2017 Teterboro Learjet Crash
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On May 15, 2017, a
Learjet 35A The Learjet Model 35 and Model 36 are a series of United States, American multi-role business jets and military transport aircraft manufactured by Learjet between 1973 and 1993. When used by the United States Air Force, they carry the designatio ...
business jet operated by Trans-Pacific Air Charter crashed while on approach to
Teterboro Airport Teterboro Airport is a general aviation relief airport situated in the boroughs of Teterboro, Moonachie, and Hasbrouck Heights in Bergen County, New Jersey.repositioning flight from
Philadelphia International Airport Philadelphia International Airport is the primary international airport serving Philadelphia, Pennsylvania, United States. It served 30.8 million passengers annually in 2024, making it the busiest airport in Pennsylvania and the 21st-busies ...
in
Philadelphia Philadelphia ( ), colloquially referred to as Philly, is the List of municipalities in Pennsylvania, most populous city in the U.S. state of Pennsylvania and the List of United States cities by population, sixth-most populous city in the Unit ...
,
Pennsylvania Pennsylvania, officially the Commonwealth of Pennsylvania, is a U.S. state, state spanning the Mid-Atlantic (United States), Mid-Atlantic, Northeastern United States, Northeastern, Appalachian, and Great Lakes region, Great Lakes regions o ...
, to Teterboro Airport in Teterboro,
New Jersey New Jersey is a U.S. state, state located in both the Mid-Atlantic States, Mid-Atlantic and Northeastern United States, Northeastern regions of the United States. Located at the geographic hub of the urban area, heavily urbanized Northeas ...
, was flying a circle-to-land approach to land on Runway 1 when it stalled and crashed into a commercial building and a parking lot. The investigation, conducted by the
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and inci ...
, determined several factors that led to the crash. The captain of the flight allowed the underqualified first officer to be the pilot flying, which was directly against company procedures. Neither flight crew member conducted an approach briefing, which led to a loss of situation awareness and a failure to maintain proper altitude during the approach. During the circle-to-land maneuver — which was conducted on an unstabilized approach and not in guidance with
air traffic control Air traffic control (ATC) is a service provided by ground-based air traffic controllers who direct aircraft on the ground and through a given section of controlled airspace, and can provide advisory services to aircraft in non-controlled air ...
instructions – the captain was focused on aligning the aircraft with the runway rather than indications in the
cockpit A cockpit or flight deck is the area, on the front part of an aircraft, spacecraft, or submersible, from which a pilot controls the vehicle. The cockpit of an aircraft contains flight instruments on an instrument panel, and the controls th ...
that showed the airspeed was too slow. This resulted in an aerodynamic stall at such a low altitude that the crew was unable to recover.


