N117FJ

HISTORY OF FLIGHT

On March 25, 1997, about 0510 eastern standard time, a Grumman American Avn. Corp. G-1159, N117FJ, operated by PAB Aviation Incorporated, was substantially damaged when it collided with an unoccupied maintenance vehicle during the landing roll at the LaGuardia Airport (LGA), Flushing, New York. The two airline transport rated pilots and two dead-heading crew members were not injured. The flight departed Lehigh Valley International Airport, Allentown, Pennsylvania, about 0430, on an instrument flight rules flight plan, destined for LGA. Night visual meteorological conditions prevailed for the positioning flight conducted under 14 CFR Part 91.

During interviews with the crew, they reported that the captain (PIC) was the flying pilot, and the copilot (SIC) was the non-flying pilot. The copilot contacted the LaGuardia air traffic control tower, local controller, about 12 miles from the airport. The controller acknowledged and cleared N117FJ to land on runway 31. The PIC and SIC reported that the visual approach and landing touchdown were uneventful. During the landing roll, while the PIC was applying reverse thrust, the controller instructed the flight to go-around. The SIC then advised the controller that the airplane was on the runway. Shortly thereafter, the PIC observed a vehicle on the centerline of the runway. The PIC's attempts to avoid the vehicle were unsuccessful, and the airplane's right wing and right main landing gear struck the vehicle. When the airplane came to rest, the PIC shut the engines down and the passengers and crew members evacuated. The crew stated that the runway lights were on during the approach and landing, and that they did not observe any lights on the vehicle located on the runway centerline.

A review of the communication tapes and transcript for the LaGuardia air traffic control tower, from 0425 to 0518, revealed that the same controller was working the local and ground control positions. At 0430:23, the controller cleared the accident maintenance vehicle, vehicle 1277, onto runway 13-31 for "lighting maintenance." At 0430:26, vehicle 1277, questioned, "four is still closed, is that correct," to which the controller responded "that's correct." No further transmissions were made to vehicle 1277 from the controller.

At 0506:57, N117FJ contacted the controller and advised that they were inbound. At 0507:03, the controller acknowledged and cleared the airplane to land on runway 31. At 0509:50, another maintenance vehicle, vehicle 51, radioed, "LaGuardia ground, vehicle five one to cross runway three one at the intersection." The controller radioed "five one hold short", and at 0510, vehicle 51 advised, "five one holding." At 0510:27, vehicle 1277 radioed, "uh twelve seven seven we're stuck on the runway, we're stuck on the runway." The controller then radioed at 0510:32, "go-around, aircraft on the runway go-around, aircraft on the runway go-around, seven fox juliet go-around." At 0510:37, the crew radioed "fox juliet's on," and at 0510:56, the controller asked the crew if everything was "ok".

The accident occurred during the hours of darkness at 40 degrees, 46minutes north latitude, and 73 degrees, 52 minutes west longitude.

AIR TRAFFIC CONTROL INFORMATION

In the NTSB air traffic control group chairman's factual report, it stated that all positions at the LaGuardia control tower were combined at the local control position with one controller making all radio communications. The accident maintenance vehicle, vehicle 1277, had communicated over the LaGuardia ground control frequency when they requested, and were given, clearance onto runway 13-31 to perform maintenance to the runway lights. Vehicle 1277 had also communicated over the ground control frequency when they radioed "uh twelve seven seven we're stuck on the runway, we're stuck on the runway." The controller transmitted over the local and ground control frequencies when he radioed "go-around, aircraft on the runway go-around, aircraft on the runway go-around, seven fox juliet go-around."

In the NTSB air traffic group chairman's factual report, under controller interviews, there was a summary of interview for the controller that worked the accident airplane and vehicle. The interview summary stated that the controller received a local control position relief briefing and went on duty at 0011. He did not recall the specifics of the briefing other than he believed runway 4-22 was closed. The controller was working combined frequencies which included the local control, ground control and class B airspace south.

During the interviews, the term "memory jogger" was used, which the LGA air traffic manager described as a "vehicle strip."

