The particular parts of the Report I find most objectionable are in the excerpts below [between the dotted lines]. My comments:
1. Nothing in the recordings or the crew’s actions can support the statement that they "…intended to make a right turn WITHIN 25 MILES" of the beacon. The mention of "25 miles" was only as part of the pre-approach briefing, where they noted the Minimum Safe Altitude of [I believe] 12,000ft within 25 miles, which was due to the high terrain on the NE part of Bali. In fact, they had a clearance to a lower altitude [because the minimum altitude for their course was lower], but they did not descent below 12,000ft until they thought they had a valid overhead "needle swing." The "25 mile" statement showed an abundance of appropriate caution, not any intention to turn early.
2. There is no evidence that "… the crew in an attempt to expedite their approach into Bali Airport, elected to execute an early right hand turn." The turn was no doubt a mistake, but it was in no way an "election." This erroneous conclusion by the accident board was probably based in part on an  error in the flight path map they were given by the US NTSB. The NTSB specialist missed a heading change that clearly showed on the FDR trace, so
the NTSB map showed a large zig-zag turn, which did not look like the proper approach procedure. I called this error to the attention of the NTSB  representative at the hearing, but he would not correct it. I spoke up about this issue on my own at the hearing, but the board ignored my input, except
[as I remember it] they did move their statement about "intention" from the "Probable Cause" to a "Finding."
3. There is no evidence that "…the pilot-in-command was not very familiar with the Indonesian Aeronautical Information Publication, specifically related to local procedures at Bali International Airport." The crew properly briefed themselves on the approach, and conducted it correctly, except of course for being in the wrong place. That was a fatal mistake, but it did not arise from intention or lack of familiarity with proper procedure.
4. The pilot did not "assume" he was "nearing" the beacon. He THOUGHT he was OVER the beacon. The whole thing was an experience I’m very glad I had, but have no wish ever to repeat.
————-
It was further disclosed that the pilot intended to make a right hand turn within 25 miles from the beacon for a track out on 261 degrees, descending
to 1 500 ft followed by a procedure turn over the water for final approach on Runway 09 which was the runway in rise given by Bali Control.
 
The Board is of the opinion that the crew in an attempt to expedite their approach into Bali Airport, elected to execute an early right hand turn for
track out on 263 degrees. By using this type of approach they were prevented from knowing their tract position. Such an early turn would necessitate the pilot’s obtaining an early indication on the ADF that the was nearing the NDB. Evidently the right hand turn was made at the time when only one of the ADF needles swung. According to the reconstruction of the flight path, based on information obtained from the flight recorder, it is evident that the
right hand turn was made at a position approximately 30 NM North of the beacon.
 
The flight crew was properly licensed and experienced to carry out the flight. However, from the available data, the Board was led to believe that the pilot-in-command was not very familiar with the Indonesian Aeronautical Information Publication, specifically related to local procedures at Bali  International Airport.
 
At this point the pilot initiated a let-down procedure by making a right hand turn for track out on 263 degrees, assuming that he was nearing the NDB.
 
 b) Cause or Probable cause(s)
 
The Board determined that the probable cause or this accident was the premature execution of a right hand turn to join the 263 degrees outbound
track which was based on the indication given by only one of the ADFs while the other one was still in steady condition."
> ———–
>George Terhune

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