Background


Operator

Trans-Pacific Air Charter was
air charter Air charter is the business of renting an entire aircraft (i.e., chartering) as opposed to individual aircraft seats (i.e., purchasing a ticket through a traditional airline). Regulation Charter – also called air taxi or ad hoc – flight ...
owned by 38-year-old Ryan Allyn Frost and his father, Robert Frost, based in
Honolulu Honolulu ( ; ) is the List of capitals in the United States, capital and most populous city of the U.S. state of Hawaii, located in the Pacific Ocean. It is the county seat of the Consolidated city-county, consolidated City and County of Honol ...
. The airline was originally known as Sunquest Executive Air Charter, which recently had its
Federal Aviation Administration The Federal Aviation Administration (FAA) is a Federal government of the United States, U.S. federal government agency within the United States Department of Transportation, U.S. Department of Transportation that regulates civil aviation in t ...
(FAA)
Air Operator Certificate An air operator's certificate (AOC) is the approval granted by a civil aviation authority (CAA) to an aircraft operator to allow it to use aircraft for commercial air transport purposes. This requires the operator to have personnel, assets and s ...
revoked. Frost took over the company, reacquired an Air Operator Certificate, and renamed the company to Trans-Pacific Air Charter. The intent was to operate chartered
transpacific flight A transpacific flight is the flight of an aircraft across the Pacific Ocean from Australasia, East and Southeast Asia to North America, South America, or ''vice versa''. Such flights have been made by fixed-wing aircraft, balloons and other t ...
s with Learjets and
Dassault Falcon The Dassault Falcon is a family of business jets, manufactured by Dassault Aviation. Dassault produce the midsize Falcon 2000S/LXS twinjet, the long-range Falcon 6X twinjet and Falcon 900LX trijet, and ultra-long range Dassault Falcon 7X/8X trij ...
s. Frost was the director of operations, charter coordinator, safety officer, and spokesman of Trans-Pacific at the time of the accident. Trans-Pacific had a system to classify first officers, using five different tiers. New first officers were rated as
SIC The Latin adverb ''sic'' (; ''thus'', ''so'', and ''in this manner'') inserted after a quotation indicates that the quoted matter has been transcribed or translated as found in the source text, including erroneous, archaic, or unusual spelling ...
-0, the lowest on the scale, and they were only allowed to act as pilot monitoring. First officers rated as SIC-2 or above would be able to act as pilot flying. The director of operations adopted this policy from a previous employer. SIC-0 first officers had to fly with a
check airman A check pilot (or check airman) is an aircraft pilot who performs an oversight, safety, and qualification role for commercial pilots undergoing evaluation. The role of the check pilot is to ensure that the flight crew member has met competency st ...
to upgrade to a SIC-1. However, there was no check airmen at Trans-Pacific qualified to fly the Learjet 35A.


Aircraft

The aircraft involved in the accident was a 36-year-old
Learjet 35A The Learjet Model 35 and Model 36 are a series of United States, American multi-role business jets and military transport aircraft manufactured by Learjet between 1973 and 1993. When used by the United States Air Force, they carry the designatio ...
, with registration N452DA and manufacturer serial number 35A-452. It was powered by two
Honeywell TFE-731 The Garrett TFE731 (now Honeywell TFE731) is a family of geared turbofan engines commonly used on business jet aircraft. Garrett AiResearch originally designed and built the engine, which due to mergers was later produced by AlliedSignal and no ...
turbofan engines A turbofan or fanjet is a type of airbreathing jet engine that is widely used in aircraft propulsion. The word "turbofan" is a combination of references to the preceding generation engine technology of the turbojet and the additional fan stag ...
. The aircraft had a
cockpit voice recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
(CVR), but did not have and was not required to carry a
flight data recorder A flight recorder is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. The device may often be referred to colloquially as a "black box", an outdated nam ...
(FDR). The aircraft was registered to
Montana Montana ( ) is a landlocked U.S. state, state in the Mountain states, Mountain West subregion of the Western United States. It is bordered by Idaho to the west, North Dakota to the east, South Dakota to the southeast, Wyoming to the south, an ...
-based A&C Big Sky Aviation, but was operated by Trans-Pacific Air Charter.