The report further stated:

"While [the controller] was on the local control position, he saw vehicles on runway 4-22. He could not recall if the yellow lights were lit on the vehicles because 'through the course of the night I worked a lot of vehicles.'"

"[The controller used] memory joggers to remind him that a vehicle is on an active runway during peak hours, busy periods and day time. He would use [memory joggers] during a midnight shift [if] "it's a factor," which would be aircraft or heavy aircraft activity. It is possible he would not use it during light traffic. [According to the controller], there [were] no facility orders, procedures, or teaching, regarding the use of memory joggers; it is a technique. He could not recall if he used any memory jogger when [vehicle] 1277 requested to enter runway 31 the morning of the accident, nor could he recall if he saw lights on the...vehicle."

"When he scanned runway 13-31, the runway was clear. He stated that at the time of the accident, 0510, there was no sun, and could not recall if there was a moon or moonlight."

"[The controller] did not experience any radio or radar problems the night of the accident, and stated that the accident airplane was the first arrival since about 0145."

The factual report also contained an additional response section which included questions from the group chairman and responses from the LGA air traffic manager. One question and response from the report stated the following:

Question: "Does the facility have any requirements regarding the use of 'memory joggers' when placing a vehicle on an active runway? If not, why not? If so, where is the requirement documented and request a copy. How is the information disseminated to the controllers?"

Response: "The use of a vehicle strip has always been part of the training process which is taught and utilized by all controllers at LaGuardia tower. Although there is no requirement for written direction, LaGuardia tower established a written directive detailing the use of the memory jogger. The directive will be incorporated in the revised standard operating procedures. (Note: The NOTICE was dated April 16, 1997 and states in part, "in light of recent events, the following procedures will [be] in effect immediately, and will be incorporated in the LaGuardia tower standard operating procedures order. A. The local and ground control positions shall not be combined prior to 0000. B. All vehicles on active runways will be on the local control frequency. C. Whenever a vehicle is cleared onto an active runway, the "VEHICLE" strip shall be placed in the local control flight strip bay for the affected runway. D. During night operations, when the Port Authority is working on the active runway(s), they will request that the runway edge light be turned off.")

COCKPIT VOICE RECORDER INFORMATION

The NTSB cockpit voice recorder (CVR) group chairman's factual report stated the following:

"The recording consisted of four channels of audio information. One channel contained the cockpit area microphone audio information. One other channel contained the first officer outgoing radio transmission only. There was no readable audio on the other two channels. Incoming ATC and other radio transmissions could only be heard on the cockpit area microphone channel through the cockpit speakers. An electrical noise was heard on both pilot channels that changed in frequency with the increase and decrease in engine RPM. . . ."

The following are excerpts from the CVR transcript:

0510:30: sound of thump similar to aircraft touching down on runway. (heard over cockpit area microphone)

0510:31: go-around, aircraft on runway go-around, aircraft on runway go-around, seven fox juliet go-around. (identified as radio transmission from controller)

0510:37: fox juliet's on. (identified as radio transmission from copilot)

0510:43: sound of impact. (heard over cockpit area microphone)

No transmissions were heard from vehicle 1277, the accident vehicle, or vehicle 51 over the CVR.

AIRPORT OPERATIONS INFORMATION

The airport group chairman's factual report, under interview summary notes, stated the following:

"On March 26, 1997, the airport group interviewed the two...electricians who were operating from the destroyed truck while working on runway 13-31. Following are interview summary notes as compiled by the airport group:

The electricians stated that at 0410, while working on the lighting system on runway 4-22, which was closed for contract maintenance work, they contacted the control tower on ground control frequency to inform them that they were working on the closed runway (4-22). At about 0430 to 0445 they requested, and were given clearance onto runway 13-31 by the tower to perform routine lighting maintenance. At that time, the control tower confirmed that runway 4-22 was still closed. The electricians began working on the runway edge lights, repairing fixtures from the north end of runway 13 moving south. They finished repairing the edge lights at about 0500 and began to move north from the south end of the runway, repairing inoperative centerline lights as they went. At about 0505 they bega...