How Not to Fly a Plane: The 2017 Teterboro Learjet crash
On the 15th of May 2017, a Learjet on final approach to Teterboro Airport in New Jersey abruptly rolled inverted and nosedived into the ground, sending a fireball ripping through an industrial office park and killing both pilots, the only people on board. The jet was normally used to transport paying customers on demand, but it went down on a repositioning flight without passengers — a fact that investigators soon found to have played a role in setting the stage for disaster. Without apparent obligation to anyone, the two pilots embarked on the short flight to Teterboro seemingly without any preparation, then blundered through some of the busiest airspace in America while violating speed limits, cursing at air traffic controllers, and ignoring approach procedures, culminating in a last minute turn to align with the landing runway long after such a maneuver had become impossible.
How could these pilots have made so many mistakes in such a short time? And what kind of company would let its pilots behave so unprofessionally? The answers, gleaned from interviews with their colleagues, bosses, and instructors, paint a picture of two pilots who never should have been together in the cockpit, both of them bottom-of-the-barrel hires in an industry struggling to find qualified applicants, who found work at a fly-by-night charter company with next to no oversight. Their fate illustrated the risks inherent to this type of operation, and cast light on the dirty underbelly of the seemingly glamorous world of on-demand jet charters, where high price tags sometimes belie an alarming absence of safety.
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Most of us have probably never needed to know how to charter a business jet flight — but for those with money to spend, it’s often tempting to skip the hassle of airline flying by booking one’s very own plane, which can fly wherever one wants and on whatever schedule one desires, with no awkward arrival times, crowded terminals, or crying babies. In the internet age, such a flight is just a click away at various “charter broker” websites that allow customers to select their origin, destination, party size, preferred aircraft category, and more, at which point the broker will find a company willing and able to fulfill the request. Many companies sustain themselves entirely off of these brokered arrangements, including one small, scrappy carrier known as Trans-Pacific Air Charter.
Trans-Pacific, as it was usually called, operated a small fleet of Learjet 35 and Dassault Falcon 50 business jets that crisscrossed the United States without any particular home base, picking up customers wherever they happened to be. The company had been built several years earlier on the ruins of a predecessor called SunQuest Aviation, which had its Air Operator Certificate revoked by the Federal Aviation Administration before it was rescued and restored to profitability by a young businessman named Ryan Frost and his dad. By May of 2017, the company had grown to five airplanes and nine pilots, but there was very little else concrete about it — the only other employees, besides Mr. Frost himself, were a secretary, the director of maintenance, and a single maintenance tech, who were all located in completely different cities. The company was nominally headquartered in Honolulu, Hawaii, and Frost had ambitions of expanding throughout the South Pacific — hence the name — but for the most part Trans-Pacific Air Charter consisted of several people and aircraft spread throughout a wide area, who were tied together only by pieces of paper and telephone calls. Even so, a better name for the company might have been “Ryan Frost, Incorporated,” because Frost was not only the company president, but also the director of operations, the charter coordinator, the chief salesperson, the director of flight safety, the flight dispatcher, the crew scheduler, and more. “Ryan wears many hats,” the chief pilot would later tell investigators, summing up the president’s multifaceted role.
Among the planes in Trans-Pacific’s fleet by the spring of 2017 was N452DA, a six- to eight-passenger Learjet 35 originally built in 1981. The Learjet 35 is perhaps most distinctive for its unique wingtip fuel tanks, but otherwise it was one of the most ubiquitous small business jets of the 20th century, with over 700 built between 1973 and 1994. This particular example had seen heavy use during its lifetime and was not in especially pristine condition, although there were no major outstanding mechanical problems. It is unclear exactly when Trans-Pacific began operating N452DA, but it was actually owned by a Montana-based entity called A&C Big Sky Aviation, and Trans-Pacific appeared to have been leasing it for some time.
On May 15th, 2017, three members of a family arrived for a brokered trip aboard N452DA from Bedford, Massachusetts, to Philadelphia International Airport. In advance of the flight, Trans-Pacific had sent ahead a two-person flight crew consisting of 53-year-old Captain Will Ramsey, a native of Utah, and a 33-year-old First Officer, Jeffrey Alino, who was from New Jersey. The two pilots had been flying together exclusively for weeks.
Captain Ramsey had about 6,900 total flying hours across a sporadic career, including an unspecified number as first officer on the Learjet 35 with a Utah-based company called D&D Aviation between 2006 and 2009, before he was laid off amid the financial crisis. He spent the next several years out of work, except for most of 2015, when he returned to his old company to fly the Beechjet, only for his contract to expire without being renewed. He remained unemployed until October 2016, when Trans-Pacific trained him to fly the Learjet again, this time as captain. His 353 hours in that position represented the sum total of his experience in command of a multi-crew aircraft.
First Officer Alino was even less experienced, with only 1,167 total hours, of which only 265 were on the Learjet. He had previously worked for a New Mexico-based Air Ambulance company called MedFlight, but left after accumulating only about 100 flight hours in six months with the company, joining Trans-Pacific at around the same time as Captain Ramsey.