Crew

The aircraft was flown by two pilots. The captain and designated
pilot-in-command The pilot in command (PIC) of an aircraft is the person aboard an aircraft who is ultimately responsible for its operation and safety during flight. This would be the captain in a typical two- or three-pilot aircrew, or "pilot" if there is only o ...
(PIC) was 53-year-old William Eugene Ramsey. Ramsey had 6,898
flight hours Flight time or block time is an aviation term referring to the total amount of time spent piloting aircraft, and serves as the primary measure of a pilot's experience. Flight time is defined by International Civil Aviation Organization (ICAO) as ...
, 353 of which were pilot-in-command on the Learjet 35A. He started flying as a
second-in-command Second-in-command (2i/c or 2IC) is a title denoting that the holder of the title is the second-highest authority within a certain organisation. Usage In the British Army or Royal Marines, the second-in-command is the deputy commander of a unit, f ...
(SIC) for
Utah Utah is a landlocked state in the Mountain states, Mountain West subregion of the Western United States. It is one of the Four Corners states, sharing a border with Arizona, Colorado, and New Mexico. It also borders Wyoming to the northea ...
-based company D&D Aviation, flying on the Learjet and Beechcraft 400. He worked as an SIC at the company from May 2006 to February 2009, but was laid off during the ongoing economic crisis for a "lack of work". In November 2015, D&D Aviation rehired Ramsey, but he only stayed with the company until December 2015 due to a failure to renew his contract. In October 2016, he completed a checkride and was able to fly for Trans-Pacific as a PIC. In February 2017, he got a new medical certificate and was required to wear
corrective lenses A corrective lens is a transmissive optical device that is worn on the eye to improve visual perception. The most common use is to treat refractive errors: myopia, hypermetropia, astigmatism, and presbyopia. Glasses or "spectacles" are w ...
. The first officer and designated SIC was 33-year-old Jeffery Alino. Alino had 1,167 flight hours, although only 265 were on the Learjet 35A. He had first worked at New Mexico-based MedFlight Air Ambulance in August 2015, but left only six months later. In September 2016, he was hired by Trans-Pacific. During a
simulator A simulation is an imitative representation of a process or system that could exist in the real world. In this broad sense, simulation can often be used interchangeably with model. Sometimes a clear distinction between the two terms is made, in ...
training session, Alino's instructor noted several deficiencies in his performance, which included not knowing how to perform takeoff checks, not knowing how to start the engines, crashing on takeoff due to incorrect flight director settings, and crashing on landing during approach. He was graded as "Not Yet Proficient" and classified as an SIC-0.


Flight

On May 15, 2017, N452DA was scheduled to fly three flights. The first flight was from
Teterboro Airport Teterboro Airport is a general aviation relief airport situated in the boroughs of Teterboro, Moonachie, and Hasbrouck Heights in Bergen County, New Jersey.Teterboro, New Jersey Teterboro ( ) is a Borough (New Jersey), borough in Bergen County, New Jersey, Bergen County, in the U.S. state of New Jersey. As of the 2020 United States census, the borough's population was 61, a decrease of 6 (−9.0%) from the 2010 United S ...
to
Hanscom Field Laurence G. Hanscom Field , commonly known as Hanscom Field, is a public use airport operated by the Massachusetts Port Authority, located outside Boston in Bedford, Massachusetts, United States. Hanscom is mainly a general aviation airport, ...
in
Bedford, Massachusetts Bedford is a town in Middlesex County, Massachusetts, United States. The population of Bedford was 14,161 at th2022 United States census History ''The following compilation comes from Ellen Abrams (1999) based on information from Abram Engl ...
. The second flight was from Hanscom Field to
Philadelphia International Airport Philadelphia International Airport is the primary international airport serving Philadelphia, Pennsylvania, United States. It served 30.8 million passengers annually in 2024, making it the busiest airport in Pennsylvania and the 21st-busies ...
in
Philadelphia Philadelphia ( ), colloquially referred to as Philly, is the List of municipalities in Pennsylvania, most populous city in the U.S. state of Pennsylvania and the List of United States cities by population, sixth-most populous city in the Unit ...
, which carried three passengers. The plan for the passengers was to continue to fly on the same aircraft on its third flight, from Philadelphia Airport to Teterboro Airport, but after the aircraft fishtailed hard on landing, they decided to drive up to Teterboro rather than fly. The pilots were not required to fly to Teterboro as a result, but decided that they would stay in a hotel in New York rather than in Philadelphia. Teterboro Airport has two
runway In aviation, a runway is an elongated, rectangular surface designed for the landing and takeoff of an aircraft. Runways may be a human-made surface (often asphalt concrete, asphalt, concrete, or a mixture of both) or a natural surface (sod, ...
s, Runway 1/19 and 6/24. Under normal wind conditions, aircraft would fly into the
headwind A tailwind is a wind that blows in the direction of travel of an object, while a headwind blows against the direction of travel. A tailwind increases the object's speed and reduces the time required to reach its destination, while a headwind has ...
and land on Runway 6. On May 15, however, the wind was coming from the northwest, which resulted in favorable conditions for landing on Runway 1. Due to other international airports in the path of Runway 1, aircraft planning to land on the runway were to do a circle-to-land approach. This approach involves using the instrument landing system (ILS) signal for Runway 6, then deviating from course around
MetLife Stadium MetLife Stadium is a multi-purpose stadium at the Meadowlands Sports Complex in East Rutherford, New Jersey, United States, 5 mi (8 km) west of New York City. It opened in 2010, replacing Giants Stadium, and serves as the home for the ...
to line up for Runway 1.


