Aviation Safety Letter 2/2005

Delayed Search and Rescue Response

An Aviation Safety Advisory from the Transportation Safety Board of Canada (TSB)

On August 26, 2004, a privately registered Piper Cherokee PA-28-235 aircraft crashed near Lake Manitoba Narrows, Man., during a night VFR flight in adverse weather conditions, and the pilot sustained fatal injuries. The pilot had filed a flight itinerary with a friend at his destination. When the pilot became overdue, the friend did not know what to do, and took no action to initiate search and rescue (SAR). The investigation (A04C0162) is ongoing.

The pilot had filed flight plans with NAV CANADA for the first two legs of his trip from Olds-Didsbury, Alta., to Kindersley, Sask., and Yorkton, Sask. At Yorkton, he filed a flight itinerary with his friend at his final destination, Gimli, Man., for the remainder of his trip from Yorkton to Gimli. The pilot diverted to Roblin, Man., while en route, and phoned his friend from Roblin to advise of the diversion and of his intention to continue onward to Gimli. The friend had no aviation experience, was unaware of the flight itinerary SAR notification requirements, and was not briefed by the pilot regarding the notification requirements.

The accident was witnessed by drivers on an adjacent highway who immediately contacted emergency response services, which in turn contacted the Trenton rescue co-ordination centre (RCC). However, had the accident occurred in a more remote location without witnesses and the pilot survived, it is likely that SAR response would have been delayed because the pilot's friend did not know what action was required when the aircraft became overdue. A review of TSB investigations from 1989 to 2004 revealed six other occurrences in which SAR response was or could have been delayed because the flight itinerary responsible person was inadequately briefed. In occurrence A89O0058, the pilot had told his wife he would be returning the same night, but no action was taken when the aircraft became overdue.

In occurrence A90W0091, the pilot had filed a flight itinerary with a relative, but the flight itinerary was so vague that it was ineffective for SAR purposes. In occurrence A91P0265, the pilot had filed a flight itinerary with his wife, and later advised his son of a revision to the flight itinerary; SAR notification occurred one day later than it should have. In occurrence A92P0212, the pilot filed a flight itinerary with his son; SAR notification occurred one day later than it should have.

In each of these occurrences, the pilots did not ensure that the person with whom the flight itinerary was filed clearly understood the SAR notification requirements. The results were that SAR response was delayed or did not occur. The TSB has not issued any previous safety communications regarding this safety deficiency.

Procedures are in place to activate SAR response for overdue aircraft. Canadian Aviation Regulation (CAR) 602.73(2) requires pilots to file a flight plan or flight itinerary for VFR flights conducted more than 25 NM from the departure aerodrome. A flight itinerary may be filed with a responsible person who has agreed with the person filing the flight itinerary to ensure that air traffic services (ATS) or an RCC are notified within a time specified by the pilot, or within 24 hr after the last reported estimated time of arrival (ETA), that the aircraft is overdue.

Regulations regarding flight itineraries place the onus to notify SAR of an overdue aircraft on persons who have agreed to take specific action, but who may not fully understand their obligations. Failure of a pilot to properly brief the flight itinerary responsible person regarding SAR notification requirements creates a risk that SAR response will be delayed in the event the aircraft becomes overdue. Such delay could result in fatalities due to lack of timely evacuation and medical care in otherwise survivable accidents.

Transport Canada may wish to consider action to improve awareness among pilots of the need to ensure the flight itinerary responsible persons understand their obligations concerning SAR notification. (Done. - Ed.)

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