Key points

• A fire in the hold of a general cargo ship at Port Hedland in March 2021 was the tenth such fire on a company ship in the past 14 years, and the fourth investigated by the ATSB, identifying similar contributing factors;
• The ATSB has issued safety recommendations to the ship’s management company, and its parent company, to implement proposed safety action across their fleets;
• The continued incidence of fires on ships during hot work shows ship operators must ensure their safety management system procedures for hot work are appropriate and properly implemented.

The Australian Transport Safety Bureau has issued safety recommendations to the managers and parent company of the cargo ship BBC Rhonetal, following an investigation into a fire in the hold of the vessel at Port Hedland, Western Australia.

The ship was alongside at Port Hedland on the morning of 25 March 2021 when a fire broke out in the lower cargo hold during hot work using a plasma torch to cut welded sea fastenings for cargo units in preparation for unloading them. The fire was not declared extinguished until three days later.

The ATSB’s transport safety investigation into the incident found this to be the tenth such fire on a ship managed under the same parent company in the past 14 years, and the fourth investigated by the ATSB, identifying similar contributing factors.

“The ATSB’s investigation found the risk of fire had not been adequately assessed by the crew prior to the commencement of the hot work,” ATSB Chief Commissioner Angus Mitchell said.

“As a result, a continuous fire watch was not maintained, and proper precautions were not taken to sufficiently protect vulnerable cargo from catching alight.”

The ATSB found BBC Rhonetal’s managers had not effectively implemented the shipboard safety management system procedures to prevent the fire.

“The continuing incidence of fires on the cargo holds of ships while performing hot work highlights the importance of adhering to shipboard procedures and recognised safe work guidelines for hot work,” Mr Mitchell said.

BBC Rhonetal’s managers have advised the ATSB that procedures for hot work will be amended to better describe the role of the fire watch, emphasising its importance in fire prevention. Fire watch requirements will also be integrated into the hot work permit procedure and additional equipment for the fire watch is to be distributed across the fleet.

The company also intends to undertake measures to educate shipboard crew on the amended procedures and the additional equipment, including through implementation of a training video.

“While the ATSB considers the safety action proposed by the ship’s managers in this case has the potential to address the hot work safety issue, no timeline has been provided for their implementation, and the ATSB has therefore issued a formal recommendation to the ship’s managers, and the parent company,” Mr Mitchell noted.

An ATSB safety recommendation remains open until it is satisfied the responsible organisation has addressed the safety issue identified.

“The ATSB is recommending the ship’s managers, Briese Heavylift, and its parent company Briese Schiffahrts, take safety action to ensure safety management system procedures are effectively implemented on BBC Rhonetal and all other relevant ships across their fleets,” Mr Mitchell said.

“Ship operators and managers must ensure that their safety management system protocols for hot work are suitable and properly implemented on board their ships,” he concluded.

“This requires regular verification that ships’ crew understand and follow prescribed safe work practices for hot work.”

Read the final report: Fire on board BBC Rhonetal, Port Hedland, Western Australia, on 25 March 2021

Key points:

• Significant fuel flow reduction resulted in engine power loss
• During the forced landing, aircraft clipped trees and collided with terrain
• Accident highlights the challenge of managing a power loss at low level

The Australian Transport Safety Bureau has issued a Safety Advisory Notice to operators of the Beechcraft Baron, urging them to inspect the aircraft’s heater fuel line to ensure electrical wiring is not rubbing and chafing against it.

The Safety Advisory Notice has been released in conjunction with a preliminary report from the ATSB’s on-going investigation into an accident involving a Baron aircraft which experienced an in-flight fire on approach to land at Kununurra Airport, Western Australia, on 16 April 2022. The aircraft was operating a charter flight from Broome with a pilot and one passenger on board.

The report, which details factual information from the investigation’s early evidence collection phase, outlines that while conducting a straight-in approach to Kununurra’s runway 12, soon after selecting the landing gear lever to the down position, the pilot received unusual indications and then detected an electrical burning smell and smoke emerging from below the left side of the aircraft’s instrument panel.

“Continuing the approach, the pilot made a ‘PAN PAN’ urgency radio broadcast, activated the SOS alert on the aircraft’s Spidertracks flight tracking unit, and switched off electrical power, by which stage flames were present,” ATSB Director Transport Safety Stuart Macleod explained.

“The pilot then discharged the on-board fire extinguisher at the flames, however the fire almost immediately returned, filling the cabin with smoke and obscuring the pilot’s view of the instrument panel and outside environment.”

Shortly after, recorded data showed that the aircraft diverged significantly to the left of the runway centre line and crossed the Ord River at low level. The aircraft then collided with the ground about 600 m beyond the river and about 800 m from the runway threshold, and was consumed by fire.

The pilot, despite sustaining serious injuries, was able to extricate themselves and the passenger from the wreckage. Sadly, the passenger later succumbed to their injuries.

“Due to the severity of the post impact fire ATSB investigators were not able to conduct a complete wreckage examination,” explained Mr Macleod.

“However, investigators were able to establish evidence of engine rotation prior to impact, while finding no evidence of pre-existing defects to the engines or flight controls that could have contributed to the accident.”

Further, the aircraft’s landing gear was observed to be stowed.

