# NTSB NYC03LA114: Saab-Scania 340B, N277MJ, Flushing, NY, May 22, 2003 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: May 21, 2003, 22:10 local (May 22, 2003, 02:10 UTC) - Place: Flushing, NY - Coordinates: 40.777221, -73.872497 - Nearby events: https://openairdocs.org/map.md?lat=40.7772&lon=-73.8725&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor, 17 uninjured - Status: Completed, report December 3, 2004 - Report: Approved by Office Director - Parties: FAA FSDO-15, North American Air Charter, Inc., Colgan Air - NTSB case key (mKey): 57034 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC03LA114 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57034/pdf - Page: https://openairdocs.org/ntsb/NYC03LA114 ## Probable cause (aircraft 2) The inadequate visual lookout and inadequate crew coordination of the Dassault DA-50 flightcrew while taxiing, which resulted in an on ground collision with a taxing Saab 340B. A factor in the accident was the dark night. ## Probable cause (aircraft 1) The inadequate visual lookout and inadequate crew coordination of the Dassault DA-50 flightcrew while taxiing, which resulted in an on ground collision with a taxing Saab 340B. A factor in the accident was the dark night. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Collision between aircraft (other than midair), taxi - to takeoff - visual lookout - inadequate, flightcrew of other aircraft (cause) - light condition - dark night (contributing factor) - airport facilities,taxiway sign(s) - not installed - crew/group coordination - inadequate, flightcrew of other aircraft (cause) - Collision between aircraft (other than midair), taxi - to takeoff - light condition - dark night - visual lookout - inadequate, flightcrew of other aircraft (cause) - crew/group coordination - inadequate, flightcrew (cause) - airport facilities,taxiway sign(s) - not installed ## Analysis (aircraft 2) The Dassault was issued taxi instructions from the ground controller, which included holding short of taxiway Echo. The PIC of the Dassault understood it as, "make two left turns and taxi to runway 13 for takeoff, via taxiways F and BB." While taxing north on taxiway BB, the Dassault collided with a Saab 340B at the intersections of taxiway's BB and E. The PIC added that both he and the co-pilot had their heads down in the cockpit as they were conducting checklists at the time of the collision. According to the captain of the Saab, he received instructions from the ground controller to cross runway 4, make a right hand turn onto "[taxiway] CC," and continue to runway 13. After crossing runway 4, the captain of the Saab "noted a Dassault airplane taxiing on '[taxiway] BB,' but had heard his 'hold short' instruction and called for the taxi checklist." As the Saab flightcrew was in the process of completing the taxi checklist, the Dassault struck their airplane from the left. Examination of taxiway BB, during the hours of darkness, by a Federal Aviation Administration (FAA) inspector revealed that there were no taxiway indicator markers informing a pilot that taxiway E was approaching. The inspector noted that taxiway BB, and its intersection with taxiway E, was dimly lit with ambient lighting, although centerline lighting was available. Review of FAA Advisory Circular 120-74, Part 91 Pilot and Flightcrew Procedures During Taxi Operations and Part 135 Single Pilot operations, revealed, "For aircraft operations where more than one pilot is in the cockpit/flight deck, the flightcrew should plan the timing and execution of aircraft checklists and company communications at the appropriate times and locations so the pilot who is not taxiing the aircraft can be available to participate in verbal coordination with the pilot who is taxiing the aircraft. This action is needed to confirm compliance with ATC taxi instructions at the appropriate times and locations. When planning these tasks, flightcrews should also consider the anticipated duration of the taxi operation, the locations of complex intersections and runway crossings, and the visibility along the taxi route. When conducting airport surface operations, you should always be aware of your situation as it relates to other aircraft operations going on around you as well as to other vehicles moving on the airport. You should know your aircraft's precise location on the movement area." ## Analysis (aircraft 1) The Dassault was issued taxi instructions from the ground controller, which included holding short of taxiway Echo. The PIC of the Dassault understood it as, "make two left turns and taxi to runway 13 for takeoff, via taxiways F and BB." While taxing north on taxiway BB, the Dassault collided with a Saab 340B at the intersections of taxiway's BB and E. The PIC added that both he and the co-pilot had their heads down in the cockpit as they were conducting checklists at the time of the collision. According to the captain of the Saab, he received instructions from the ground controller to cross runway 4, make a right hand turn onto "[taxiway] CC," and continue to runway 13. After crossing runway 4, the captain of the Saab "noted a Dassault airplane taxiing on '[taxiway] BB,' but had heard his 'hold short' instruction and called for the taxi