Accident

Captain Ramsey filed an
instrument flight rules In aviation, instrument flight rules (IFR) is one of two sets of regulations governing all aspects of civil aviation aircraft operations; the other is visual flight rules (VFR). The U.S. Federal Aviation Administration's (FAA) ''Instrument Fl ...
(IFR) flight plan from Philadelphia to Teterboro at 14:15, with a planned en route time of 28 minutes and a cruising altitude of . This planned altitude was determined to be inappropriate for such a short flight. Additionally, this was the only preflight preparation that either flight crew member conducted, as the weather briefing was conducted before the first flight of the day. At 14:33, the crew contacted clearance delivery for Philadelphia, who gave the flight's prescribed clearance with the exception of the planned altitude, with the controller giving the flight an altitude of 10 minutes after departure. At 15:00:51, the captain said to the first officer, "okay I think we're next man. hand on your yoke," giving control of the flight to the first officer. As First Officer Alino was rated as an SIC-0, he was not allowed to be the pilot flying, and Captain Ramsey giving the controls over to him was a violation of
standard operating procedure A standard operating procedure (SOP) is a set of step-by-step instructions compiled by an organization to help workers carry out routine operations. SOPs aim to achieve efficiency, quality output, and uniformity of performance, while reducing mis ...
s. Four minutes later, N452DA was cleared for takeoff. The aircraft climbed through safely and contacted Philadelphia approach control soon afterward, where it was cleared to climb and level off at . At 15:06,
air traffic control Air traffic control (ATC) is a service provided by ground-based air traffic controllers who direct aircraft on the ground and through a given section of controlled airspace, and can provide advisory services to aircraft in non-controlled air ...
(ATC) cleared the aircraft to take a shortcut to
waypoint A waypoint is a point or place on a route or line of travel, a stopping point, an intermediate point, or point at which course is changed, the first use of the term tracing to 1880. In modern terms, it most often refers to coordinates which spe ...
MAZIE. Shortly after, the captain instructed the first officer to control basic flight parameters, including altitude and
airspeed In aviation, airspeed is the speed of an aircraft relative to the air it is flying through (which itself is usually moving relative to the ground due to wind). In contrast, the ground speed is the speed of an aircraft with respect to the sur ...
. Ramsey told Alino to "keep us below two fifty," instructing him to keep the airspeed below , the limit for aircraft flying below . However, they exceeded that speed, and when ATC asked, "N452DA, what's your airspeed?" Ramsey admitted that they were flying at and that they violated the speed limit. At 15:12, he asked ATC if they could climb any higher, but ATC replied, "unable higher, I would have to spin you back around and sequence you with the rest of the traffic goin' into Teterboro." The first officer commented on this by saying to the captain, "it's like she doesn't like us," with the captain replying, "she's a # idiot. get us someone else if she can't do it." The crew contacted New York approach control at 15:14, where they were given instructions to line up with the ILS for Runway 6 to circle-to-land one Runway 1. After asking ATC to repeat the
altimeter setting Altimeter setting is the value of the atmospheric pressure used to adjust the scale of a pressure altimeter so that it indicates the height of an aircraft above a known reference surface. This reference can be the mean sea level pressure ( QNH), ...
, Captain Ramsey expressed shock and confusion about the instructions ATC gave them. "What the # are they doing man? circling six?" he said in the cockpit to Alino, followed by, "he was saying circling # six or something. I don't know what the # they thinkin' we're doin'. we're # hundreds of miles away man." This was an incorrect statement by the captain, as when he made this comment to the first officer, the aircraft was only away from Teterboro. A minute later, he realized their true distance to the airport and said, "we're # gonna be there in ten minutes. I gotta get the # ATIS #. I didn't realize we're that # close." The crew tuned into the ATIS frequency, but turned it off after only acknowledging the altimeter setting. At 15:19:17, ATC instructed the crew to fly on a heading 90° to intercept the localizer for Runway 6. The aircraft turned on that heading but flew through the localizer course at 15:20:20. Soon after, First Officer Alino reported to the captain that he had the runway in sight. However, he was looking at
Newark Liberty International Airport Newark Liberty International Airport is a major international airport serving the New York metropolitan area. The airport straddles the boundary between the cities of Newark, New Jersey, Newark in Essex County, New Jersey, Essex County and E ...