Trans-Pacific had a tiered second-in-command system for First Officers, with levels ranging from 0 to 4, wherein a level 0 first officer was only allowed to act as pilot monitoring, while levels 2 and above were given full authority to fly the airplane. The intent of the system, which Ryan Frost had adapted from a previous employer, was to confer on new first officers a level of responsibility that matched their skill level. During the months he had spent flying for Trans-Pacific, Alino had yet to progress past level 0, although that was not entirely his own fault: while his fellow pilots generally assessed his skills as marginal, the tier system required that level 0 first officers fly with a management pilot or check airman to evaluate their readiness before they could progress to level 1, and Trans-Pacific had no management pilots or check airmen qualified to fly the Learjet, so not only was Alino technically stuck at level 0 for the foreseeable future, so was the company’s other Learjet First Officer, whose skills were said to be superior.
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With Captain Ramsey at the controls and First Officer Alino monitoring, as company rules required, N452DA departed Bedford, Massachusetts with the three passengers on board at 10:09 a.m., and proceeded uneventfully toward Philadelphia. The weather that day was wild, with localized heavy rain and gusty winds throughout the northeastern United States, and the landing in Philadelphia apparently became rather squirrely. According to the recollection of one passenger, the plane was hit by a sudden gust just before touchdown that resulted in an extreme sideslip and hard landing that left him thinking they were going to crash. Witnesses are somewhat contradictory about what happened next. According to this same passenger, the plan had been for the group to attend a golf tournament and then continue with the same crew and plane to Teterboro, New Jersey later that evening; however, the landing scared them so much that they decided to drive instead, telling the pilots not to wait around for their return. At the same time, that passenger’s mother, who was also on board, stated that the trip was booked from Bedford to Philadelphia without mentioning Teterboro, nor does the NTSB report suggest that the subsequent flight to Teterboro was ever supposed to be carrying passengers.
However, what is known for sure is that N452DA was needed in Teterboro anyway in order to meet the upcoming days’ schedule, so Ramsey and Alino were called upon to ferry the plane to New Jersey without passengers later that afternoon. While most of Trans-Pacific’s flights were conducted under Part 135 of the Federal Aviation Regulations (charter and air taxi operations), the flight to Teterboro was to be a non-revenue flight conducted under the less restrictive Part 91 (private and general aviation). Unfortunately, this fact appears to have gone to Captain Ramsey’s head, because he treated the flight like he was driving a car, and not as though he was flying a twin engine jet through some of America’s busiest airspace, as will be seen momentarily.
This casual attitude toward the repositioning flight began well before it actually took off, with the pre-flight planning stage. Company rules required that pilots possess weather information that is less than three hours old prior to departure, but Ramsey had last checked the weather at 6:37 that morning, before flying to Bedford to pick up the passengers, and eight and a half hours had since passed. The forecast for Teterboro now warned of strong, gusty winds out of the northwest, but since he didn’t check the weather, he probably wasn’t aware of this. He also filed only the most cursory flight plan, listing an en route time of 28 minutes with a cruising altitude of 27,000 feet, which was almost physically impossible — it’s ludicrous to imagine climbing so high during such a short flight, especially when considering the way the busy airspace in that region is managed, which he should have anticipated. Most likely, he just threw in some numbers without any thought, which certainly leads one to wonder what else he was omitting. For instance, there was no evidence that the pilots briefed any of the procedures they could expect to fly, including the approach to Teterboro, which was a questionable decision given the very limited time available to do so en route.
After firing up the engines and taxiing from the apron, the cockpit voice recorder captured Captain Ramsey giving First Officer Alino control of the airplane: “Okay, I think we’re next, man,” he said. “Hand on your yoke.” As mentioned earlier, Alino was not yet allowed to fly the airplane, being a level 0 first officer, and Ramsey was about to discover why.
As they sat waiting for permission to take off, the pilots idly commented on events around them with an abundance of swearing. Observing a small single-engine Pilatus, First Officer Alino said “Fuck Pilatuses,” to which Captain Ramsey agreed; moments later, listening to the tower call a helicopter about its lack of a transponder code, Ramsey said, “Dude, you’re in fucking controlled airspace. Yeah, bother the poor controller because you didn’t get a clearance for VFR!”
Interspersed between these comments, Ramsey instructed Alino on such matters as where to put his thumb on the thrust levers, to which Alino insistently replied, “I’ve been learning!”
Cleared for takeoff at 15:03, N452DA was rolling at 15:04, as Ramsey gave a continuous stream of instruction to his first officer: “Alright, a little more. Keep advancing it slowwwwly, don’t go crazy on it. Little more, more, more, more…”
Moments later, N452DA lifted off, and Ramsey called “positive rate,” followed by “gear up, yaw dampener engaged,” two items that should be called out by the pilot flying. “Ya gotta tell me to do that,” he said to Alino, who clearly was not fully aware of the expectations on him as pilot flying, for obvious reasons. Shortly thereafter, following calls of “four hundred feet” and “flaps up,” Ramsey called the After Takeoff checklist complete. This would turn out to be the only checklist completed by either crewmember at any point during the flight.
