The crocodile. That prehistoric beast that’s all snapping jaws and sharp teeth (and false tears).

This modern day dinosaur has a cool talent – it can lurk under the water, still as a log, barely breathing, heart rate slowed to a mere sporadic tick… but when needed, it can suddenly leap into action, reacting without a pause.

What has this got to do with flying?

Well, one of the toughest challenges we face as pilots is making that transition from the slow, steady (sleepy) cruise phase into the dynamic, risk-riddled arrival and approach phases.

As a long haul pilot, I witness this in myself a lot. We cruise for many an hour, during which it is very easy to relax into the seat, vaguely monitor stuff, occasionally check a few things until we reach our destination and then…

WHAM!!!!!!

It’s all systems GO! We have to wrench our brain into thinking, assessing, adapting, monitoring. We have to wake up, be vigilant and act fast. This is much like the crocodile – nothing happens for a long time and then suddenly we must spring into action.

The only problem is… we are not crocodiles. We don’t have the ability to go from 0 to 1000 that rapidly. We don’t have sensors that switch our brains on immediately when the smallest thing triggers it. We just aren’t designed to function that way.

On top of that, the challenges at the airport and on our arrivals and approaches are rarely big triggers. They are more often than not smaller, insidious things which require consideration, discussion and mitigation. This all means that if we are not already operating to a decent level of alertness and vigilance, then we are probably going to miss stuff.

Less prehistoric, scaly murder machine, and more gloopy, slow-paced garden slug.

When too much gets missed…

The outcome of not giving the preparation and threat management all the attention it requires is a potential incident accident. This is something starkly, and tragically, proven in the Astra BizJet N1125A crash (CFIT) which occurred in March 2024 at KHSP/Hot Springs, Virgina.

The NTSB Final Report starts out with what I think is a key line – ‘After an uneventful flight’.

After an uneventful flight, what do our vigilance levels look like? Probably much lower than they should be, and again, we aren’t built to simply spring into action at the first sign of danger (or a meal).

We need to raise our levels beforehand. So how do we do this?

Well, by doing things like TEM briefings. Discussing the threats, planning the mitigations, and bringing ourselves into that vigilant state, together as a crew.

Reading the report on N1125A the CVR data did not indicate any briefing was conducted by this crew meaning they did not mentally prepare themselves for the challenges, or ensure they were both aware and vigilant.

And KHSP airport is a rather challenging from the looks of it. It sits up on a ridge amidst fairly lumpy terrain, with an elevation of just under 3800’. The weather conditions at the time were also difficult – snow storms in the area, gusty winds and up and down drafts resulting from these.

The lack of preparation and proper briefings, combined with other environmental challenges, are part of what led to the accident because the small, not-in-themselves all that triggering errors quickly built up.

What happened?

The crew were cleared for ILS runway 25, and ATC cleared them to route direct to the IF, to pass it at or above 6100’. Around 2 minutes later however, the controller queried the aircraft’s altitude, saying he showed them at 5900’ msl. The crew disregarded this stating they were at the cleared altitude of 6100’. They were in fact 200’ low.

As they approached the inbound localiser course, the aircraft captured F-LOC. However, this was a system generated course, not the actual ILS signal which they had not tuned. They were also descending in vertical speed, maintaining a constant descent rate as opposed to being on the ILS generated glideslope. When they became visual with the runway, they still remained in VS.

With about 1.5nm to go to the runway, the PM (referred to as SIC throughout the report) reported full deflection below glideslope, and moments later announced speed was 15 knots above reference speed.

The approach was not stable.

The PF however did not make any corrections and instead disconnected the autopilot and continued. Around 1000’ the PM suggested they go-around, but the captain did not acknowledge this. At 500’, the first officer again called for a go-around and was ignored a second time.

300’ prior to the runway, the aircraft impacted rising terrain.

How did this happen?

As always, we want to ask ‘how’ in order to understand and learn, not to judge.

So, some of the contributing factors in this are clear – the crew did not tune the ILS. They were not receiving ILS generated signals at all, only FMC generated advisory guidance, and without the ILS tuned, the EGPWS did not provide the ‘Glideslope’ aural alerts to warn them they were significantly below the glide. Many of the barriers had been removed.

The crew also likely had not set the local QNH. With 1013hPa set as opposed to 1004hPa QNH, this accounts for their being around 200’ below the cleared altitude.

