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Tue, Apr 06, 2010

NTSB Letter Urges FAA To Improve SAR Responses To Downed Aircraft

Says Communications Problems Hamper Speedy Rescue Of Crash Survivors

In a letter to FAA Administrator Randy Babbitt, the NTSB says the FAA should work to improve communications between it and the Air Force Rescue Coordination Center (AFRCC), which has responsibility for initiation and coordination of SAR activities in the domestic United States.

The letter cites a case in which a Piper PA-38-112, N9247T crashed into trees and rising mountainous terrain at Amicalola Falls State Park in Dawsonville, Georgia. The pilot was attempting to stay below overcast cloud conditions. The certificated commercial pilot, the sole occupant, eventually died as a result of the accident, and the airplane sustained substantial damage. The flight originated from Habersham County Airport, Cornelia, Georgia, about 1400 local time, destined for Lunken Field, Cincinnati, Ohio. Evidence indicates that the pilot likely survived the accident and activated an emergency transponder code but died before the airplane was located.

Shortly after the crash, the letter says, controllers at the Atlanta Air Route Traffic Control Center (ZTL) noticed an unidentified stationary radar target about 50 nm north of Atlanta. Beginning about 1534, the target transmitted transponder code 7700, which is a dedicated emergency code reserved for use by aircraft in distress, and its use by the accident pilot caused a special flashing "EMRG" alert to appear on ZTL radar displays.

About 1552, the ZTL traffic management coordinator (TMC) notified the AFRCC of ELT reports and observation of the 7700 code. During the call, the TMC stated that there were “numerous ELT reports…north of Atlanta” and that he did not believe that an incident number had been assigned. The AFRCC controller replied that an incident had been reported south of Atlanta. The TMC noted that the reports he was calling about were north of Atlanta and that “…we actually show an emergency beacon flashing north of the airport.” (In using the term “emergency beacon,” the TMC was attempting to communicate the observation of a 7700 emergency transponder signal, which provides more specific location information than ELT reports and indicates more definitively that an emergency has actually occurred.) At the AFRCC controller’s request, the TMC provided the information in the ELT reports, and the call concluded.

The AFRCC controller did not provide an incident number to the TMC, which would have indicated that she understood that the TMC’s report indicated a new incident. Rather, she associated the report with the incident south of Atlanta. Once the report for the incident south of Atlanta was closed, that also ended any activity related to the ELT reports and radar observations north of Atlanta provided by ZTL’s TMC.

As a result, no SAR effort was begun for N9247T until family members reported the accident airplane missing the following day. As there was evidence that the pilot survived the crash, this was a critical SAR failure. Based on the family's report of the missing airplane, the Dayton, Ohio, Flight Service Station (FSS) issued an Alert Notice (ALNOT) about 1247. According to the AFRCC’s mission log, the AFRCC began attempting to locate the airplane immediately upon receipt of the ALNOT. Air searchers located the airplane about 49 hours after the accident, and the ground team arrived shortly afterward. The team reported that the pilot was deceased.

The NTSB says that the lack of standard phraseology for communications between FAA and AFRCC personnel about particular observations, such as the observation of an emergency 7700 transponder code, clearly hindered the SAR effort in this event. For example, the AFRCC controller also did not understand that the TMC's report of “an emergency beacon flashing north of the airport” indicated that ZTL was observing a 7700 emergency code on radar. If the AFRCC controller had understood that ZTL was forwarding not only ELT reports but also a radar observation of an emergency 7700 code north of Atlanta, she likely would have recognized that two separate events were occurring and assigned a new incident number to the emergency 7700 code instead of associating the new information with the previous ELT reports south of Atlanta.

The NTSB recommends that the FAA develop, in conjunction with the AFRCC, specific phraseology for communicating about the location, time, and nature of ELT signals and emergency beacon codes. The NTSB further recommends that the FAA amend FAA Order 7110.65, “Air Traffic Control,” to prescribe the use of the phraseology requested in Safety Recommendation A-10-1.

The NTSB further recommends that the FAA provide training for all FAA personnel who may be required to interact with the AFRCC, ensuring that personnel understand the AFRCC's incident reporting process and recognize that new incidents are always assigned a unique incident number.

FMI: www.ntsb.gov, www.faa.gov

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