An NTSB review of recorded radar data showed that the last position recorded by ZNY for the airplane was 5.6 nm south of the outer marker, not 2 nm south as reported in the ALNOT. The last few radar targets tracked directly toward the crash site. The airplane was eventually located about 0.6 nm south of the last radar target and about 300 yards from the closest road.  

If the FAA radar data had been immediately evaluated and made available to the AFRCC, as well as the Pennsylvania State Police or other local first responders, the delay in determining the aircraft's last known radar position would have been almost completely eliminated, and searchers could have located the airplane and rescued the survivors much sooner than 8 hours after the accident. 

Moulton, Alabama

On May 13, 2007, about 1730 central daylight time, a Hughes 369A helicopter, N468WE, impacted terrain in Bankhead National Forest near Moulton, Alabama. The helicopter was destroyed, and the commercial pilot was killed. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for this personal flight conducted under the provisions of 14 CFR Part 91.10  

The helicopter's route passed just east of Birmingham, Alabama, and, about 1548, the pilot contacted Birmingham Terminal Radar Approach Control (BHM TRACON) to request radar flight-following. The controller instructed the pilot to set the aircraft's transponder to 0335 but was unable to establish reliable radar contact. Because the controller could not see the aircraft target consistently, he was unable to provide radar service. The controller instructed the pilot to change back to code 1200, the default code used for uncontrolled flights, and cleared the pilot to change frequencies.  

The helicopter did not arrive at Muscle Shoals as planned. The pilot's family reported the flight overdue to Lockheed flight service. An ALNOT was issued about 2315 local time, and the AFRCC began to coordinate a search for the aircraft. According to the mission log, in response to the ALNOT, BHM TRACON reported that the pilot had contacted the facility between 1600 and 1700. AFRCC asked the Memphis Air Route Traffic Control Center to provide radar data, but the facility reported that it was unable to provide the requested data because no one was on duty who could produce the needed report.  

About 0215 on May 14, BHM TRACON reported that it was unable to provide any further information on its contact with the pilot because only one controller was on duty, and he could not review the recordings.  

About 0320, USAF radar analysts assisting in the search reported that they were unable to identify a radar track on the helicopter. According to a summary placed in the mission log about 0703 the day after the accident, the lack of FAA radar data was preventing the CAP radar analyst from contributing to the search, and BHM TRACON had still not provided any further details on its contacts with the accident helicopter.  

About 0912, BHM TRACON controllers reported the helicopter's last known position as the last observed 0335 code, without noting that the flight continued on code 1200. More than 4 hours later, BHM TRACON controllers provided an updated position based on the continued 1200 codes. The new position was passed from the AFRCC to the CAP about 1414.  

The CAP continued the search, integrating the new information into the search plan along with other leads provided by USAF analysts. About 1921, the CAP radar analyst confirmed the accuracy of the last position supplied by BHM TRACON controllers, stating that three different radars showed the helicopter's flight ending near that position. About 1320 on May 15, the Alabama CAP notified the AFRCC that the accident helicopter had been located, approximately 36 hours after the aircraft was reported missing.  

NTSB investigators reviewed the information used to support the search for the helicopter and reviewed AFRCC's efforts to obtain FAA data needed to help locate it. It was immediately apparent that all the information needed to locate the helicopter was recorded at BHM TRACON during and after its contact with the pilot. The controller's instruction to set the aircraft's transponder to 0335 served to positively identify the aircraft.  

Even though the controller was unable to see the helicopter on his radar display, the targets were recorded by the radar data processing system. After the pilot changed the transponder setting from 0335 to 1200, the target trail continued directly to the accident site. Had the BHM TRACON radio communications and radar data been made available to a trained radar analyst immediately after the facility responded positively to the ALNOT, the crash location likely would have been available within minutes, and search teams likely would have been able to reach the accident site much sooner. 

Boynton Beach, Florida  

On October 27, 2007, about 2012 eastern daylight time, a Piper PA-28-181, N8155C, was substantially damaged when it impacted trees and terrain in Boynton Beach, Florida, following a loss of engine power. The certificated flight instructor and the private pilot were fatally injured, and the passenger was seriously injured. Night visual meteorological conditions prevailed, and no flight plan had been filed for the instructional flight, which was operating under the provisions of 14 CFR Part 91.12  

The investigation of this accident is ongoing, but, according to preliminary ATC information, radar contact with the accident airplane was initially established by Palm Beach Approach (PBI) about 1813, shortly after the airplane departed its base at Palm Beach County Park Airport, Lantana, Florida. The pilots conducted practice instrument approaches at four airports, with the last approach occurring at Pompano Beach Airpark, Pompano Beach.  