checklist." As the Saab flightcrew was in the process of completing the taxi checklist, the Dassault struck their airplane from the left. Examination of taxiway BB, during the hours of darkness, by a Federal Aviation Administration (FAA) inspector revealed that there were no taxiway indicator markers informing a pilot that taxiway E was approaching. The inspector noted that taxiway BB, and its intersection with taxiway E, was dimly lit with ambient lighting, although centerline lighting was available. Review of FAA Advisory Circular 120-74, Part 91 Pilot and Flightcrew Procedures During Taxi Operations and Part 135 Single Pilot operations, revealed, "For aircraft operations where more than one pilot is in the cockpit/flight deck, the flightcrew should plan the timing and execution of aircraft checklists and company communications at the appropriate times and locations so the pilot who is not taxiing the aircraft can be available to participate in verbal coordination with the pilot who is taxiing the aircraft. This action is needed to confirm compliance with ATC taxi instructions at the appropriate times and locations. When planning these tasks, flightcrews should also consider the anticipated duration of the taxi operation, the locations of complex intersections and runway crossings, and the visibility along the taxi route. When conducting airport surface operations, you should always be aware of your situation as it relates to other aircraft operations going on around you as well as to other vehicles moving on the airport. You should know your aircraft's precise location on the movement area." ## Factual narrative (aircraft 2) On May 21, 2003, at 2210 eastern daylight time, a Saab 340B, N277MJ, operated by Colgan Air Inc., as flight 5056, was substantially damaged when it was struck by another airplane, while taxing at the La Guardia Airport (LGA), Flushing, New York. The other airplane, a Dassault DA-50, N664B, sustained minor damage. Neither of the 2 pilots and 6 passengers aboard the Saab were injured, nor were any of the 2 pilots and 7 passengers onboard the Dassault; however, a flight attendant in the Saab received minor injuries. Night visual meteorological conditions prevailed at the time of the accident. The Saab was operating as a scheduled passenger flight conducted under 14 CFR Part 121. The Dassault was operating as business flight conducted under 14 CFR Part 91. According to the pilot-in-command (PIC) of the Dassault, his airplane was parked at the "five towers" area located on the west side of the airport. At 2205, the PIC received taxi instructions from the LGA ground controller, which the PIC understood as, "make two left turns and taxi to runway 13 for takeoff, via taxiways F and BB." While taxing north on taxiway BB, the Dassault collided with the Saab at the intersections of BB and E. The PIC added that both he and the co-pilot had their heads down in the cockpit as they were conducting checklists at the time of the collision. According to the captain of the Saab, the airplane was pushed off the gate to spot 22, where the first officer then called the LGA ground controller for taxi clearance. The taxi instructions provided by the ground controller were to proceed via "[taxiway] A short of [taxiway] K," for an inbound Boeing 737. The flight was then cleared from "[taxiway] A to [taxiway] E, and to hold short of runway 4". The flight received further instructions to cross runway 4, make a right hand turn onto "[taxiway] CC," and continue to runway 13. After crossing runway 4, the captain "noted a Dassault airplane taxiing on '[taxiway] BB,' but had heard his 'hold short' instruction, and called for the taxi checklist." As the Saab flightcrew was in the process of completing the taxi checklist, the Dassault struck their airplane from the left. Excerpts of the cockpit voice recorder (CVR) transcript prepared from the Dassault DA-50 recorder, revealed the following: At 2205:56, the co-pilot radioed the LGA ground controller and stated, "Falcon November six six four Bravo five towers taxi." The ground controller replied, "Falcon six six four Bravo roger runway one three two left turns to join double Bravo hold short of taxiway echo." Following the instructions, the cockpit area mike recorded a sound similar to increasing engine rpm. At 2206:08, the co-pilot responded to the ground controller, "okay left and left to join double Bravo hold short Echo six four Bravo." At 2206:16, the co-pilot stated, "taxi lights... taxi lights brakes two." The captain responded, "ok they're checked one on." At 2206:37, the co-pilot stated, "okay this is double bravo... right? this is Bravo? yeah." At 2205:56, the captain stated, "he said two lefts." The co-pilot replied, "yeah so here's Bravo yep okay." At 2206:46, the flight crew began challenge and response conversation consistent with items from the taxi checklist. The conversation continued for about 36 seconds. At 2207:23, the cockpit area mike recorded a sound similar to propeller rpm, followed by the co-pilot stating, "whoa..." At 2207:26, the cockpit area mike recorded a sound similar to the sound of an impact and shattering glass. At 2207:27, the LGA ground controller transmitted, "Falcon six four bravo. I asked