Aviation safety investigations & reports

Flight preparation event involving Kavanagh Balloons E-260, VH-FSR, near Alice Springs Airport, NT, 13 July 2013

Investigation number:
AO-2013-116
Status: Completed
Investigation completed

Final Report

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What happened

On the morning of 13 July 2013 a Kavanagh E-260 balloon, registered VH-FSR, was being prepared for a charter tourist flight near Alice Springs, Northern Territory. Due to the wind conditions at the time, the passengers were pre-loaded into the balloon basket as it lay on its side. As one of the passengers prepared to enter the basket, their scarf became entangled in a fan that was being used to inflate the balloon envelope. Consequently, the passenger was rapidly drawn into contact with the fan’s steel guard and the scarf was pulled tightly around their neck. Despite being provided with first aid, and subsequent medical treatment, the passenger died as a result of their injuries several days later.

What the ATSB found

The ATSB found that pre-loading of the passengers during the inflation process, although appropriate in the wind conditions, resulted in them coming into close proximity to the operating inflation fan. Additionally, the mesh and steel tubing guard positioned around the inflation fan was ineffective in preventing loose items of clothing from becoming entangled in the wooden fan blades and driveshaft. As a result, when the passenger approached the balloon basket in preparation for loading, their scarf was drawn into the fan blades, leading to fatal injuries.

The pilot conducted two safety briefings prior to the proposed flight that advised the passengers to remain clear of the fan as it was noisy and dangerous. A warning sign fitted to the fan was also pointed out. However, none of the passengers recalled that the specific danger of fan entanglement had been mentioned.

What's been done as a result

Shortly after this accident, the ATSB forwarded a Safety Advisory Notice (SAN) to balloon operators highlighting the circumstances of this occurrence and advising that they review their risk controls in relation to the safety of inflation fans. With the assistance of the Professional Balloon Association of Australia and the Australian Ballooning Federation (ABF) the SAN was also provided to their members. The ABF and Northern Territory (NT) WorkSafe also issued safety alerts highlighting the danger of fan entanglement.

The balloon operator made a number of changes to prevent a similar accident, including:

  • modification of all fan guards to reduce the likelihood of entanglement
  • establishment of a passenger exclusion zone in the vicinity of the fan
  • assignment of a crew member whose sole duty was to operate and supervise the fan
  • inclusion of detail on the danger of entanglement in the passenger briefing card.

Safety message

This accident highlights how quickly entanglement in industrial equipment, such as the inflation fan, can cause fatal injury. While highlighting the danger to those unfamiliar can reduce the risk, isolating the hazard through effective fan safeguarding and passenger control is the most effective method of preventing such tragic accidents.

Download Final report
[Download  PDF: 4.09MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety actions

Sources and submissions

Appendices

Safety Issue

Go to AO-2013-116-SI-01 -

Safety Advisory Notice

The Australian Transport Safety Bureau advises balloon operators to review their risk controls in relation to the safety of cold-air inflation fans, especially in relation to passenger proximity to operating fans, and the security of loose items, such as passenger clothing.
 

Safety issue details
Issue number: AO-2013-116-SI-01
Who it affects: Balloon operators
General details
Date: 13 July 2013   Investigation status: Completed  
Time: 0720 CST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): near Alice Springs Airport    
State: Northern Territory   Occurrence type: Aircraft Separation  
Release date: 09 December 2015   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Kavanagh Balloons  
Aircraft model E-260  
Aircraft registration VH-FSR  
Serial number E260-403  
Type of operation Charter  
Sector Balloon  
Damage to aircraft Nil  
Departure point near Alice Springs, NT  
Last update 14 November 2018