Following takeoff, N452DA was cleared to climb to 4,000 feet, and Ramsey instructed Alino on the best techniques for leveling off. Shortly after that, at 15:06, they were given a shortcut direct to waypoint MAZIE, which was the second waypoint on their flight plan, shaving several minutes off the already short journey. Ramsey did not appear to appreciate the implications of this, and instead continued instructing Alino to “watch the altitude” and “watch the airspeed, don’t go above two fifty,” noting the universal 250-knot speed limit below 10,000 feet in US airspace. In response, Alino pulled back power, to which Ramsey said, “Much fucking better.”
“I thought you were going to say why are you fucking up?” said Alino.
“No, no, much fucking better,” said Ramsey. “You’ve been paying attention to what I’ve been doing. You’re fucking understanding the shit. You know what to fucking look for now.”
A minute later, referring to the speed limit again, Ramsey said, “And if they give us fucking higher…”
“We wouldn’t have to worry about it,” Alino said, finishing the thought.
Philadelphia approach control now warned them of traffic at their 10 o’clock position at four miles, but Ramsey couldn’t spot it. “Traffic is failed,” he said to Alino, “Don’t ask me why fucking traffic is failed.”
Meanwhile, the controller provided heading instructions, threading the Learjet through the crowded airspace. “November four five two delta alpha, turn left heading three six zero, it’s a vector for sequence, I’ll have you back direct MAZIE in a few more moments.”
Turning left of their original course, Ramsey complained that they would miss waypoint MAZIE: “Someone’s coming up behind us that the — what they fucking wanna do,” he said. “There’s no one in front of us, they want someone to climb over the top of us so they give us fucking forty-five degree bank to fucking MAZIE.”
“Fuck those guys,” Alino agreed.
“Yeah, what the hell man. We’re a fucking Learjet, get us fucking higher,” Ramsey complained.
“We could go faster,” Alino agreed.
At that moment, the controller called and asked, “November four five two delta alpha, what’s your airspeed?”
Ramsey glanced down and realized they had violated the speed limit. “We’re showing right now at twwwo siiiixty,” he said sheepishly. “Four five two delta alpha.”
“Slowing down,” said Alino.
“Yes sir. Shit, I just admitted I violated fucking airspace, but we’re far enough away,” said Ramsey.
“That’s why I was like ahhhh, come on baby slow down for me,” said Alino.
“Eh, it’s within ten,” said Ramsey. “I don’t think we’ll be violated for that.”
Seconds later, however, Ramsey’s focus was back on their altitude. He didn’t like that they had been left at 4,000 feet, and he didn’t appear to understand why they had not been cleared to a higher altitude. “Okay, where the fuck man?” he said. “Who, why the fuck are they jacking us on this? Let us get the fuck up and go home!”
“That’s why, they don’t want us to go home,” Alino joked.
Finally, at 15:12, after turning past MAZIE, Ramsey decided to ask for a higher altitude. “Yeah, four five two delta alpha, any chance we can get higher?” he said over the radio.
“Four five two delta alpha, unable higher,” said the controller. “I would have to spin you back around and sequence you with the rest of the traffic going into Teterboro.” In fact, she had made space so that N452DA could slip right into the queue for Teterboro at its current altitude, and they would lose their position if they climbed higher.
“Ha! It’s like she doesn’t like us,” Alino exclaimed.
A minute later, Ramsey said, mockingly, “Yeah now don’t fucking put us at fucking four thousand all the fucking way. What the fuck!?”
“And zigzagging,” said Alino, referring to the multiple turns they had been ordered to make.
“Yeah, she’s gonna fucking carry it, we — we won’t fucking make it if we got four thousand,” said Ramsey. “She’s a fucking idiot. Get us someone else if she can’t do it! I fucking filed for, shit… what is it? For twenty-seven, man.” He still did not appear to understand that they were already being sequenced for approach to Teterboro and that a cruising altitude of 27,000 feet had always been a ridiculous prospect.
Moments later, they switched frequencies to contact New York Approach, which called them at 15:14. “Lear four five two delta alpha, New York Approach, Newark altimeter two niner seven five, fly heading zero two zero, vector ILS six, circle one,” the controller said.
The controller’s statement indicated that they were being lined up for an instrument landing system approach to runway 6 at Teterboro, followed by a circle to land on runway 1. This type of approach, known as a circling approach, is becoming increasingly uncommon in airline operations but is still frequently used in the world of on-demand and general aviation. The basic idea is that if the wind favors a runway that doesn’t have any landing aids, or a runway that is impractical to approach directly due to terrain or traffic, inbound aircraft can use the landing aids for a different runway, then break off, maneuver (“circle”) to the desired runway, and land visually. At Teterboro, runway 6, which points northeast, was equipped with a full instrument landing system (ILS) featuring a localizer, which helps planes align with the runway, and a glideslope, which helps them maintain the proper vertical profile. However, the wind was blowing out of the north at 16 knots with gusts to 32 knots, creating heavy crosswinds on runway 6 and instead favoring runway 1, which pointed north, into the wind. However, a straight-in approach to runway 1 was impractical because it conflicted with the approach corridors into the nearby Newark and LaGuardia International Airports, so it was standard procedure at Teterboro to clear planes for an ILS approach to runway 6, followed by a circle to land on runway 1, when that runway was favored.