you to hold short of Echo." At 2207:30, the flight crew of the SAAB transmitted to the LGA ground controller, "hey ah ground Colgan fifty fifty six we just got hit by an airplane over here." The LGA ground controller replied, "all right I asked the ah..." Throughout the CVR transcript, there was no mention of, or calls for, reviewing the airport layout diagram. Examination of taxiway BB, during the hours of darkness, by a Federal Aviation Administration (FAA) inspector revealed that there were no taxiway indicator markers informing a pilot that taxiway E was approaching. The inspector noted that the taxiway, and its intersection with taxiway E, was dimly lit with ambient lighting, although centerline lighting was available. FAA Advisory Circular (AC) 150/5340-18C, Standards for Airport Sign Systems, contained the FAA standards for the installation of signs on airport runways and taxiways. It was recommended that all airports install a system of taxiway guidance signs in accordance with the standards in Chapter 1 of the circular. Installing the components of the taxiway guidance sign system in accordance with paragraph 3 of Chapter 1 represented an acceptable means of compliance with the requirements of Federal Aviation Regulation, Part 139, for those airports that are certificated under this regulation. Chapter 1 of the AC included: "A properly designed and standardized taxiway guidance sign system is an essential component of a surface movement guidance control system necessary for the safe and efficient operation of an airport. It should: a. Provide the ability to easily determine the designation or name of any taxiway on which the aircraft is located. b. Readily identify routes toward a desired destination. c. Indicate mandatory holding positions. d. Identify boundaries for approach areas, ILS critical areas, and runway safety areas/obstacle free zones (OFZ)." "A sign array consisting of taxiway direction signs should be installed prior to each taxiway/taxiway intersection if an aircraft would normally be expected to turn at or hold short of the intersection. The direction signs in the array should include a sign panel (taxiway designation and an arrow) for each taxiway that an aircraft would be expected to turn onto or hold short of. A taxiway location sign should be included as part of the sign array unless it is determined to be unnecessary. If an aircraft normally would not be expected to turn at or hold short of the intersection, the sign array is not needed unless the absence of guidance would cause confusion." A recommendation was issued by the FAA to the Port Authority of New York and New Jersey requesting that a sign be installed on taxiway BB, prior to taxiway E, identifying that the E taxiway is approaching. According to a representative from the Port Authority of New York and New Jersey at LGA, the recommendation from the FAA was accepted and was to be complied with by September 2004. Review of FAA Advisory Circular 120-74, Part 91 Pilot and Flightcrew Procedures During Taxi Operations and Part 135 Single Pilot operations, revealed: "Take some time and study the airport layout. If you have a flightcrew, make sure the airport diagram is readily available to each flight crewmember. Check your expected taxi route against the airport diagram or taxi chart. Pay special attention to any tricky or complex intersections along the taxi route….If you have other flight crewmembers, make sure you identify critical times or locations on the taxi route where verbal coordination between the pilot in command (PIC) and the second in command (SIC)/first officer (FO) will be necessary to ensure correct aircraft navigation and crew orientation. For aircraft operations where more than one pilot is in the cockpit/flight deck, the flightcrew should plan the timing and execution of aircraft checklists and company communications at the appropriate times and locations so the pilot who is not taxiing the aircraft can be available to participate in verbal coordination with the pilot who is taxiing the aircraft. This action is needed to confirm compliance with ATC taxi instructions at the appropriate times and locations. When planning these tasks, flightcrews should also consider the anticipated duration of the ## Factual narrative (aircraft 1) On May 21, 2003, at 2210 eastern daylight time, a Saab 340B, N277MJ, operated by Colgan Air Inc., as flight 5056, was substantially damaged when it was struck by another airplane, while taxing at the La Guardia Airport (LGA), Flushing, New York. The other airplane, a Dassault DA-50, N664B, sustained minor damage. Neither of the 2 pilots and 6 passengers aboard the Saab were injured, nor were any of the 2 pilots and 7 passengers onboard the Dassault; however, a flight attendant in the Saab received minor injuries. Night visual meteorological conditions prevailed at the time of the accident. The Saab was operating as a scheduled passenger flight conducted under 14 CFR Part 121. The Dassault was operating as business flight conducted under 14 CFR Part 91. According to the pilot-in-command (PIC) of the Dassault, his airplane was parked at the "five towers" area located on the west side of the airport. At 2205, the PIC received taxi instructions