and not Teterboro. ATC reminded the crew to intercept the localizer, to which Captain Ramsey acknowledged. However, in the cockpit, he and the first officer expressed confusion about where Teterboro truly was. Within a minute, they realized that they were seeing Newark rather than Teterboro, with Alino commenting, "Yeah that was Newark. That was Newark. I thought that was Teterboro." After they properly intercepted the localizer for Runway 6, Ramsey continued to instruct Alino on how to manage the engine power levers and the airspeed. Whilst setting up the
flight management system A flight management system (FMS) is a fundamental component of a modern airliner's avionics. An FMS is a specialized computer system that automates a wide variety of in-flight tasks, reducing the workload on the flight crew to the point that mod ...
(FMS), ATC instructed the crew to fly to VINGS, a waypoint on the localizer path for Runway 6. The captain entered VINGS into the FMS and while he was doing so, the first officer tried to tell the captain to take over the controls for him, but no handover of controls took place. The captain said, "you still got the localizer on your side so we're doin' good." The first officer responded with, "alright. I don't wanna # up." ATC then instructed the aircraft to slow down to from and to descend at 15:23. While the crew did slow down the aircraft, they did not descend and as a consequence, they remained above the
glideslope In aviation, instrument landing system glide path, commonly referred to as a glide path (G/P) or glide slope (G/S), is "a system of vertical guidance embodied in the instrument landing system which indicates the vertical deviation of the ai ...
. At 15:26, ATC gave three instructions to the flight crew of N452DA: contact Teterboro tower, cross waypoint DANDY at , and begin the circle-to-land maneuver at waypoint TORBY. Captain Ramsey acknowledged these instructions but failed to comply with any of them. He did not make First Officer Alino descend to and they kept flying at . Once they passed DANDY, the
autopilot An autopilot is a system used to control the path of a vehicle without requiring constant manual control by a human operator. Autopilots do not replace human operators. Instead, the autopilot assists the operator's control of the vehicle, allow ...
failed to capture the glideslope signal as their altitude was too high. After passing DANDY, Ramsey told Alino to follow the glideslope but not descend below . This was above the approach height for the path between DANDY and TORBY of , so the aircraft remained above the glideslope. The crew only contacted Teterboro tower after being reminded to do so again by ATC. The aircraft passed TORBY at and instead of starting the circle-to-land maneuver, it continued to fly towards Runway 6. At 15:29:07 while descending to , ATC asked the crew, "you gonna start that turn?" Despite being only from the start of Runway 6, too close to start and complete the circle-to-land maneuver safely, Captain Ramsey simply replied, "yeah sir we're doin' it right now." Captain Ramsey directed First Officer Alino to start a right turn as part of the circle-to-land maneuver, in which the aircraft descended from to . The first officer tried to tell the captain in the turn, "your flight controls," but the captain did not respond. Soon after at 15:29:18, the enhanced ground proximity warning system (EGPWS) issued an aural "five hundred" feet altitude alert, followed three seconds later by "sink rate, pull up!" First Officer Alino soon gave control of the flight to Captain Ramsey, to which Ramsey acknowledged and assumed control. He told Alino to watch the airspeed, which was decreasing as the aircraft entered a left turn. As the
bank angle A banked turn (or banking turn) is a turn or change of direction in which the vehicle banks or inclines, usually towards the inside of the turn. For a road or railroad this is usually due to the roadbed having a transverse down-slope towards the ...
of the aircraft increased, the wings started to produce less
lift Lift or LIFT may refer to: Physical devices * Elevator, or lift, a device used for raising and lowering people or goods ** Paternoster lift, a type of lift using a continuous chain of cars which do not stop ** Patient lift, or Hoyer lift, mobile ...
and the airspeed of the aircraft started to decrease. The first officer called out, " V-ref," indicating that the aircraft's speed was falling below the landing reference speed. He followed this call with, "add airspeed, airspeed, airspeed, airspeed." At this time, the bank angle had increased to 35° to the left and the airspeed had fallen to . Captain Ramsey announced, "stall," to which First Officer replied, "yup." The EGPWS once again issued a "sink rate, pull up!" warning as the right wing stalled. The aircraft went into an inverted attitude as it rapidly rolled to the right. The right wingtip of the aircraft impacted a commercial building which was shortly followed by N452DA crashing into a
parking lot A parking lot or car park (British English), also known as a car lot, is a cleared area intended for parking vehicles. The term usually refers to an area dedicated only for parking, with a durable or semi-durable surface. In most jurisdi ...
. The wreckage of the aircraft was distributed along a long debris path south of Runway 1, which damaged or destroyed three buildings and sixteen vehicles. Both pilots were killed on impact.