If the pilots had reviewed the weather before departing, they could have anticipated that they would be asked to fly this approach, but they had not, and after asking for the controller to repeat the altimeter setting, Ramsey expressed confusion: “What the fuck are they doing man?” he asked. “Circling six!?” A minute later, he said, “He was saying circling fucking six or something. I don’t know what the fuck they thinking we’re doing. We’re fucking hundreds of miles away man.”
Evidently, Ramsey did not know where he was, because at that moment they were 48 nautical miles from Teterboro. In fact, the entire distance from Philadelphia to Teterboro was less than 100 miles, so it was unclear why he thought they were “hundreds of miles away,” unless he simply had no concept of where his destination was located.
Incredibly, Alino was equally clueless. “Dude, we’re gonna get there like fucking an hour, and you’re gonna look at me and you’re gonna say why is the time like this?”
Needless to say, they were not going to be there in an hour. It wouldn’t take an hour to get there in a car at this point, let alone in a jet traveling at 250 knots. Moments later, having apparently done the math, Ramsey seemed to realize this, as he suddenly said, “Be there in twenty fucking minutes.”
Shortly after that, the controller cleared them to descend and maintain 3,000 feet, which prompted Ramsey to exclaim, “We’re fucking gonna be there in ten minutes. I gotta get the fucking ATIS. Shit. I didn’t realize we’re that fucking close. Of course I don’t have fucking GPS, that’s why.”
As Ramsey tuned in to the Teterboro Automated Terminal Information Service broadcast, or ATIS, in order to learn about the weather at their destination, New York approach called with an instruction: “Learjet two delta alpha, turn right heading one two zero.”
This southeasterly heading would put them on course to intercept the localizer to align with runway 6, but the pilots appeared not to understand. “What the fuck!?” Ramsey exclaimed. “One two zero!?
“Yes sir,” said Alino. “Turn right to one two zero sir.”
“Holy shit,” Ramsey muttered, clearly displeased that he was being directed southeast on a generally northeast-bound flight, although if he had been paying attention to his position he should have seen this coming.
In the background, the ATIS could be heard: “…advise on initial contact you have information zulu…”
Before the broadcast could finish, Ramsey turned it off. “Zulu,” he said. “Information zulu. Who the hell knows what’s going on in Teterboro. Don’t have time to listen to it.” Had he continued listening, as he should have done, he would have learned about the strong, gusty winds, but he did not. Instead, he turned his attention to locating visual landmarks. “I guess we’re fucked — do you see New York out there anywhere?” he asked.
“Negative, we’re so fucking far from it. Like — ” said Alino.
“Yeah.”
“We’re in the boonies,” Alino concluded.
“Well, it’s less than fifty miles man. That’s why. Two five zero on the speed sir,” said Ramsey. “That’s why. We’re less than fifty miles away. Fuck. No wonder they’re s — got us so fucking low. But they got us at fucking three thousand. Really?” he exclaimed. “What the fuck over? And we’re going fucking south, we’re not going fucking north. I don’t know what. Well it must be a flow issue.”
Concluding his rant, Ramsey finally said, “Let’s do the checklist,” although he didn’t specify which one. He spent the next minute calculating their approach and landing speeds, before concluding that the landing reference speed was 119 knots, and their approach speed would be 126 knots. According to company and manufacturer procedures, the approach speed in gusty wind conditions should be the reference speed (Vref) plus twenty knots until all maneuvers are complete, due to the risk of losing airspeed during sudden wind gusts while turning. However, Ramsey was apparently still unaware of the wind conditions at Teterboro, and he did not add 20 knots to their approach speed to compensate. Nor did he conduct an approach briefing to discuss how the approach would be flown, and the descent checklist was not heard on the cockpit voice recording either.
Now, at 15:19, the controller cleared them to fly due east to intercept the localizer for runway 6. “Fucking runway 6 ILS,” Ramsey said. “Set this up on your side. One oh one point nine.” This was the frequency for the instrument landing system at Teterboro, which could be programmed into their navigation equipment in order to track the localizer and glideslope. However, if they had looked at their charts, they would have noticed that the approach required them to descend to 1,500 feet by waypoint DANDY in order to intercept the glide slope, and since DANDY was defined only by its distance from the VOR (Very high frequency Omnidirectional Range) radio beacon at Teterboro, they would need to tune one of the navigation receivers to the frequency for the VOR, while the other tracked the ILS. But this was not done.
Instead, N452DA kept flying east, passing straight through the runway 6 localizer, at which point Alino said, “Runway in sight.”
“For six?” Ramsey asked.
“Learjet two delta alpha, make sure you intercept the localizer,” the controller said, noting that they had overshot.
“Right there,” Alino said, presumably pointing toward what he thought was the airport.
“What the fuck, over?” Ramsey said. “Zero six zero, why aren’t you not — intercepting it. I guess it’s fucking left. We’re making the left.”
“Learjet two delta alpha, left turn twenty heading if you need it to join,” the controller said, trying to help them out.
Finally, Ramsey seemed to realize what was going on: Alino was looking for the airport in completely the wrong place. “Fuck, that’s why,” he said. “There we go. Fucking runway’s out there somewhere. I don’t know why you’re looking over there.”