from the LGA ground controller, which the PIC understood as, "make two left turns and taxi to runway 13 for takeoff, via taxiways F and BB." While taxing north on taxiway BB, the Dassault collided with the Saab at the intersections of BB and E. The PIC added that both he and the co-pilot had their heads down in the cockpit as they were conducting checklists at the time of the collision. According to the captain of the Saab, the airplane was pushed off the gate to spot 22, where the first officer then called the LGA ground controller for taxi clearance. The taxi instructions provided by the ground controller were to proceed via "[taxiway] A short of [taxiway] K," for an inbound Boeing 737. The flight was then cleared from "[taxiway] A to [taxiway] E, and to hold short of runway 4". The flight received further instructions to cross runway 4, make a right hand turn onto "[taxiway] CC," and continue to runway 13. After crossing runway 4, the captain "noted a Dassault airplane taxiing on '[taxiway] BB,' but had heard his 'hold short' instruction, and called for the taxi checklist." As the Saab flightcrew was in the process of completing the taxi checklist, the Dassault struck their airplane from the left. Excerpts of the cockpit voice recorder (CVR) transcript prepared from the Dassault DA-50 recorder, revealed the following: At 2205:56, the co-pilot radioed the LGA ground controller and stated, "Falcon November six six four Bravo five towers taxi." The ground controller replied, "Falcon six six four Bravo roger runway one three two left turns to join double Bravo hold short of taxiway echo." Following the instructions, the cockpit area mike recorded a sound similar to increasing engine rpm. At 2206:08, the co-pilot responded to the ground controller, "okay left and left to join double Bravo hold short Echo six four Bravo." At 2206:16, the co-pilot stated, "taxi lights... taxi lights brakes two." The captain responded, "ok they're checked one on." At 2206:37, the co-pilot stated, "okay this is double bravo... right? this is Bravo? yeah." At 2205:56, the captain stated, "he said two lefts." The co-pilot replied, "yeah so here's Bravo yep okay." At 2206:46, the flight crew began challenge and response conversation consistent with items from the taxi checklist. The conversation continued for about 36 seconds. At 2207:23, the cockpit area mike recorded a sound similar to propeller rpm, followed by the co-pilot stating, "whoa..." At 2207:26, the cockpit area mike recorded a sound similar to the sound of an impact and shattering glass. At 2207:27, the LGA ground controller transmitted, "Falcon six four bravo. I asked you to hold short of Echo." At 2207:30, the flight crew of the SAAB transmitted to the LGA ground controller, "hey ah ground Colgan fifty fifty six we just got hit by an airplane over here." The LGA ground controller replied, "all right I asked the ah..." Throughout the CVR transcript, there was no mention of, or calls for, reviewing the airport layout diagram. Examination of taxiway BB, during the hours of darkness, by a Federal Aviation Administration (FAA) inspector revealed that there were no taxiway indicator markers informing a pilot that taxiway E was approaching. The inspector noted that the taxiway, and its intersection with taxiway E, was dimly lit with ambient lighting, although centerline lighting was available. FAA Advisory Circular (AC) 150/5340-18C, Standards for Airport Sign Systems, contained the FAA standards for the installation of signs on airport runways and taxiways. It was recommended that all airports install a system of taxiway guidance signs in accordance with the standards in Chapter 1 of the circular. Installing the components of the taxiway guidance sign system in accordance with paragraph 3 of Chapter 1 represented an acceptable means of compliance with the requirements of Federal Aviation Regulation, Part 139, for those airports that are certificated under this regulation. Chapter 1 of the AC included: "A properly designed and standardized taxiway guidance sign system is an essential component of a surface movement guidance control system necessary for the safe and efficient operation of an airport. It should: a. Provide the ability to easily determine the designation or name of any taxiway on which the aircraft is located. b. Readily identify routes toward a desired destination. c. Indicate mandatory holding positions. d. Identify boundaries for approach areas, ILS critical areas, and runway safety areas/obstacle free zones (OFZ)." "A sign array consisting of taxiway direction signs should be installed prior to each taxiway/taxiway intersection if an aircraft would normally be expected to turn at or hold short of the intersection. The direction signs in the array should include a sign panel (taxiway designation and an arrow) for each taxiway that an aircraft would be expected to turn onto or hold short of. A taxiway location sign should be included as part of the sign array unless it is determined to be unnecessary. If an aircraft normally would not be expected to turn at or hold short of the intersection, the sign array is not needed unless the absence of guidance would cause confusion." A recommendation was issued by the FAA to the