Aviation Accident Summaries

Aviation Accident Summary ERA20LA094

Homestead, FL, USA

Aircraft #1

N970TC

Airborne America AX9-140

Analysis

The commercial pilot who owned the hot air balloon tour company departed on a revenue tour flight with eight passengers onboard. The pilot reported that his preflight review of weather conditions indicated light wind at the surface and aloft. After about 50 minutes of flight, the pilot was approaching a field for landing when, while crossing overhead a set of power lines, the balloon encountered a “downdraft” and entered a “rapid descent.” The basket contacted the power lines, then slid to the ground. The pilot did not have current flight review, and the balloon’s registration had expired. Several passengers provided statements in which they recounted that, throughout the flight, the balloon was flying low enough that they could easily communicate with people on the ground, and that the basket contacted trees twice and a power pole once during the flight. After contacting the trees, the pilot laughed and stated that he was “cleaning the bottom of the basket.” Examination of the balloon’s flightpath indicated that after departure, the balloon tracked downwind at low altitude (below 500 feet) near multiple obstacles, structures, and powerlines for most of the flight, and although the pilot reported that a downdraft occurred, the passengers did not report it, and there was no indication of any thunderstorms, convective activity, or high winds around the time of the accident. The balloon impacted the power lines with the lower part of the envelope and flying wires that held the basket to the canopy. The balloon came to rest with the envelope draped over the power lines and the basket in a small group of trees directly below the lines, 10 to 12 feet above the ground. Electrical arcing occurred and showers of sparks flew on and around the passengers. The accident resulted in serious injury to two of the passengers, and minor injury to four of the passengers. The events of the accident flight displayed a pattern of poor decision-making by the pilot both before and during the flight; including his decision to operate the balloon without a valid registration, his decision to operate the flight without a valid flight review, and his decision to fly the balloon at very low altitudes in proximity to obstructions, structures, and powerlines, which increased the potential of collision. The Federal Aviation Administration had conducted no surveillance of the operator/pilot before the accident. Given the circumstances of this accident, it is likely that with a more robust system of oversight and surveillance of balloon operators, the Federal Aviation Administration could have identified the accident pilot/operator as a potential safety risk and taken steps to mitigate this risk.