“Yeah that was Newark,” said Alino. “That was Newark. I thought that was Teterboro.” Incredibly, he had mistaken Newark International Airport for Teterboro and was flying toward the wrong airfield. Now, with that embarrassing error cleared up, they finally turned left to intercept the localizer and align with runway 6.
Now flying in the correct direction, Ramsey continued to coach Alino on power settings and airspeeds, while the controller instructed them to fly to waypoint VINGS, which lay on the localizer course for runway 6. Ramsey typed in VINGS to bring it up in his flight management system (FMS) so that the autopilot could fly them there, although if they had properly briefed the approach, he probably would have had it set up already, since VINGS was the initial approach fix, where the published approach procedure begins.
“On the FMS we’re there, we’re going direct VINGS at this time. Twelve miles away to VINGS,” said Ramsey. “You still got the localizer on your side so we’re doing good.”
“Alright,” said Alino. “I don’t want to fuck up.”
The controller now instructed them to maintain 240 knots until crossing VINGS, then decelerate to 180 knots. Ramsey again coached Alino on maintaining airspeed, instructing him to reduce power to idle as they passed VINGS. This reduction in power caused the plane to descend, which was not a problem because the approach procedure called for a descent from 2,000 feet to 1,500 feet between VINGS and the next waypoint, DANDY. But Ramsey appeared not to realize this, so he said, “No, no, no no, don’t fucking do that yet, we haven’t captured the glideslope.” One look at his chart would have told him that they needed to descend to 1,500 feet to intercept the glideslope at DANDY, but he remained unaware of this, and N452DA remained at 2,000 feet.
At this point, New York approach called them for what should have been the last time. “Learjet two delta alpha, contact Teterboro tower one one niner point five,” the controller said. “Be sure you cross DANDY at [unintelligible] hundred feet, circle at TORBY.”
TORBY was the last waypoint on the approach to runway 6, and was where flights normally broke off the approach, leaving the localizer and glideslope to maneuver (or “circle”) to land on runway 1.
“Alright, DANDY at two hundred feet,” Ramsey read back, citing a nonsensical altitude. “Circle at TORBY, nineteen five. Four five two delta alpha.”
“Uh, DANDY at fifteen hundred feet, two delta alpha,” said the controller.
Ramsey corrected his mistake, and they carried on. But they did not descend to 1,500 feet, and in fact Ramsey appeared to have it in his head that they would descend to 1,500 after crossing DANDY, and not before, even though the approach chart literally included the words “Mandatory 1,500 at DANDY.” First Officer Alino asked if he should descend, and Ramsey told him, “not yet.”
Moments later, N452DA reached DANDY, still at 2,000 feet, and passed through the glideslope from below. The autopilot failed to capture the glideslope and the plane did not descend, probably because Ramsey had forgotten to arm the system’s “glideslope capture” mode.
“It did not capture, trim the nose over,” Ramsey said, instructing Alino to pitch down to chase after the glideslope, which was now below them. “Follow your glideslope, do not go below fifteen,” he added. He did not seem to be aware that the approach chart permitted a descent to 1,300 feet between DANDY and TORBY.
As the approach continued, the pilots’ lack of understanding of the situation only deepened. “Follow the fucking glide slope,” Ramsey exclaimed.
“Alright, you said don’t go below one — ” Alino started to say.
“Yeah, don’t go below fifteen till I call TORBY,” Ramsey repeated.
Alino leveled off, maintaining 1,550 feet. He was clearly rather confused, having been told not to descend below 1,500 feet until TORBY, while also being told to chase the glideslope, while the height of the glideslope at TORBY was 1,300 feet. He couldn’t follow both commands simultaneously! And to make matters worse, they had actually passed TORBY already, but Ramsey seemed to think it was still ahead of them.
Additionally, neither pilot realized that they had not complied with the controller’s request to call the tower. “Delta alpha, contact Teterboro tower nineteen five,” New York Approach repeated. Ramsey acknowledged and punched in the Teterboro tower frequency, while telling Alino to “bring it on down” to the minimum altitude for the circling approach, which was 760 feet. In fact there was no need to adhere to this altitude: having passed TORBY and with the runway in sight, they were free to navigate visually to runway 1 however they liked. Furthermore, they had already overshot the point at which the controller specifically told them to initiate the maneuver, and they were still proceeding toward runway 6, but neither pilot seemed to be aware that they were digging a hole for themselves.
As N452DA drew nearer and nearer to the runway, the Teterboro tower controller asked where they would be parking, and Ramsey replied, “Yeah, we’re gonna be at Jet Aviation, four five two delta alpha. Cleared to land one.”
Turning to Alino, Ramsey said, “’Kay, we’re gonna circle for runway one. So go ahead. Break off the autopilot.”
Alino switched off the autopilot and took full manual control of the plane. “There ya go,” he said.
“Hand on the fucking — ” Ramsey started to say, before the controller interrupted him.
Noticing that the Learjet had not begun the circling maneuver, the controller said, “Delta alpha, you gonna start that turn?”
“Yeah sir, we’re doing it right now, four sixty [sic] delta alpha,” Ramsey replied.