Port Authority of New York and New Jersey requesting that a sign be installed on taxiway BB, prior to taxiway E, identifying that the E taxiway is approaching. According to a representative from the Port Authority of New York and New Jersey at LGA, the recommendation from the FAA was accepted and was to be complied with by September 2004. Review of FAA Advisory Circular 120-74, Part 91 Pilot and Flightcrew Procedures During Taxi Operations and Part 135 Single Pilot operations, revealed: "Take some time and study the airport layout. If you have a flightcrew, make sure the airport diagram is readily available to each flight crewmember. Check your expected taxi route against the airport diagram or taxi chart. Pay special attention to any tricky or complex intersections along the taxi route….If you have other flight crewmembers, make sure you identify critical times or locations on the taxi route where verbal coordination between the pilot in command (PIC) and the second in command (SIC)/first officer (FO) will be necessary to ensure correct aircraft navigation and crew orientation. For aircraft operations where more than one pilot is in the cockpit/flight deck, the flightcrew should plan the timing and execution of aircraft checklists and company communications at the appropriate times and locations so the pilot who is not taxiing the aircraft can be available to participate in verbal coordination with the pilot who is taxiing the aircraft. This action is needed to confirm compliance with ATC taxi instructions at the appropriate times and locations. When planning these tasks, flightcrews should also consider the anticipated duration of the ## Aircraft 1 - Registration: [N277MJ](https://openairdocs.org/deregistered/N277MJ-2020-12-14), registration cancelled 2020-12-14, S/N 340B-277 (OpenAirDocs) - Reported make and model: Saab-Scania AB (Saab) 340B - Registry model: [Saab-Scania SAAB 340B](https://openairdocs.org/model/saab-scania-saab-340b) (registry code 7860101) (OpenAirDocs) - Registry engine: [GE CT7-SER series](https://openairdocs.org/engine/ge-ct7-ser-series) (registry code 30031, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 340B-277 - Airframe hours: 367 - Engines: General Electric CT7-9B 1600 horsepower turbo prop; General Electric CT7-9B 1600 horsepower turbo prop - Damage: Substantial damage - Flight: Part 121 - Operator: Colgan Air dba US Airways Express, doing business as Colgan Air - Registered owner: First Security Bank - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, May 6, 2003, 72 hours before - Departed: LGA, New York, NY - Destination: MHT, Manchester, NH - Flight plan: IFR - Airport: LGA, La Guardia Airport ## Aircraft 2 - Registration: N664B (not matched to a registry record) - Reported make and model: Dassault Aviation DA-50 - Category: Airplane - Serial number: 200 - Airframe hours: 6606 - Engines: Garrett TFE 731 3700 lbs thrust turbo fan; Garrett TFE 731 3700 lbs thrust turbo fan; Garrett TFE 731 3700 lbs thrust turbo fan - Damage: Minor damage - Flight: Business, Part 91 - Operator: North American Air Charter, Inc. - Registered owner: Wells Fargo Bank North West - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, January 23, 2003, 62 hours before - Departed: LGA, Flushing, NY - Destination: BIKF, Keflavik - Flight plan: IFR - Airport: LGA, La Guardia Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N277MJ; age 35; injuries: none; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review April 22, 2003; seat: left; flight hours: 4,837 total, 1,317 in this make and model, 4,524 as pilot in command, 136 in the last 90 days, 54 in the last 30 days, 5 in the last 24 hours - Co-pilot, aircraft N277MJ; age 28; injuries: none; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review August 2, 2003; seat: right; flight hours: 1,582 in this make and model, 1,461 as pilot in command, 143 in the last 90 days, 67 in the last 30 days, 5 in the last 24 hours - Pilot, aircraft N664B; age 58; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review December 27, 2002; seat: left; flight hours: 12,684 total, 1,500 in this make and model, 10,200 as pilot in command - Co-pilot, aircraft N664B; age 23; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; last flight review May 7, 2003; seat: right; flight hours: 4,000 total, 200 in this make and model ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 50° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 2,200 ft overcast - Temperature: 57 °F, dew point 55 °F - Altimeter: 30.18 inHg - Observed at: LGA ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20030521010181A](https://openairdocs.org/incident/20030521010181A), May 21, 2003: Saab 340B, New York, NY, Substantial damage. (-23) On may 21, 2003, at 2210 eastern daylight time, a Saab 340B, N277MJ, operated by colgan airwarys inc., as flight 5056, was substantially damaged when it… - [Accident 20030521010182A](https://openairdocs.org/incident/20030521010182A), May 21, 2003: Amd FALCON50MYST, New York, NY, Minor damage. (-23) On may 21, 2003, at 2210 eastern daylight time, a saab 340B, N277MJ, operated by colgan airways inc., as flight 5056, was substantially damaged when it… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.