In the course of communications with the PBI approach controller, the pilot indicated that he was unable to maintain altitude because of engine trouble. The pilot’s final transmission indicated that he intended to land on a road.  

According to FAA communications transcripts, about 2010 the PBI approach controller asked for the assistance of another pilot in the area in locating the accident airplane. About 2014, a second pilot contacted the controller and offered to help, and about 2017, that pilot reported receiving an ELT signal. Over the next hour, several other pilots assisted in the search and were able to determine the general location of the ELT signal. About 2129, a Palm Beach County Sheriff's Office helicopter crew reported to the controller that they had located the wreckage. 

Postaccident review of FAA radar data recorded at PBI showed that the aircraft was last observed about 2011, westbound and descending through 100 feet. The wreckage was located on a residential golf course about 900 feet west of the last radar target. The NTSB is concerned that, even though the PBI controller noticed the accident immediately and solicited assistance in locating the aircraft from nearby pilots and a local law enforcement helicopter, it still took an hour and 18 minutes to find the wreckage and the surviving passenger. Because of the dark night conditions, accurate location information would have helped guide responders to the correct location.  

FAA radar data contained a direction of flight and last known position very close to the location of the wreckage; however, that information was not made available to local responders to assist in the search. According to information provided by PBI, no technically qualified persons were available when the accident occurred to search the radar data recordings and produce the needed radar data. The NTSB believes that if the last recorded radar latitude and longitude position and direction of flight had been supplied to local responders, the time needed to find the aircraft and rescue the survivor would have been substantially reduced.  

District Heights, Maryland  

On September 27, 2008, about 2358 local time, Trooper 2, a medical evacuation helicopter, N92MD, operated by the Maryland State Police (MSP), crashed in District Heights, Maryland, while attempting to transport two automobile accident victims to Prince George's Hospital Center, Cheverly, Maryland.13 The pilot, a flight paramedic, a local emergency medical technician, and one of the automobile accident victims were killed. The second automobile accident victim survived the helicopter crash and was eventually rescued. The NTSB is concerned that it took about 2 hours to locate the downed helicopter despite the crash having occurred in an urban area while operating under IFR and receiving radar service from the FAA.  

Trooper 2 had departed from a landing zone in Waldorf, Maryland, intending to transport the two medical patients to Prince George's Hospital Center. Because of low ceilings and poor visibility in the area, the pilot was unable to locate the hospital helipad and elected to divert to Andrews Air Force Base (ADW).  

He contacted Potomac Consolidated TRACON (PCT) and was subsequently cleared for the ILS approach to runway 19R at ADW. As the aircraft intercepted the final approach course, the pilot was instructed to contact the ADW tower and did so. About 2 minutes later, when Trooper 2 was about 4 nm north of the runway, the helicopter began a rapid descent that ended on a road in Walker Mill State Park. The last radar target for Trooper 2 was recorded about 2357:50 at 700 feet.  

The tower controller noticed that Trooper 2 was no longer visible on radar about 2359. Within a few minutes, initial actions to locate the helicopter began. In radio contacts with the ADW fire chief and phone conversations with the PCT acting operations manager, the tower controller reported losing radar contact with Trooper 2 when the helicopter was about 2 to 2.5 nm north of the airport.  

As the ground search commenced, the MSP Forestville barrack supervisor requested that the ADW tower controller provide a latitude and longitude location for the aircraft. The tower controller was unable to supply the information, replying that the coordinates would be “whatever two miles north of the field is.”  

In postaccident interviews, PCT management reported that PCT and ADW have an automation tool known as CountOps, which can produce an accurate last known latitude and longitude position of aircraft as soon as the aircraft is noted missing. However, CountOps was not used after Trooper 2 crashed. The ADW controller had never been trained on the locating capability of the software, likely because that capability was not the software’s primary purpose. 

The PCT operations manager did not obtain or refer to any recorded PCT radar data after he was advised of the accident. The FAA provided no assistance in locating the crash other than the ADW controller's recollection of the last position shown on the tower radar display.  

Following the accident, ground searchers were provided with conflicting and inaccurate information from various sources about the helicopter's last known position. Had FAA radar data been used to provide a location to the search teams, the confusion would likely have been reduced, and the searchers could have immediately gone to the correct area. The wreckage was eventually located about 0.3 nm south of the last target, approximately 2.5 nm from ADW.  