By this point they were practically abeam the threshold of runway 1, and maneuvering to land on it would require two impossibly steep turns in quick succession. No pilot should ever have attempted to circle to land from such a position — the very idea verges on insanity. But having been told to turn right, Alino did so, keeping one eye on his target as he attempted the nigh-impossible maneuver. The tower controller watched in disbelief as the Learjet turned so steeply that he could see the bottom of the plane pointed directly at him. Unable to maintain altitude during the turn, the plane rapidly descended from 650 to 350 feet.
Overwhelmed by the situation, First Officer Alino shouted, “Your flight controls,” but Captain Ramsey did not respond.
“SINK RATE, PULL UP!” blared the Enhanced Ground Proximity Warning System (EGPWS).
“Meeeeh!” Alino exclaimed. “I’m gonna give ya your controls okay?”
This time, Ramsey acknowledged. “Alright, my controls,” he said.
“Your flight controls,” Alino repeated.
“Fucking eh,” said Ramsey, sounding angry. This was not the time to effect a control handover, right in the middle of a complex maneuver — but Alino never should have been asked to perform that maneuver in the first place.
“Watch my airspeed,” Ramsey said, and then he turned the plane sharply back in the opposite direction in a desperate attempt to align with the runway.
“Looking good,” Alino said. But as the bank steepened, the wings began to lose lift, and their airspeed started dropping as the plane struggled to stay in the air. “Vref,” Alino now called out, warning that their speed was dropping below the landing reference speed.
“No,” said Ramsey. It is unclear what he was referring to.
In a matter of seconds, their speed fell rapidly, from the approach speed of 126 knots, through Vref at 119 knots, down to just 111 knots, which was dangerously slow. Alino had no trouble recognizing the danger, and with agitation evident in his voice, he shouted, “Add airspeed! Airspeed, airspeed, airspeed!”
At that moment, Ramsey finally realized that he had screwed up, as the rapid loss of airspeed in the steep turn quickly led to a stall. I discussed the mechanics of stalls during a turn in my recent article on Braniff flight 352, but it suffices to say that as bank angle increases, the risk of stall increases, because the tilted wings are not effectively directing lift upward against the downward pull of the aircraft’s own weight. The steeper the bank, the more lift is required; and to produce more lift, the angle of attack, or the angle of the wings into the oncoming airstream, must increase. When the angle of attack reaches the critical point, a stall will occur, regardless of airspeed, although decreasing airspeed will result in a more rapid increase in angle of attack, causing the stall to happen faster. Because it was both banking and losing speed, N452DA quickly reached its stall angle of attack, the right wing stalled first, and the plane rolled rapidly to the right, opposite Ramsey’s commands.
“Stall!” Ramsey shouted, but it was too late to recover.
“Yup,” said Alino. “Airspeed, airspeed!” he again shouted, as the cockpit filled with the sound of rushing wind. Turning nearly inverted, the plane plunged to the ground as Ramsey shouted expletives.
“SINK RATE! PULL UP!” the EGPWS blared.
“Aaaaahhh shit!” Ramsey screamed, broadcasting his last words over the Teterboro tower frequency.
A split second later, still banked more than 90 degrees to the right, N452DA clipped the corner of an office building and plunged nose-first into a parking lot, immediately triggering an enormous explosion. Fire billowed over Teterboro as the wreckage plowed through numerous cars before screeching to a halt in an alley, consumed in flames. For the pilots, there was no hope: both died instantly on impact.
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The fiery crash in Teterboro caused extensive damage to buildings and vehicles and received substantial media coverage as a result, although miraculously no one on the ground was hurt, in part because many office workers had left the area at the end of their shift minutes earlier. Considering the damage, the size of the plane involved, and the services provided by the company, the National Transportation Safety Board decided to organize a full investigation, dispatching several investigators to the scene.
As for the immediate cause, pilots and controllers who witnessed the crash were largely in agreement that this was a classic case of a circling approach stall. Will Ramsey and Jeffrey Alino were hardly the first pilots to attempt a circle-to-land maneuver from too close to the runway, banking too steeply and stalling the airplane — in fact, such accidents happen relatively frequently in general aviation and small charter operations. For example, in 2021, another business jet crashed at Tahoe Truckee Airport in California, killing all 6 people on board, after stalling during maneuvers for a circling approach. In these types of accidents, pilots become fixated on the runway and attempt to maneuver toward it without ensuring that they have sufficient airspeed to accomplish a steep turn without stalling. These crashes are simple and preventable, but they continue to happen for a variety of reasons, including insufficient training, hubris, and lack of knowledge of previous accidents.
In order to understand why the crew of N452DA attempted such an ill-advised maneuver, the NTSB listened to the Learjet’s cockpit voice recorder, and got far more than they bargained for. First of all, it was obvious that First Officer Alino was flying the plane, even though as a “level 0” second-in-command he was not permitted to do so. He struggled with basic tasks such as maintaining airspeed and altitude, violating the 250-knot speed limit multiple times, and Captain Ramsey was forced to provide nearly constant coaching, to the detriment of his other duties, such as completing checklists and preparing for the approach. At several points he appeared uncomfortable with what was being asked of him, but he lacked the assertiveness to clearly express his discomfort, and at no point did he question any of Ramsey’s dubious ideas. Furthermore, after takeoff the pilots did not complete any checklists; they did not conduct an approach briefing; and they did not finish listening to the ATIS broadcast to obtain the latest weather information.
