ART-2025 • Module 7 • Case Study: VT-PHO
Human Factors Breakdown — Guwahati • 24 Jul 2019

Case Snapshot VT-PHO Gear-Up Contact

  Event Background No injuries
  • Date / Time: 24 July 2019 ~1720 IST
  • Location: RWY 02, Guwahati (VEGT)
  • Helicopter: Dauphin AS365 N3, Regn. VT-PHO
  • Operator: Pawan Hans Ltd.
  • Flight Type: Training / recency check sortie (not passenger ops)
  • Crew: Two pilots (Examiner in left seat, Pilot Under Check in right seat)
  • Damage: Scrape marks on belly/tail area due to brief gear-up runway contact. No fire.
  • Weather: VMC, ~5 km vis, light winds – weather not a factor.

So: helicopter brushed the runway with landing gear retracted, then went around, lowered gear, and landed safely.

Why is this in ART-2025?
  • Because nothing “failed” mechanically. The system worked. Humans did not.
  • Because both pilots were experienced. This was not a rookie solo case.
  • Because it shows how checklist discipline, attention management, and CRM decide whether a normal training sortie becomes an accident report.
  • Because ATC also lives in high workload + repetition + “we’ve done this 1000 times before.” Same trap.

Sequence of Events Minute-by-minute

  Timeline Approach RWY 02
  1. ~1645 IST: VT-PHO departs Guwahati for a training / recency check. Examiner (left seat) is supervising; Pilot Under Check (right seat) is flying.
  2. Later in sortie: They return for circuits. Examiner tells the pilot he will simulate a single-engine scenario (left engine failure).
  3. Final approach RWY 02: The helicopter is now being flown as if one engine is failed. Workload = high. Attention is on power management and directional control.
  4. ~60 seconds before touchdown: Cockpit gives a “Landing Gear Not Extended” warning. This is a designed cue: basically “Check gear, it’s still UP.” → Nobody calls it out. → Nobody acts on it.
  5. Flare / touchdown: Helicopter makes runway contact on the belly / tail area (gear still UP). Scraping noise heard.
  6. Immediate recovery: Examiner takes control, cancels the simulated engine-failure condition, selects gear DOWN, and performs a go-around.
  7. Second landing: With gear extended and locked, helicopter lands uneventfully near TWY G and taxis to hangar.

Important: After gear was selected DOWN it worked perfectly. So it was not a technical malfunction. It was not weather. It was an attention + procedure miss.

  Error Chain — Visual Flow
1. Training sortie → Simulated engine failure on approach 2. PF attention locked on power / control, not on checks
3. “GEAR NOT DOWN” alert shows up 4. No call-out / challenge from PNF
5. Touches runway on belly (gear retracted) 6. Examiner recovers → gear down → safe full stop
7. Post-flight inspection finds scrape damage but no injury 8. DGCA opens investigation

Human Factors Triggers Why two experts still missed it

  HF / Contributing Elements COMPLETE
Skill Fade / Habit Transfer:
The pilot flying had not flown this Dauphin type in over a year. Recently he had been flying a single-engine helicopter with fixed skids (no retractable gear). His “muscle memory” did not include “gear down before landing.”
Checklist Omission:
The mandatory Pre-Landing Checklist (first item = “Landing Gear — DOWN / 3 green”) was not called. Neither pilot verbally confirmed gear locked.
High Workload / Distraction:
Simulating an engine failure in short final overloaded the PF and pulled attention away from basic configuration. When cognitive load spikes, humans tunnel: “Keep flying, don’t crash,” and forget routine items.
CRM Gap (Cross-Monitoring):
The examiner (PNF) did not challenge “Gear?” / “Three green?” / “Checklist?” The safety net (monitoring pilot) also tunnelled on the simulated failure.
Warning Ignored:
The cockpit generated “Landing Gear Not Extended” warning about a minute before contact. Nobody responded. This is classic inattentional blindness under saturation.
  Human Factors Flow
Skill fade + type change → pilot mental model = “helicopter lands without worrying about gear”
Engine-out simulation on final → workload spike → tunnel vision
Checklist skipped → no “GEAR DOWN / 3 GREEN” verbal cross-check
Warning light appears → not actioned because brain already “busy saving the approach”
RESULT: Belly contact on runway → luckily recoverable, but absolutely reportable

Investigation Findings Probable Cause

  DGCA Conclusion Human Error
  • No technical defect was found in the landing gear. It extended normally afterwards.
  • The environment was fine: daylight, VMC, serviceable runway, no abnormal ATC factor.
  • Direct cause: The helicopter touched the runway with landing gear retracted.
  • Why? The crew did not carry out the Pre-Landing Checklist and did not react to the “Landing Gear Not Extended” warning.

DGCA stated probable cause as:

“Non-adherence to pre-landing checklist and disregard of cockpit warning ‘Landing Gear Not Extended’ by the crew led to the gear-up runway contact. Human factors were contributory.”

Note this carefully
  • Nothing exotic failed. The barrier that failed was discipline, not hardware.
  • This is why investigators treat checklist culture and cross-monitoring as safety defences, not “formality.”

Lessons for ATC / Ops Apply to us

  Controller Takeaways Reflection

“This was cockpit, not tower.” Yes — but human factors are the same people-problem we live with in TWR/APP/ACC every shift:

  • High workload tunnel vision: During unusual / emergency / simulation, ATCOs may fixate on one task (e.g. one inbound with fuel emergency) and forget a standard call to someone else. Same pattern.
  • Checklist skip under pressure: You “know” Crash Bell has to be ≥60 sec, you “know” to call AOCC/WSO/MLU — but in a real sudden event, if you don’t read it off a known block, details get lost.
  • Assumption that ‘the other guy is watching’: We assume Assistant / Supervisor / Planner is catching anything we miss. In reality, they’re also saturated at that exact moment.
  • Old habit vs new procedure: After transfer from another unit, or shift on a different position, you may apply yesterday’s habit in today’s console. Exactly like skid-gear vs retractable-gear habit in VT-PHO.

So this is not a “helicopter problem”. This is a human cognitive loading problem. Same brain, different workplace.

  Map It To ATC Reality
1. Busy period / abnormal situation in TWR or APP → You get task-saturated
2. You assume your standard checklist is “obvious” → You don't actually read it
3. Supervisor is also busy → Cross-check / challenge doesn’t happen
4. A routine safeguard (like Crash Bell duration, ARFF call, runway occupancy warning) is missed
5. Outcome still safe? maybe Outcome reportable? definitely Outcome career-impacting? possibly

Recommendations Prevention

  Good Practice Going Forward COMPLETE
Do not “compress” standard calls just because it's training.
Training is not a licence to skip SOP steps.
Stage / brief simulations.
Don’t introduce simulated failures exactly at the point where routine safety checks (gear down / crash bell / ARFF alert / strip marking) must happen.
Speak the checklist out loud.
“Gear down, three green.” “Crash bell sounded, ≥60 seconds.” “AOCC / ARFF / WSO informed at time ____.” Saying it out loud forces both people to hear the safety barrier.
Challenge each other.
If you are the monitoring pilot / planner / WSO and you do not hear the call-out, you ASK. Silence = NOT DONE.
Respect human limits.
Workload saturation is physics, not ego. When load spikes, brains drop steps. That is exactly why procedures exist: to hold the line while you are busy saving the situation.
One-line takeaway

“Nothing was wrong with the helicopter. The only thing that failed was ‘We Forgot.’”
Our job in ops and ATC is to build systems that do not allow “We Forgot” to go unnoticed.