On 24 April 2016, the pilot of Kavanagh Balloons B400, registered VH-WNV (WNV) prepared to land at Rothbury near Cessnock New South Wales. On board were the pilot and 16 passengers.
After a gentle touchdown, the pilot advised the ground crew that the balloon needed to be moved back about 10 m from the tree line. The pilot checked that the neck of the balloon was not obstructed and then turned on the pilot light of one of the two burners.
Moments later the pilot noted that the wind had pushed part of the neck of the balloon back on itself, and there was black smoke emanating from this area. As the balloon envelope kept sliding on itself, the fire continued and some of the melted fabric began to drip onto the occupants of the basket.
The pilot quickly re-directed the ground crew from the task of pulling the top of the balloon down, to assisting the passengers to disembark and move away to a safe area. The pilot pulled the smart vent to rapidly release any air. Both the ground crew and the pilot (still in the basket) discharged fire extinguishers. Within a few minutes, the crew were able to spread the balloon envelope out and extinguish the fire.
During the emergency disembarkation, two of the passengers received minor injuries. The lower section of the balloon envelope was substantially damaged.
The Federal Aviation Administrations’ (FAA) comprehensive Balloon Flying Handbook FAA-H-8083-11A (2008) covers all aspects of balloon flying including aeronautical decision-making. This is a systematic approach to the mental process used by a pilot to determine the best course of action in response to a given set of circumstances. It builds on the foundation of conventional decision-making, but enhances the process to decrease the probability of pilot error.
At about 0725 Eastern Standard Time (EST) on the morning of 24 April 2016, the pilot of a Kavanagh Balloons B-400, registered VH-WNV (WNV), prepared to land at Rothbury near Cessnock, New South Wales (Figure 1). On board the scenic flight were the pilot and 16 passengers. The balloon was one of a number of balloons conducting a similar scenic flight that morning.
The pilot had selected a landing site, and informed the ground crew by radio, but the light wind carried WNV, and the other balloons in the group, a little further past this site. The pilot in WNV (and the other balloon pilots) then selected a nearby paddock for landing, and updated the ground crew accordingly. The pilot lined the balloon up to land, but then noticed a small dam along the intended landing path. The pilot manoeuvred the balloon over the dam before turning off the burners, and making a gentle landing.
Figure 1: VH-WNV landing area (green circle)
Source: Airservices Australia: Extract of Sydney World Aeronautical Chart, annotated by ATSB
The manoeuvring over the dam resulted in the balloon being a little closer to the tree line than ideal (Figure 2). Mindful that the ground crew had to pack up the 400,000 cubic foot balloon once the passengers has disembarked, the pilot advised them that they would move the balloon back about 10m further from the trees. To assist with this process, and make the balloon more buoyant, the pilot checked the neck of balloon was still sufficiently open, and then turned on the pilot light of one of the two burners.
Moments later, the pilot again checked the neck of the balloon and noticed the gentle wind had blown part of the deflating balloon back on itself and there was black smoke emanating from this area. The pilot then observed that some of the fabric had melted and had begun to drip onto the occupants of the basket. The pilot quickly re-directed the ground crew from the task of pulling the top of the balloon down, to assisting the passengers disembark and move away to a safe area.
To avoid any potential of the balloon becoming aloft during the disembarkation process, the pilot pulled the smart vent to rapidly release air. The pilot reported it was difficult to assess the extent of the fire from the basket, but they were aware that the balloon envelope ‘sliding’ on itself was adding more fabric as ‘fuel’ to the fire.
The balloon envelope deflated and landed next to the basket. The pilot (still on board) and the ground crew, after ensuring the passengers were safe, discharged fire extinguishers. Within a few minutes, the crew were able to spread the balloon envelope out and extinguish the fire.
During the emergency disembarkation, two of the passengers received minor burn injuries. The lower section of balloon envelope was substantially damaged.
The pilot had logged over 1,330 flying hours, with about 350 hours on the Kavanagh Balloons B‑400.
In hindsight, the pilot advised that the decision to move the balloon back 10 m to assist the ground crew with the collapse and pack-up of such a large balloon was not the correct one. Other balloons landing nearby did not attempt to move their balloons away from the tree line.
This occurrence highlights how quickly events may change. The simple decision by an experienced pilot to move the balloon back 10 m from the tree line to assist the ground crew inadvertently led to a fire.
The Federal Aviation Administrations’ (FAA) comprehensive Balloon Flying Handbook (2008) covers all aspects of balloon flying including aeronautical decision-making. Aeronautical decision-making is a systematic approach to the mental process used by pilots to determine the best course of action in response to a given set of circumstances. It builds on the foundation of conventional decision-making, but enhances the process to decrease the probability of pilot error.
As almost all ballooning operations are conducted as single-pilot operations, ballooning uses a variant of crew resource management, known as single-pilot resource management. This integrates:
- human resources
- situational awareness
- decision-making process
- risk management
One way in which the risk management decision path can be framed is through the perceive-process-perform model, which offers a structured way to manage risk.
- Perceive the hazard by looking at:
– pilot experience, currency, condition
– aircraft performance, fuel
– environment (weather, terrain)
– external factors.
- Process the risk level by considering:
– consequences posed by each hazard
– alternatives that eliminate hazards
– reality (avoid wishful thinking)
– external factors (‘get-home-itus’).
- Perform risk management:
– transfer – can someone be consulted?
– eliminate – can hazards be removed
– accept – do benefits outweigh risk?
– mitigate – can the risk be reduced?
Other decision-making models are also covered in the manual.
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|Date:||24 April 2016||Investigation status:||Completed|
|Location:||near Cessnock Airport (Rothbury)||Investigation type:||Occurrence Investigation|
|State:||New South Wales||Occurrence type:||Fire|
|Release date:||28 September 2016||Occurrence class:||Operational|
|Report status:||Final||Occurrence category:||Accident|
|Highest injury level:||Minor|
|Aircraft manufacturer||Kavanagh Balloons|
|Type of operation||Ballooning|
|Damage to aircraft||Substantial|
|Departure point||Cessnock, NSW|