Investigation

The investigation into the crash was conducted by the
National Transportation Safety Board The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and inci ...
(NTSB).


Crew's actions during flight

The NTSB discovered that multiple times throughout the flight, Captain Ramsey coached First Officer Alino on maintaining basic skills of flight. This task, which was non-standard and against policy at Trans-Pacific, degraded the captain's
situational awareness Situational awareness or situation awareness, often abbreviated as SA is the understanding of an environment, its elements, and how it changes with respect to time or other factors. It is also defined as the perception of the elements in the envi ...
of the flight. This was shown through the captain's lack of awareness of where the destination was. The NTSB deemed that his pre-flight selection of a cruising altitude of was inappropriate for a 28-minute flight. The NTSB noted that his failure to notice the aircraft's true distance to Teterboro during the flight showed . The NTSB highlighted the flight crew's failure to conduct proper pre-flight briefings. Policy at Trans-Pacific required the PIC include planned routing, navigation aids, approach briefing, and en route weather in a pre-flight briefing before every flight. However, the only evidence of any pre-flight planning was the IFR flight planned filed by Captain Ramsey before the flight. The investigators determined that the lack of proper planning contributed to mistakes made by the pilots in-flight. The NTSB determined that the crew's confused reaction to being given a circle-to-land approach and their failure to clarify this instruction with the controller would likely have been prevented if they conducted a proper pre-flight briefing. These errors resulted in the crew's failure to stay on the proper approach path during the
descent Descent may refer to: As a noun Genealogy and inheritance * Common descent, concept in evolutionary biology * Kinship, one of the major concepts of cultural anthropology **Pedigree chart or family tree **Ancestry **Lineal descendant **Heritage ** ...
. The NTSB deemed that the crew's failure to verify what type of approach they would be conducting resulted in confusion and several errors that led to them not starting the circle-to-land maneuver on time. Captain Ramsey also showed a lack of professionalism; on the 30-minute CVR transcript, there were a total of 131 expletives, or one every 14 seconds. During the circle-to-land maneuver, the NTSB determined that pilots disregarded multiple warnings from the EGPWS and the
angle of attack In fluid dynamics, angle of attack (AOA, α, or \alpha) is the angle between a Airfoil#Airfoil terminology, reference line on a body (often the chord (aircraft), chord line of an airfoil) and the vector (geometry), vector representing the relat ...
(AOA) indicator inside the cockpit. If they listened to these warnings, they would have realized that their approach was unstable and conducted a
go-around In aviation, a go-around is an aborted landing of an aircraft that is on Final_approach_(aeronautics), final approach or has already touched down. A go-around can either be initiated by the pilot flying or requested by air traffic control for var ...
. Their decision to start the maneuver was also deemed inappropriate by the NTSB. Captain Ramsey's decision to continue the approach rather was unsafe as they were not on a stabilized approach. After First Officer Alino successfully transferred controls to Ramsey, the NTSB believed that Ramsey became focused on lining up the aircraft with the runway visually, ignored calls from the EGPWS and the first officer, and did not look at the AOA indicator. The NTSB concluded that his focus on attempting to align the aircraft with the runway distracted him from keeping the airspeed of the aircraft stable, which resulted in a stall.


