The Unstabilized Approaches and the Chief Pilot's “Example”
You are the newly appointed SMS manager for a Part 135 operator with 11 aircraft and 42 pilots. Over the last 90 days three crews reported unstable approaches into the same mountain airport (6,700 ft runway, 4.2° visual glidepath, displaced threshold due to a 400-ft NOTAM): one landed 2,400 ft down the runway at 148 KIAS, one went around at 260 ft AGL, and one landed with a 22-knot tailwind that tower reported after the fact. The captain in the first event has 11 years of service, filed an ASAP report within 24 hours, and states that the company's descent-planning SOP assumes a 3° path and a non-displaced threshold. There is no FOQA or flight data monitoring program. The chief pilot wants to remove that captain from the schedule for two weeks “to make an example.” The director of operations wants the ASAP report excluded from any corrective action. The company has an SMS accepted by the FAA but no written just-culture policy and no risk matrix in active use.
1. Should the captain in the first event be removed from the schedule? Walk through the decision using just-culture criteria.
Read the worked answer
Work the just-culture decision tree rather than the outcome.
- Was the conduct intentional or a knowing violation? No evidence. The crew flew what the SOP told them to fly.
- Was it at-risk behavior (risk not recognized or normalized)? Possibly on the tailwind event, but the first event is best characterized as an inadvertent error produced by a SOP/airport mismatch.
- Does it fall in the ASAP exclusion list (substance, criminal act, intentional disregard, gross negligence)? No, and the report was filed within the program window, before the company or FAA learned of it another way.
Therefore: protect the report, and respond with corrective action, not discipline - an airport-specific training module, a review of descent planning with that crew, and a documented debrief. Removing an 11-year captain for two weeks to “make an example” would signal that reporting is dangerous; your only data source in a non-FOQA operation would dry up within weeks, and the next three unstable approaches would go unreported.
Separate the three events and evaluate each on its own facts - the tailwind landing may warrant a closer look at the crew's wind-monitoring and go-around decision. Record the rationale in writing, tell the chief pilot no, and explain why, privately. If any event later shows deliberate disregard, the program's exclusions let you act.
2. Build the risk assessment and the control set for this airport. What is the hazard, and what are you actually going to change?
Read the worked answer
Hazard: a mismatch between company descent planning (3° assumed, threshold not displaced) and the airport's actual geometry (4.2° path, displaced threshold, NOTAM), compounded by no feedback loop and commercial pressure to land.
Risk assess on a 5x5 matrix: severity catastrophic (runway excursion), likelihood high (three events at one airport in 90 days) → unacceptable; treat before further scheduled operations.
Controls, in order of strength:
- Eliminate/reduce: an airport-specific procedure page with the correct path angle, displaced-threshold distance and required touchdown zone; revised stabilized-approach criteria (stable by 1,000 ft in IMC / 500 ft VMC, on speed, on path, checklist complete) with an explicit go-around expectation; temporary restriction until the SOP is revised.
- Engineering: use published vertical guidance/VNAV where available, verify TAWS/RA alerting is serviceable, and confirm the approach is not flown on a 3° flight-path angle.
- Administrative: mandatory NOTAM and airport briefing item, special-airport qualification for that field, and pairing guidance for low-experience crews.
- Training: energy management and tailwind awareness at the threshold (ALAR-type module).
Assign owners and due dates, log it in the safety risk management record, and re-assess at 30/60/90 days. Also test the other two events for the same common factor before you declare the cause “pilot error.”
3. How will you know whether the controls worked without FOQA? Design the measurement.
Read the worked answer
Use four layers, because no single one is sufficient:
- Data you already own. Many jets record parameters to a quick-access recorder or can dump FMS/flight data; a low-cost FDM service, or third-party ADS-B/approach data, can give approach stability, go-around, and long-landing metrics without installing a full FOQA program. Scope it to the two or three airports that matter first.
- Reporting trends. ASAP submission rate, unstable-approach reports, and go-around counts. Warn the accountable executive now that a rise in reports in the first 60 days is a leading indicator of a healthy culture, not a degradation.
- Observation. Line checks and a short LOSA-style observation program focused on approach briefings, stabilized-approach callouts, and go-around decisions.
- Audit. Compare the revised SOP and airport page against what crews actually fly on the next ten arrivals.
Set targets (e.g., zero long landings at that airport; 100% of crews brief the displaced threshold; go-arounds supported in every debrief). Review at the safety review board at 90 days. If the long-landing rate is unchanged, the control failed - do not assume the training worked because nobody complained.