Addressing Weaknesses in Data Analysis and Dissemination  

The failure of the FAA to provide accurate, complete, and readily available radar data early in the SAR process led to unnecessary delays, as exemplified in the above accidents. For example, in the Philipsburg, Pennsylvania, accident, ZNY transmitted an ALNOT containing an incorrect last known position and did not provide an update to the AFRCC even though the facility's recorded data contained a much more accurate location.  

Radar data recorded by BHM TRACON eventually led searchers directly to the crash site, but not until a day and a half after the aircraft was reported overdue because BHM TRACON could not provide complete and timely information to AFRCC. Similarly, after the Boynton Beach, Florida, accident, ground searchers would have had a last known position within 900 feet of the crashed airplane within minutes of the accident if PBI approach had provided a location based on the best available radar data.  

In the District Heights, Maryland, accident, the PCT operations manager on duty when Trooper 2 crashed did not examine recorded radar data for the flight or consult software tools such as CountOps to locate the helicopter. PCT supplied no information to assist the search teams.  

FAA directives14 and the postaccident reporting form (Form 8020-3, “Facility Accident/Incident Notification Record”) do not provide any guidance on expeditious provision of FAA radar or other location data to support SAR response or any direction to managers or controllers on assisting SAR responders in locating downed aircraft, other than the requirement to issue an ALNOT when an aircraft is believed to be overdue.  

Therefore, the NTSB recommends that the FAA amend Order 7110.65, “Air Traffic Control,” to require that, when radar or other location data are available to air traffic controllers that indicate to a reasonable likelihood the location of a downed aircraft, the information be immediately provided to appropriate local first responders and the AFRCC.  

The circumstances of these accidents and associated SAR responses also indicate that FAA SAR assistance has been limited by a lack of personnel qualified to provide assistance. In the Moulton, Alabama; Boynton Beach, Florida; and District Heights, Maryland, accidents, ATC personnel explicitly said that the controllers available lacked qualified personnel to provide the needed data.  

In the Philipsburg, Pennsylvania, accident, ATC personnel provided incorrect location information. The data available to ATC personnel are often complex, and SAR situations present a variety of complications with which most ATC personnel are unfamiliar. Providing adequate data analysis often requires expert knowledge so that situations can be assessed and all relevant radar and communications data expeditiously obtained and provided to searchers in a useful form.  

The expertise needed includes ability to identify all FAA resources that may be able to provide information useful for SAR purposes; familiarity with the different types of ATC facilities; ability to identify all radar sites providing coverage in the area of interest; familiarity with the data recording capabilities of those facilities and the use of appropriate data extraction tools; network access as necessary to remotely retrieve SAR-related data; ability to analyze, organize, deliver, and explain FAA data to SAR providers; and authorization to require support from local facilities to provide data that are not remotely accessible, including directing the use of overtime and after-hours staff support if necessary to support a SAR activity.  

The FAA currently has limited ability to provide expert help to its ATC personnel and, as shown by the accidents cited above, has no standard procedure by which ATC personnel obtain expert help when SAR efforts are needed. Establishing a group of FAA SAR experts would be an efficient way of providing assistance to ATC personnel.  

Therefore, the NTSB recommends that the FAA establish and staff a technical assistance group charged with providing immediate assistance at all times to ATC facilities and SAR providers in any SAR situation. Such a group should be  

1) Able to identify all FAA resources that may be able to provide information useful for SAR purposes;  

2) Familiar with the different types of ATC facilities;  

3) Able to identify all radar sites providing coverage in the area of interest;  

4) Familiar with the data recording capabilities of those facilities and the use of appropriate data extraction tools;  

5) Provided with network access as necessary to remotely retrieve SAR-related data;  

6) able to analyze, organize, deliver, and explain FAA data to SAR providers; and

7) authorized to require support from local facilities to provide data that are not remotely accessible, including directing the use of overtime and after-hours staff support if necessary to support a SAR activity. At least one member of this group should be available 24 hours a day, every day, on a rotating basis, to initiate SAR assistance.  

The NTSB further recommends that the FAA amend Orders 7110.65, “Air Traffic Control,” and 8020.16, “Air Traffic Organization Aircraft Accident and Incident Notification, Investigation, and Reporting,” to require any ATC facility that becomes aware of a possible need for SAR to immediately notify the technical assistance group created pursuant to Safety Recommendation A-10-6 and make all relevant data available for its use.  