The weather conditions potentially affected the pilots’ view of the runway, partially obscuring it or making the visual judgement of their position on the glide more difficult., leading to the failure to recognise the low profile or the terrain.

Here’s what the NTSB report says:

But how is this useful? What can anyone takeaway from this? Don’t make poor decisions and have bad judgement?

Finding the takeaways

Many of the contributing factors in this could have been caught or avoided. They were, on their own, fairly minor. I think they are also things we ALL see from time to time in our own operations. They are often small, corrected immediately and do not lead to an outcome like this.

However, if we read through these and think “Yeah, I’ve experienced that before” on even the smallest point, then this can enable us to be aware and prevent it which is why it is worth talking about.

Because this accident did not happen due one BIG factor. It happened because of a chain of many, and the earliest weaknesses in that chain were the failure to prepare and brief.

Good SOPS

Good SOPs would have fixed many of the things that developed throughout this – cross checking heights on the approach, confirming correct QNH, sticking to stabilised approach criteria, checking the ILS is tuned and identified.

Again, these are all relatively minor things. We’ve all missed one or two in our day. But when they are combined with other factors, this is when the chain builds. The mistuned ILS led to the lack of aural alerts which combined with the fact the aircraft was low…

So vigilance with regards our procedures is a key barrier to outcomes like this. We shouldn’t be thinking of SOPs as annoying things to keep us in line, but rather as critical things to help keep us out of trouble!

Using our SOPs prior to TOD is one of the simplest ways to bring ourselves out of our ‘cruise complacency’ and to ensure we don’t miss critical items for the approach and landing.

Proper Briefings

TEM briefings are another. We’ve all heard the overly long briefings where the PF jabbers on and on and we completely lose all capacity to listen, let alone use the information being droned at us. But this is NOT a proper briefing.

A briefing should be threat forward – what are the issues we will face today, and what can we do about them?

Interactive – so you are both on the same page, and you capture things the other might miss.

Scalable – so based on the experience and knowledge of you and your co-pilot on that day, in those conditions. I think of this as covering the ‘me threats’.

Cognitive – recap on the pertinent points so they are solidly in your mind, and so the mitigations to them are clear for everyone.

Instead of relying on our brain to act like the crocodile and spring into action, we are providing our brains with the means to both identify when things are not going how they should, and to be adaptable and resilient to these.

Intervention

Intervention comes in two forms. It comes from the PF with regards the aircraft – if it isn’t doing what you want it to, fix it! And from the PM to the PF – if what they’re doing doesn’t look right, fix it!

Of course, there are various levels. When it comes to the PM-PF intervention, ‘asking’ and ‘suggesting’ are our first two. The appropriateness of a level of intervention is dependent on the criticality of the error, and the time available to fix it.

So the ‘suggestion’ to go-around at 1000’ may have been appropriate, but a suggestion at 500’ when the PF had failed to respond or make any correction earlier was not. A direct ‘go-around’ or a forceful takeover – ‘I have controls, go-around’ – were needed.

The report does not provide much information on the pilots, however, for me the constant reference to PIC and SIC make it clear gradients remain in aviation which should not. In flight, in a critical situation, it is PF and PM and both are equally responsible for ensuring safety.

The human factor

In this case, we can possibly make the assumption that the PF was over his capacity, his judgement was therefore reduced, and with it his ability to make sound decisions. In a multi-crew environment, sometimes it is up to the pilot monitoring to monitor the other pilot too. And yes, this can be tough when the other pilot is far more experienced, far older and in this case the ‘Chief’.

I might have over-used the crocodile analogies at this point, but I think it still works – we have to manage intervention appropriately. A captain once told me his method for handling workload and prioritising threats – ask yourself what is the closest crocodile to the canoe. Because if you don’t deal with what is right in front of you, it will bite you. Taking over might destroy CRM but you can build that up again. The alternative is far less easy to rebuild.

Think ‘crocodile’ thoughts

Rather than expecting to react like a crocodile, we should be considering the threats as if they are one – something that is lurking beneath the surface, hidden, waiting to bite us.

We cannot rely on ‘being woken up’ out of our long cruise induced lower alertness levels by some big trigger. Instead, we need to raise our alertness by identifying threats, planning and prepare for them. In doing so, we build up our awareness and our ability to handle them.

The best way to do this is through maintaining SOPs which are designed to support us, carrying out proper TEM processes, and by briefing one another so that we are all on the same page.

The accident of N1125A is a stark reminder of how missing many small things can easily, and tragically, escalate into something serious if we don’t!