The cockpit atmosphere that Ramsey cultivated was beyond casual: throughout the flight, both pilots — but especially Ramsey — cursed profusely, demonstrated a careless attitude toward flight operations, and professed contempt for the pilots and controllers around them. At the same time, the pilots seemed to have almost no understanding of where they were or what they were doing, as evidenced by Ramsey’s statements about their distance from Teterboro, his ill-advised requests to climb to a higher altitude, and both pilots’ confusion about the approach they were being asked to fly. Ramsey did not appear to understand that he was being vectored properly for the ILS approach to runway 6; Alino mistook Newark for Teterboro and overshot the localizer; and Ramsey misread his charts and caused them to fly too high on approach. The navigation equipment was not properly configured to display key waypoints or capture the glideslope, and while attempting to coach Alino through the descent, Ramsey ignored the air traffic controller’s instructions to contact the tower and circle at TORBY. In fact, he did not even mention circling until after he had coaxed Alino down to the circling minimum of 760 feet, which was not applicable with the runway in sight, and which did not occur until well after passing TORBY due to Ramsey’s previous mistakes regarding their altitude. The pilots then recklessly attempted to circle to land on runway 1 while only one mile from the threshold of runway 6, necessitating a series of steep turns during which they failed to maintain sufficient airspeed.
On top of this litany of errors, the NTSB noted that poor planning played a major role in the sequence of events. The first sign of trouble was the planned en-route altitude, which was unreasonable for the route in question, indicating minimal forethought. Although the flight promised to be uncomfortably short, the pilots also did not brief the route or the expected approach before takeoff, nor did this occur in flight; consequently, they were confused and unsure what to do when ordered to fly an ILS approach to runway 6 followed by a circle to runway 1. Ramsey seemed to be figuring out the approach as he went along, unable to anticipate each subsequent step, which led to errors.
Furthermore, the pilots did not acquire the latest weather information for Teterboro before the flight, which was required, nor did they ask for updated weather during the flight. They were not aware of the fact that the wind was gusting heavily at Teterboro until they began to experience turbulence on arrival, and they did not follow company procedures for flight in gusty conditions by adding 20 knots to their Vref speed while maneuvering to the runway. The significance of this omission shouldn’t be understated. The NTSB in fact determined that the airplane stalled at 111 knots, which was 9 knots higher than the nominal stall speed at that bank angle and configuration, probably because they were struck by a gust of wind that momentarily reduced their relative airspeed and increased their angle of attack. Had the pilots been flying the maneuver at the company’s recommended speed of Vref + 20 knots, the stall may not have occurred.
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In summary, the pilots did just about everything wrong throughout the flight, from the moment of takeoff to the final, deadly spiral into the ground. But why was their behavior so egregious? Who were these two men? And how did they end up together in the cockpit of a Learjet?
When Will Ramsey and Jeffrey Alino joined Trans-Pacific Air Charter in the fall of 2016, the aviation industry was facing a significant pilot shortage, much as it does today. In fact, Trans-Pacific president Ryan Frost complained that it was “absolutely impossible” to find qualified Learjet pilots, and that the lack of personnel was the company’s biggest barrier to growth prior to the accident. Evidently, the company was willing to hire just about anyone who had ever set foot in a Learjet.
It was under these circumstances that Frost received a recommendation to hire Will Ramsey, who was unemployed and hadn’t flown a Learjet since 2009. According to those who knew him, Ramsey was a bit of an odd personality. At his previous employers, he was the subject of bizarre rumors; it was said that he did not have any bank accounts and refused to speak to hotel check-in clerks. Other coworkers said he expressed paranoid beliefs and was skeptical of seatbelts. Of course, being weird isn’t a crime, but he had committed actual crimes as well: in 2002, his driver’s license was suspended, and he had a 1986 conviction for misdemeanor assault with a deadly weapon, which he did not disclose to the FAA. More pertinently, he was also something of a below average pilot: during the 1990s, he was disapproved for his flight instructor certificate, his pilot multi-engine land rating, and his instrument airplane rating due to insufficient skill; in all cases he was able to pass his checks and receive the rating on the second attempt. Pilots who flew with him at his previous employer, D&D Aviation in Salt Lake City, said he was not proactive with checklists, only did things when asked, was often unprepared, and seemed disinterested in flying the airplane. One pilot judged him to be “ineffective in his role” and stated that he was “not ready to be pilot in command.” Later, when Trans-Pacific sent him to Learjet training, his simulator instructor had to administer extra training sessions before he could recommend him for a check ride, specifically because he had difficulty with circling approaches.