Trans-Pacific's operations and oversight

The pilot's lack of adherence to
standard operating procedure A standard operating procedure (SOP) is a set of step-by-step instructions compiled by an organization to help workers carry out routine operations. SOPs aim to achieve efficiency, quality output, and uniformity of performance, while reducing mis ...
s (SOPs) was also addressed in the final report. Commenting on three accidents that occurred between 2014 and 2016 that also involved violations of SOPs, the NTSB showed that Trans-Pacific, along with FAR part 135 operators in general, did not have the proper resources to monitor and detect pilots that have deficiencies. The lack of a flight data monitoring (FDM) method was pointed out as a reason for Trans-Pacific's failure to properly monitor Captain Ramsey's and First Officer Alino's performance. At the time of the crash, Trans-Pacific did not have an FDM or any formal safety programs to report poor pilot performance. Their safety management system (SMS) was deemed incomplete by the NTSB and did not properly identify and mitigate potential hazards, such as pairing two inexperienced pilots together. The company lacking the safety assurance component of their SMS meant that they did not identify that SIC-0 first officers could not advance according to policy. The disregard of SOPs during the flight was also attributed to Trans-Pacific's improper crew resource management (CRM) training. Their CRM training consisted of a 27-slide computer presentation which covered all topics required by the FAA to some extent. The NTSB determined that the materials in the presentation did not describe the effects of planning, briefing, and decision-making on workload and time management or the responsibilities of the PIC as a leader. The NTSB also pointed out the FAA's failure to maintain proper oversight of Trans-Pacific. The principal operations inspector at the FAA responsible for Trans-Pacific stated that he had little first-hand knowledge with its operations and that he had never done a logistical inspection of any FAR part 135 operations. As a result, he was unaware if pilots at the companies he was responsible for were following SOPs. The NTSB determined that proper oversight of Trans-Pacific would have helped to identify problems within the company. Additionally, ineffective safety assurance systems within the FAA did not identify operators that had violations of SOPs. Trans-Pacific's policy in regard to SICs was criticized by the NTSB. The inability for SICs to develop pilot flying skills resulted in SICs at the company having a lack of experience. The lack of any check airmen to oversee Learjet SICs was highlighted as a factor that reduced the ability to discover noncompliance to SOPs. The NTSB concluded that proper staffing at Trans-Pacific would have identified issues with SICs sooner and would have allowed them to gain experience in line with company policies.


Final report

In their final report, the NTSB determined that the probable cause of the crash was:


Aftermath

In July 2018, a company who had property significantly damaged by the crash filed a lawsuit against Trans-Pacific and A&C Big Sky Aviation. They claimed $15,000 in damages "due to the carelessness, negligence and recklessness" that resulted in the crash.


See also

*
Midwest Express Airlines Flight 105 Midwest Express Airlines Flight 105 was a scheduled domestic passenger flight that crashed into an open field in Oak Creek, Wisconsin shortly after taking off from General Mitchell International Airport on September 6, 1985. The airplane, a McDo ...
(1985) – Accident involving improper FAA oversight *
Airblue Flight 202 Airblue Flight 202 was a scheduled domestic passenger flight departing from Karachi—a sprawling coastal metropolis in southern Pakistan and the nation's largest city—en route to Islamabad, the country's capital city located in the northern ...
(2010) – Crashed during an improper circling maneuver on approach


Notes


References


External links


NTSB final reportNTSB investigation docketAnimation produced by the NTSB about the crashAn analysis of the NTSB final report, produced by the Air Safety InstituteHow Not to Fly a Plane: The 2017 Teterboro Learjet crash
{{Aviation accidents and incidents in the United States in the 2010s T T T T T T Teterboro, New Jersey Aviation accidents and incidents in the United States in 2017