What happened
On the morning of 16 July 2016, a Kavanagh Balloons E-300 hot-air balloon, registered VH-LPG, departed for a one-hour scenic flight from Irishtown, Western Australia (WA). On board were the pilot and 16 passengers.
The balloon departed at about 0700 Western Standard Time (WST), and reached a maximum altitude and speed of about 3,500 ft above mean sea level (AMSL) and 39 kt, respectively. The balloon tracked in a south-easterly direction. During the flight, the pilot instructed the ground crew to proceed to the racecourse at York, WA, to meet the balloon for the landing. After about 52 minutes of flight covering a distance of about 33 km, the pilot made an approach to a vacant paddock near York. The balloon made an initial ground contact with about 15 kt forward speed. When the balloon struck the ground, the pilot was ejected from the balloon basket. The basket was then dragged over the top of the pilot as the balloon envelope continued to deflate. The balloon envelope came to rest draped over trees and a fence with the basket lying on its side (Figure 1).
The pilot was seriously injured, and air lifted to the Royal Perth Hospital. One passenger received a minor injury and the balloon sustained minor damage.
Figure 1: Final resting position of VH-LPG
Source: WAPOL
Weather
The weather forecast for the area (ARFOR)[1] predicted wind at 3,000 ft AMSL to be from the north-north-west at 40 kt. The closest recorded aerodrome forecast (TAF)[2] or regular report (METAR)[3] was Cunderdin, about 49 km to the north-east. The forecast wind at Cunderdin was from the north-north-west at 10 knots. At 0630 the recorded wind was north-north-easterly at 12 kt and at 0700 from the same direction at 6 knots.
Kavanagh Balloons flight manual
The procedures for the security of the pilot and passengers for a Kavanagh Balloon are incorporated into the Kavanagh Balloons flight manual, Section 4 – Normal Procedures.
- Paragraph 4.11.10 Pilot restraint harness, states ‘If a pilot restraint harness is fitted, it should be worn during take-off and for the duration of the flight including the landing... The restraining strap should be shortened to restrict the movement of the pilot within the compartment in preparation for the landing. This will maintain the correct pilot position during the landing.’
- Paragraph 4.12 Approach to landing, states ‘When horizontal landing speed is expected, passengers should be made aware that the basket may tip forward and they should take a lower-than-normal landing position to avoid being thrown forwards out of the basket.’
Civil Aviation Regulation 251
Civil Aviation Regulation (CAR) 251 details the circumstances in which pilots and passengers must wear a seat belt or safety harness, which includes during take-off and landing.
Ballooning exemption
Civil Aviation Order 95.53 section 3 Exemption 3.1 (f) specifically exempts manned balloons engaged in charter operations from CAR 251. However, the Civil Aviation Safety Authority have indicated that the use of a pilot restraint in passenger transport balloons is a proposal under consideration, which is subject to consultation.
ATSB comment
The pilot of the balloon was seriously injured during this accident and therefore not able to participate in an interview. There was no pilot restraint harness fitted to the balloon on the incident flight.
Safety action
Whether or not the ATSB identifies safety issues in the course of an investigation, relevant organisations may proactively initiate safety action in order to reduce their safety risk. The ATSB has been advised of the following proactive safety action in response to this occurrence.
Operator
As a result of this occurrence, the balloon operator has advised the ATSB that they are taking the following safety actions:
Pilot safety harnesses
The operator has modified all their hot-air balloons and fitted them with pilot restraint harnesses.
Safety message
Landing with forward speed in a balloon poses the risk of personnel thrown forwards out of the balloon basket, which can then place them in the path of the basket. Passengers are briefed about this risk and are able to use both hands to secure themselves to a handhold for landing. However, the balloon pilot is required to continue using their hands to control the balloon throughout the landing sequence and is therefore exposed to a higher risk of being thrown out of the balloon basket.
Installation and use of a pilot restraint harness, in accordance with the balloon and harness manufacturers’ recommendations, will reduce the risk of a pilot being thrown out of the balloon basket during landing.
Aviation Short Investigations Bulletin - Issue 53
Purpose of safety investigationsThe objective of a safety investigation is to enhance transport safety. This is done through:
It is not a function of the ATSB to apportion blame or provide a means for determining liability. At the same time, an investigation report must include factual material of sufficient weight to support the analysis and findings. At all times the ATSB endeavours to balance the use of material that could imply adverse comment with the need to properly explain what happened, and why, in a fair and unbiased manner. The ATSB does not investigate for the purpose of taking administrative, regulatory or criminal action. TerminologyAn explanation of terminology used in ATSB investigation reports is available here. This includes terms such as occurrence, contributing factor, other factor that increased risk, and safety issue. Publishing informationReleased in accordance with section 25 of the Transport Safety Investigation Act 2003 Published by: Australian Transport Safety Bureau © Commonwealth of Australia 2016
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- An area forecast issues for the purposes of providing aviation weather forecasts to pilots. Australia is subdivided into a number of forecast areas.
- Aerodrome forecasts are a statement of meteorological conditions expected for a specific period of time, in the airspace within a radius of 5 NM (9 km) of the aerodrome.
- Routine aerodrome weather report issued at fixed times, hourly or half-hourly.