In general, these former colleagues agreed that Will Ramsey needed to be paired with a competent first officer. Unfortunately, Jeffrey Alino was anything but. In contrast to Ramsey, his personality was cheerful and outgoing and he was liked by his coworkers, but his piloting skills were frankly terrible. (He also had a criminal record of his own, including convictions for street racing and third degree assault on a police officer, which he did disclose.) In 2009, his attempt to acquire a private pilot’s license was disapproved twice within three days; he only passed on the third attempt two weeks later. Colleagues at his previous employer, the Medflight air ambulance company in New Mexico, stated that he wanted to learn, but consistently failed to do so; one said he would teach Alino some principle, and it would seem like he understood, but then he would immediately make the same mistake again. He didn’t try to blame others and was aware of his own lack of proficiency, but he struggled with basic aspects of flying the airplane. One Medflight pilot put it bluntly: Alino’s problem was that he was just not very smart.
By early 2016, several Medflight captains had become sufficiently concerned about Alino’s lack of piloting skill that they planned to start documenting his difficulties in writing. However, before the plot could get underway, Alino left to work for Trans-Pacific Air Charter. His new employer sent him to Learjet simulator training in Texas, at which time he had about 100 hours in the Learjet. That isn’t a lot of time, but his instructor was nevertheless bewildered to discover that he did not know how to start the engines or conduct a pre-flight check. On his very first simulated flight, he crashed on takeoff due to over-rotation, and once in the air he struggled with basic procedures and didn’t know what to do during routine checks. He was unable to control the airplane’s speed or altitude during stall scenarios, flew upside down during the high bank angle recovery module, and crashed on landing during a simulated ILS approach to JFK. He had to undergo multiple days of extra training before he could pass his check ride, in part because he struggled to master — you guessed it — circling approaches. And once he was flying on the line, other Trans-Pacific Learjet pilots said he was “prone to errors” and was “not ready for a higher second-in-command level.”
Taken together, it could be said that Will Ramsey had an attitude problem compounded by a moderate skill problem, while Jeffrey Alino had a serious skill problem that negatively complemented his captain’s shortcomings, allowing Ramsey to go completely off the rails. Inexperience was part of the issue: Alino rarely flew at Medflight and had virtually no time behind the yoke, and the way Trans-Pacific was structured only compounded the problem, as his “level 0” rating prevented him from acquiring much-needed hands-on experience, and the lack of qualified management pilots precluded the possibility of advancement. This system incentivized captains to break company rules and let level 0 first officers fly the airplane, and interviews with other Trans-Pacific pilots revealed that this was commonly done on repositioning legs without passengers. Nevertheless, given the depths of Alino’s aptitude problem, he certainly was not ready to fly the approach to Teterboro that day, nor was he ready to check Ramsey’s worst tendencies. In fact, it’s unclear whether more training and experience would ever have brought him to an acceptable level.
Despite these issues, Trans-Pacific had no real mechanism for detecting and dealing with these skill deficiencies, nor did it have any way to avoid pairing two struggling pilots. The company’s safety system amounted to “tell Ryan if you see something wrong,” but Ryan Frost himself seemed only vaguely aware of the depths of Alino’s difficulties. There was also no way to detect whether pilots were adhering to standard operating procedures, because the Learjet didn’t have room for a jump seat observer, and the company didn’t have a flight data monitoring system. Nor did the Federal Aviation Administration exercise any operational oversight, because there was no mechanism to allow inspectors to ride along on revenue charter flights.
This lack of accountability at multiple levels allowed the accident pilots’ personality and skill deficiencies to metastasize undetected, like mold in the bottom of a coffee cup, growing in unexpected and colorful directions. But this situation was not unique to that particular crew, or even to that particular company. There are numerous small charter companies out there like Trans-Pacific with almost no administrative staff, limited oversight, and the willingness to hire anyone with a pulse. Wealthy individuals book flights with these companies in part because chartering a jet is seen as more glamorous than packing onto a 737 like the rest of us, but what they get for their money is not a higher standard of safety, but a much lower one, an artifact of these carriers’ low position in the aviation industry’s broader pecking order.
That these companies will always be left with lower quality pilots on average is an unfortunate reality: after all, most pilots want to progress to the airlines, which are usually perceived to have better salaries, better schedules, and greater prestige. However, the NTSB felt that this doesn’t have to result in an unacceptably low level of safety. As a result of the accident in Teterboro, the agency issued several recommendations aimed at improving pilot quality at Part 135 charter operators, including that the FAA require these companies to establish performance programs for under-performing pilots; provide better guidance to help these companies train their pilots on leadership and crew resource management; and require flight data monitoring programs to ensure compliance with standard procedures. These measures, if taken, could help mitigate the risks associated with the realities of small charter operations, and in the years since the crash the majority of these recommendations have been implemented.
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Today, the crash of Learjet N452DA remains infamous in pilot circles as a shining example of how not to fly an airplane. That is an unfortunate reality that the pilots’ families now have to live with because of the choices they made. Their fate is a brutal reminder that professionalism matters, that procedures matter, and that common sense matters. The crash might have been avoided if they had conducted an approach briefing, or if they had checked the weather, or if someone had said, “we can’t make the runway from here, let’s go around.” But the company and the pilots themselves had created an environment in which the slow normalization of deviance, the gradual acceptance of successive imperfections, progressed unchecked until the atmosphere in the cockpit had degraded so totally that these elements of basic airmanship went out the window. The end result was anarchy in the air. It shouldn’t have to be said that pilots should take their jobs more seriously than that — but apparently there are some people out there who need to hear it.
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