Software, such as CountOps, which was available to the controllers at the time of the District Heights, Maryland, accident, can further expedite information sharing by performing simple radar data analysis. Although such software cannot substitute for an expert, overall analysis of SAR data needs, CountOps or similar software could allow nontechnical staff to quickly provide more accurate location information to SAR responders.  

Therefore, the NTSB recommends that the FAA provide to all ATC facilities software, and appropriate training in its use, that will permit nontechnical ATC operational personnel to immediately access latitude, longitude, and altitude data related to, at a minimum, the final 2 minutes of flight for aircraft operating on a specified transponder code.  

Finally, the helicopter involved in the District Heights, Maryland, accident was equipped with automatic dependent surveillance–broadcast (ADS-B) position reporting, which provided location information. ADS-B data are not used by FAA ATC facilities in the Washington, DC, area; however, the data are recorded by an FAA contractor as part of a test program.  

The contractor informed NTSB investigators that there are about 31 aircraft in the Washington, DC, area equipped with ADS-B. The list of equipped aircraft and the data from these aircraft are not immediately accessible to FAA facilities or the AFRCC, and, thus, those facilities may not use this valuable resource for locating aircraft. As the FAA incorporates future surveillance systems that rely on ADS-B data, more aircraft will have ADS-B equipment, and an ADS-B-equipped aircraft will likely become the target of a SAR mission.  

Therefore, the NTSB recommends that the FAA establish procedures for identifying aircraft equipped with ADS-B capabilities to personnel responsible for SAR and to the technical assistance group created pursuant to Safety Recommendation A-10-6 and for providing expeditious access to ADS-B location data when needed to support SAR activities. 

Therefore, the NTSB makes the following recommendations to the Federal Aviation Administration:  

Develop, in conjunction with the Air Force Rescue Coordination Center, specific phraseology for communicating about the location, time, and nature of emergency locator transmitter signals and emergency beacon codes. (A-10-1)  

Amend Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to prescribe the use of the phraseology requested in Safety Recommendation A-10-1. (A-10-2)  

Provide training for all Federal Aviation Administration personnel who may be required to interact with the Air Force Rescue Coordination Center (AFRCC), ensuring that personnel understand the AFRCC's incident reporting process and recognize that new incidents are always assigned a unique incident number. (A-10-3)  

Require air traffic control facilities to enter all Air Force Rescue Coordination Center (AFRCC) contacts on Federal Aviation Administration Form 7230-4, “Daily Record of Facility Operations,” and, in circumstances where that contact results in the AFRCC assigning a new incident number to the event, require facilities to contact the AFRCC at least once per shift for a status update until the AFRCC advises that an incident has been resolved. (A-10-4)  

Amend Federal Aviation Administration Order 7110.65, “Air Traffic Control,” to require that, when radar or other location data are available to air traffic controllers that indicate to a reasonable likelihood the location of a downed aircraft, the information be immediately provided to appropriate local first responders and the Air Force Rescue Coordination Center. (A-10-5)  

Establish and staff a technical assistance group charged with providing immediate assistance at all times to air traffic control (ATC) facilities and search and rescue (SAR) providers in any SAR situation. Such a group should be  

1) Able to identify all Federal Aviation Administration (FAA) resources that may be able to provide information useful for SAR purposes;  

2) Familiar with the different types of ATC facilities;  

3) Able to identify all radar sites providing coverage in the area of interest;  

4) Familiar with the data recording capabilities of those facilities and the use of appropriate data extraction tools;  

5) Provided with network access as necessary to remotely retrieve SAR-related data;  

6) Able to analyze, organize, deliver, and explain FAA data to SAR providers; and  

7) Authorized to require support from local facilities to provide data that are not remotely accessible, including directing the use of overtime and after-hours staff support if necessary to support a SAR activity. At least one member of this group should be available 24 hours a day, every day, on a rotating basis, to initiate SAR assistance. (A-10-6) 

Amend Federal Aviation Administration Orders 7110.65, “Air Traffic Control,” and 8020.16, “Air Traffic Organization Aircraft Accident and Incident Notification, Investigation, and Reporting,” to require any air traffic control facility that becomes aware of a possible need for search and rescue to immediately notify the technical assistance group created pursuant to Safety Recommendation A-10-6 and make all relevant data available for its use. (A-10-7) 

Provide to all air traffic control (ATC) facilities software, and appropriate training in its use, that will permit nontechnical ATC operational personnel to immediately access latitude, longitude, and altitude data related to, at a minimum, the final 2 minutes of flight for aircraft operating on a specified transponder code. (A-10-8)