Factual Information

HISTORY OF FLIGHT On January 19, 2020, about 0745 eastern standard time, an Airborne America AX9-140 (S.2), N970TC, incurred minor damage when it was involved in an accident in Homestead, Florida. The pilot and four passengers were uninjured, two passengers received minor injuries, and two passengers were seriously injured. The balloon was operated as a Title 14 Code of Federal Regulations Part 91 revenue sightseeing flight. The local sightseeing flight was operated by Sunrise Balloons Miami LLC. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which departed about 0657. The pilot stated that, before the flight, he checked several weather websites and called flight service. He reported that the weather was clear and cool, the surface wind was from 100° at 3 knots, and the winds aloft were in the single digits (6 knots). After about 50 minutes of flight, the pilot began looking for a place to land. As the balloon crossed over a set of powerlines, he “felt a strong downdraft” and the balloon entered a “rapid descent.” The pilot stated that he applied maximum burner heat, the balloon contacted the powerlines, and he then deflated the envelope while shutting off the burner valves. The basket “slid gently to the ground” and came to rest among brush and scrub trees. Several of the passengers provided statements regarding the flight. One passenger reported that, before departure, the pilot stated that his nickname was “Captain Fly Low”; he was also wearing a patch on his shirt with that name. The passengers reported that, during the flight, the balloon was low enough to easily communicate with people on the ground as they flew over, and that the basket contacted trees two different times during the flight, after which the pilot laughed and stated that he was “cleaning the bottom of the basket.” The basket also contacted the top of a power pole. During the landing approach, the pilot started repeatedly yelling an expletive as the balloon continued toward power lines and trees. The pilot then yelled for all the passengers to "get down, get down!" and actuated one of the burners to try and rise above the power lines. The balloon struck the power lines with the lower part of the envelope and flying wires that held the basket to the canopy. The balloon came to rest with the envelope draped over the power lines with the basket in a small group of trees directly below the lines, 10 to 12 feet above the ground. Electrical arcing occurred and showers of sparks flew on and around them. The sparks burned their hair and skin; a portion of the basket, as well as the foliage below the basket, caught fire. One passenger's pants caught fire, and he tried to put the fire out with his hands and then jumped out of the basket. The trees could not hold the basket and the basket slid out of the trees onto the ground. The rest of the occupants then turned the basket on its side and egressed. One of the passengers reported that, after egress, the pilot asked if they were ok, then asked if they still wanted their champagne. Residents in the area that observed the accident called 911 and ran over to assist. The first emergency services personnel arrived at the accident site at 0756. A passenger heard one of the ground crew tell the police that the balloon hit a downdraft; however, none of the passengers reported adverse weather conditions before, during, or after the flight, nor did they hear the pilot or ground crew mention anything about downdrafts. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with a rating for lighter-than-air balloon. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on June 1, 2017. He reported 881 total hours of flight experience. His most recent flight review was completed on September 22, 2017. A review of FAA Program Tracking and Reporting Subsystem operator/airman surveillance records for the operator and the pilot revealed that no surveillance activities of either had occurred prior to the accident. AIRCRAFT INFORMATION The balloon envelope and basket were manufactured in 1989. The balloon was powered by two propane burners, was equipped with four pressurized fuel cylinders, and the partitioned basket had a capacity of nine occupants. The date of the balloon's most recent annual inspection and total hours of operation was not provided by the pilot/operator. A review of FAA records indicated that the balloon's registration had expired on July 31, 2019, and its registration number was no longer authorized for use. METEOROLOGICAL INFORMATION The 0756 recorded weather at Homestead Air Reserve Base (HST), Homestead, Florida, located about 8 nautical miles southeast of the accident site, included wind from 110° at 3 knots, visibility 10 statute miles, clear skies, temperature 19°C, dew point 16°C, and altimeter setting of 30.12 inches of mercury. WRECKAGE AND IMPACT INFORMATION Several of the powerlines were severed upon impact. The fabric of the balloon above the bottom rim tape (which displayed damage prior to the flight, according to a passenger) received more damage. The skirt (scoop) was torn and burned in several places. The leather trim which covered the top rail of the basket was torn in several places, the bottom of the basket displayed areas of thermal damage, and the frame of the basket was bent and distorted. ADDITIONAL INFORMATION Balloon Flightpath Examination of the balloon’s flightpath along with passenger-supplied photographs and video indicated that, after departure the balloon tracked downwind to the northwest at low altitude (below 500 feet) near multiple obstacles, structures, and powerlines for much of the flight. Balloon Manufacturer's Guidance According to the balloon manufacturer's flight manual, section 2.9, LANDING PROCEDURE, when choosing a landing site, the pilot should allow for possible variations in the wind at ground level, and choose a site: (a) Free of obstructions, especially power lines; (b) Overshoot area should also be clear; (c) Field free of crops and animals; (d) If possible, look for upwind shelter to reduce speed; (e) If possible, choose a field with good accessibility for retrieve crew, and minimum inconvenience for the owner. The manual also stated: Do not fly into power lines at any cost. If contact is inevitable descend as fast as possible so that the contact of the wires is with the envelope and not with the basket assembly. Shut down the fuel system and vent lines before contact. If the balloon is caught in the wires DO NOT TOUCH ANY METAL PAR'I'S. If possible, remain in the basket until the power is shut off. Never attempt to remove the balloon until the power authority has arrived. Do not allow crew members to make contact between the ground and the basket until the power is shut off. Balloon Flying Handbook The FAA Balloon Flying Handbook (FAA-H-8083-11A), 7-7, "Maneuvering," states, "The balloon is officially a non-steerable aircraft." Although a hot air balloon has no direct controls for steering, a balloon's flightpath can be indirectly influenced using the burner and parachute valve. The handbook also states: Being knowledgeable of the wind at various altitudes, both before launch and during flight, is the key factor for maneuvering. Maneuvering, or steering, comes indirectly from varying one's time at different altitudes and different wind directions. The FAA Balloon Flying Handbook further stated that, when contour flying or during an approach to a landing site, the potential of collision with trees, power lines, and other obstacles is increased. For balloons, landing accidents consistently account for over 90 percent of the total number of accidents in any given year. The most common causal factors for landing accidents include collision with obstructions in the intended landing area. These accidents account for the majority of injuries to pilots and damage to balloons. Accidents are more likely during landing because the tolerance for error is greatly diminished and opportunities for pilots to overcome errors in judgment and decision-making become increasingly limited, particularly in high wind conditions. NTSB Recommendations On April 7, 2014, the NTSB issued recommendations to the FAA (A-14-11 and A-14-12) to