Aviation safety investigations & reports

In-flight fire involving Kavanagh B-350 hot air balloon, VH-ZYO, near Coldstream, Victoria on 26 December 2018

Investigation number:
AO-2019-001
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 886KB]
 

What happened

On 26 December 2018, a Kavanagh B-350 hot air balloon, registration VH-ZYO, operated as a scenic charter flight by Go Wild Ballooning, departed from Wandin, Victoria with the pilot and 15 passengers on board.

After 20 minutes in flight, and while operating at an altitude of about 800 ft, the pilot recalled hearing a small explosion from the front left burner and observed that a small fire had started on the outside of the burner. The pilot switched off the vapour valve at the fuel tanks to the front two burners and disconnected the hoses.

About a minute later, the pilot attempted to put out the fire using one of two on-board extinguishers, but the fire re-ignited almost immediately. After a further minute, the pilot discharged the second fire extinguisher, but again the fire re-ignited.

Moments later, the pilot’s compartment caught fire. The pilot was wearing a cotton shirt, synthetic vest, rolled-up pants, and rubber slip-on shoes and began to feel uncomfortable with his proximity to the fire. He then moved from the pilot’s compartment to the back left compartment of the basket.

About 8 minutes after the fire started, the pilot identified a suitable landing position and began the approach. During the descent, the basket struck some treetops and the ropes became tangled in the branches. Passengers reported that the branches whipped around and into the basket, with one passenger sustaining cuts to his hand. The pilot freed the ropes from the tree and brought the balloon to rest in the paddock below. As the basket touched the ground, the passengers jumped out and ran to safety.

The fire continued to burn as the pilot secured the balloon. When emergency services arrived on site, flames had engulfed the balloon. By the time firefighters extinguished the flames, the fire had destroyed the balloon.

What the ATSB found

  • The ATSB found that the in-flight fire was the result of a fuel leak at the front left burner. Due to severe fire damage, the source of the leak could not be determined conclusively, but it was considered most likely to be the main ball valve, liquid fire valve or liquid fire valve connection to the main valve block.
  • The hand-wheel valve on the liquid outlet of the fuel tank and the pilot burners were not shut-off, which resulted in the pilot being unable to control the fire. Installation of a 90-degree valve on the liquid fuel outlet may have assisted the pilot to recognise that the liquid fuel valve was not shut-off.
  • In addition, the pilot's clothing did not meet the recommended industry standards for personal protective equipment, which increased the risk to his personal safety.

What's been done as a result

As a result of this occurrence, the Civil Aviation Safety Authority released an Airworthiness Bulletin (AWB 02-063) to address some of the pertinent issues surrounding this occurrence. The AWB included:

  • a recommendation to inspect critical componentry
  • the use of 90-degree shut-off valves for the fuel tank liquid outlets
  • a reminder to close off liquid and vapour valves in the event of a fire
  • a reminder to wear appropriate personal protective equipment.

In addition, Go Wild Ballooning has advised the ATSB that they have replaced all hand-wheel valves with 90-degree valves on all fuel tanks and reviewed the company policy on protective clothing.

Safety message

In the event of an in-flight balloon fire, the first priority is isolation of the fuel supply at the fuel tank. It is good practice to rehearse emergency procedures by standing in the basket to run through the checklist steps.

Further ways to reduce risk to individuals and improve survivability outcomes include:

  • wearing appropriate protective clothing that includes cotton long‑sleeved shirts and long trousers, leather gloves, and enclosed footwear
  • utilising componentry that provides a visual indication of the system status, for example, 90‑degree valves on liquid outlets.

On-board view of in-flight fire involving VH-ZYO

On-board view of in-flight fire involving VH-ZYO. Source: Passenger photo

Source: Passenger photo

Download final report
[Download  PDF: 886KB]
 
 
 

The occurrence

General details
Date: 26 December 2018   Investigation status: Completed  
Time: 0615 EDT   Investigation level: Short - click for an explanation of investigation levels  
Location   (show map): near Coldstream (ALA)   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Fire  
Release date: 28 June 2019   Occurrence category: Accident  
Report status: Final   Highest injury level: Minor  

Aircraft details

Aircraft details
Aircraft manufacturer Kavanagh Balloons  
Aircraft model B-350  
Aircraft registration VH-ZYO  
Serial number B350-368  
Operator Go Wild Ballooning  
Type of operation Ballooning  
Sector Balloon  
Damage to aircraft Destroyed  
Departure point Wandin, Victoria  
Destination Coldstream, Victoria  
Last update 16 July 2019