address operational deficiencies in commercial sightseeing (air tour) balloon operations that have resulted in occupant injuries and a fatality. They were derived from the NTSB's investigations of several air tour balloon accidents. The accidents highlighted operational deficiencies in commercial air tour balloon operations, such as operating in unfavorable wind conditions and failure to follow flight manual procedures, that the NTSB considered a result of the lack of oversight relative to similar airplane and helicopter air tour operations. In its recommendations, the NTSB stated that, depending on gondola capacity, balloons can carry more than 20 passengers per flight. Given the various safety deficiencies noted in the NTSB's investigations of the subject balloon accidents, the potential for a high number of fatalities in a single air tour balloon accident is of particular concern if air tour balloon operators continue to conduct operations under less stringent regulations and oversight. Although such an accident had yet to occur in the United States at the time of the issuance of the recommendations, a high-fatality accident occurred in Egypt on February 26, 2013, when a commercial air tour balloon carrying 21 occupants experienced a fire on board, resulting in 19 deaths. On July 30, 2016, about 0742 central daylight time, a Balóny Kubícek BB85Z hot air balloon, N2469L (NTSB Case No. DCA16MA204), crashed into a field after striking high voltage powerlines while landing near Lockhart, Texas. The 15 passengers and pilot onboard were fatally injured. The NTSB determined that the probable cause of this accident was the pilot's pattern of poor decision-making that led to the initial launch, continued flight in fog and above clouds, and descent near or through clouds that decreased the pilot's ability to see and avoid obstacles. Contributing to the accident were (1) the pilot's impairing medical conditions and medications and (2) the FAA's policy to not require a medical certificate for commercial balloon pilots. The investigation further concluded that the FAA's primary method of oversight—sampling balloon operators at festivals and events—does not effectively target the operations that pose the most significant safety risks to members of the public who choose to participate in commercial balloon sightseeing activities. As a result of this investigation, the NTSB classified Safety Recommendations A-14-011 and -12 as "Closed—Unacceptable Action/Superseded," due in part to the FAA’s lack of action in response to the recommendations which addressed the need for commercial balloon operators to have a Letter of Authorization (LOA) and the need for FAA principal operations inspectors to include, in their general surveillance activities, commercial balloon operators that hold an LOA, respectively. As a result, in 2017, the NTSB issued Safety Recommendation A-17-45 to the FAA which recommended the following: Analyze your current policies, procedures, and tools for conducting oversight of commercial balloon operations in accordance with your Integrated Oversight Philosophy, taking into account the findings of this accident; based on this analysis, develop and implement more effective ways to target oversight of the operators and operations that pose the most significant safety risks to the public. On August 2, 2018, the FAA stated that it planned to develop and implement more effective ways to target oversight of operators that pose the most significant safety risk to the public. The FAA also stated that it would identify operators of balloons 140,000 cubic feet or larger and then increase surveillance of those operators. On September 18, 2018, the NTSB asked the FAA to provide information regarding how it determined the 140,000-cubic ft threshold for increased oversight and classified Safety Recommendation A-17-45 “Open—Acceptable Response.” On April 9, 2021, the FAA stated that it no longer planned to increase surveillance of commercial balloon operators because it found a significant reduction in fatal accidents involving commercial balloon operations between August 1, 2016, and April 29, 2020. The FAA attributed this decrease to the effectiveness of its policies, procedures, and tools for overseeing commercial balloon operations as well as industry’s efforts to improve the safety of these operations. On February 4, 2022, the NTSB expressed concern that the FAA only reviewed data for balloon accidents with fatalities and not significant injuries. Accident data for the period between August 1, 2016, and October 29, 2021, included a total of 48 balloon accidents, which resulted in 9 fatalities and 37 serious injuries. Pending a more risk-based approach to identifying balloon operators that require FAA oversight, Safety Recommendation A-17-45 remained classified “Open—Unacceptable Response.” On April 13, 2021, the NTSB expressed concern with the FAA’s lack of action in response to Safety Recommendation A-17-45 and reiterated and classified the recommendation “Open—Unacceptable Response” in NTSB investigation report No. DCA20SP001, Enhance Safety of Revenue Passenger-Carrying Operations Conducted Under Title 14 Code of Federal Regulations Part 91. In that investigation report, the NTSB found that under the current regulatory framework for revenue passenger-carrying operations, which includes sightseeing flights conducted in hot air balloons, a lack of structured pilot training, deficiencies in pilot skills and decision-making, and inadequate aircraft maintenance were occurring. The NTSB also found that the FAA needed to provide its inspectors with sufficient guidance to pursue more comprehensive oversight of Part 91 revenue passenger-carrying operators. Such guidance and oversight could help ensure that these operators are properly maintaining their aircraft and safely conducting operations. As a result, the NTSB issued Safety Recommendations A-21-9, -10, -12, -13, and -14, which asked the FAA to do the following: Develop national safety standards, or equivalent regulations, for revenue passenger-carrying operations that are currently conducted under Title 14 Code of Federal Regulations Part 91, including, but not limited to, sightseeing flights conducted in a hot air balloon, intentional parachute jump flights, and living history flight experience and other vintage aircraft flights. These standards, or equivalent regulations, should include, at a minimum for each operation type, requirements for initial and recurrent training and maintenance and management policies and procedures. (A-21-9) Develop national safety standards, or equivalent regulations, for revenue passenger-carrying operations that are currently conducted under Title 14 Code of Federal Regulations Part 91, including, but not limited to, sightseeing flights conducted in a hot air balloon, intentional parachute jump flights, and living history flight experience and other vintage aircraft flights. These standards, or equivalent regulations, should include, at a minimum for each operation type, requirements for initial and recurrent training and maintenance and management policies and procedures. (A-21-10) Develop and continuously update a database that includes all of the revenue passenger-carrying operators addressed in Safety Recommendations A-21-9 and -10 to facilitate oversight of these operations. (A-21-12) Require safety management systems for the revenue passenger-carrying operations addressed in Safety Recommendations A-21-9 and -10. (A-21-13) For the revenue passenger-carrying operations addressed in Safety Recommendations A-21-9 and -10, provide ongoing oversight of each operator’s safety management system once established. (A-21-14) On June 16, 2021, the FAA reported that these recommendations had been assigned to the FAA’s Flight Standards Service, which is evaluati

Probable Cause and Findings

The pilot's decision to operate the balloon at low altitude near obstructions, structures, and powerlines, which resulted in the balloon contacting powerlines. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of balloon tour operators.

 

Source: NTSB Aviation Accident Database

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