Mr Macleod said that given the extent of fire damage to the aircraft wreckage, determining the circumstances of the fire initiation and development is challenging and remains under investigation.

However, the ATSB previously investigated an in-flight fire involving a Beech 58 in February 2014.

“Two pilots were conducting a ferry flight from Darwin to Gove, when the pilot in the left seat observed smoke and flames by their left leg adjacent to the circuit breaker panel,” said Mr Macleod.

The left-hand seat pilot immediately switched off the electrical master switch and discharged the fire extinguisher at the flames, while the right-hand seat pilot took control of the aircraft and conducted an emergency descent and landing.

“A post-incident engineering inspection found that wiring had penetrated the heater supply fuel line, causing it to arc out and burn a hole in the fuel line.”

Given the similarity of some of the circumstances of the 2014 incident to the April 2022 Kununurra accident, the ATSB is advising Beech Baron operators to conduct a detailed inspection of the aircraft’s heater fuel supply line and nearby wiring.

“It is important to stress that the ATSB’s investigation into the Kununurra accident is on-going, and we are yet to make formal findings as to the accident’s contributing factors,” Mr Macleod said.

“However, given what we do understand of this accident, we believe it is prudent for Baron operators to examine the area below the pilot’s circuit breaker panel and areas forward of this under the instrument panel.

“The ATSB also encourages operators to report any identified issues to the Civil Aviation Safety Authority and the aircraft manufacturer.”

Mr Macleod said a final report, which will detail safety analysis and findings, will be released at the conclusion of the investigation.

“However, as we have with the release of this preliminary report and Safety Advisory Notice, if at any time as the investigation continues, we are made aware of safety critical information, the ATSB will immediately share that with relevant stakeholders so that they may take appropriate safety action.”

Read the preliminary report: In-flight fire and collision with terrain involving Beechcraft B58 Baron, VH-NPT, near East Kimberley Regional Airport, Kununurra, Western Australia, on 16 April 2022

Read the SAN: Beechcraft Baron heater fuel supply line inspection

A preliminary report has been released from an ongoing transport safety investigation into a collision between a passenger train and a truck at a level crossing near Bendigo, Victoria.

On the morning of 13 July 2022, a farmer unlocked and opened the gates of a passive level crossing (which was not available for public access), to allow a truck onto their property to collect hay.

A short time later, the truck arrived at the crossing, and proceeded onto it.

The driver of an approaching V/Line passenger train reported seeing the truck approach the crossing, and sounding the train’s horn.

When the truck did not stop, the train driver made an emergency brake application, and was in the process of turning their seat away when the collision occurred.

The truck driver was seriously injured in the collision, and the train driver sustained minor injuries. Fortunately, none of the passengers on-board the train were injured.

The leading car of the train was substantially damaged, with both of its bogies derailed. The accident also resulted in substantial damage to the track infrastructure and the truck.

An investigation by the Office of Chief Investigator, Transport Safety, which investigates rail occurrences in Victoria on behalf of the Australian Transport Safety Bureau, is ongoing.

“This preliminary report has been released to provide the public and industry with the factual information established in the early evidence collection phase of our investigation,” Chief Investigator, Transport Safety Mark Smallwood said.

“The investigation is continuing and will include review and examination of the arrangements for the use of this level crossing, the operation of the truck and the train involved, and the configuration of the level crossing.”

A final report will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken,” Mr Smallwood said.

Read the preliminary report: Collision between passenger train and truck, at Goornong, Victoria, on 13 July 2022

Key points:

• Significant fuel flow reduction resulted in engine power loss
• During the forced landing, aircraft clipped trees and collided with terrain
• Accident highlights the challenge of managing a power loss at low level

A Piper Cherokee Six light aircraft’s forced landing and collision with terrain following engine power loss soon after take-off from Moorabbin Airport highlights the challenges pilots face when they experience an engine failure or power loss at low level, an ATSB investigation notes.

On 22 June 2021, the pilot of the PA-32-200 Cherokee Six was conducting circuits at Moorabbin Airport, in Melbourne’s south-east.

As the aircraft was climbing after take-off at about 500 ft above ground level, fuel flow to the engine significantly reduced. Within 12 seconds, the engine lost power and the aircraft commenced descending.

In response, the pilot targeted a glide speed of 90 kt and searched for a site to make a forced landing within a 30° arc either side of the aircraft’s nose. They then identified one of few clear areas available for a landing within gliding range and manoeuvred the aircraft towards that area.

As the aircraft approached the selected area, the pilot recognised that insufficient height remained to clear trees, but contact was unavoidable.

The aircraft impacted the trees before colliding with rising ground. The pilot sustained serious injuries in the accident, and the aircraft was destroyed.

“This accident highlights the challenges pilots face when confronted with a loss of engine power at low level and with few suitable forced landing areas within the glide capability of the aircraft,” said ATSB Director Transport Safety Stuart Macleod.

“It reaffirms to pilots that they can best mitigate the effects of a loss of power through forward planning, which reduces mental workload under stress, and always maintaining control of the aircraft.”

Maintaining glide speed and using no more than a moderate bank angle avoids entering a stall and/or spin, Mr Macleod noted.

“During a forced landing, aim to arrive at the ground with wings level and the aircraft level with the ground, as this improves your prospects of survivability,” he said.

The ATSB’s investigation determined that a significant reduction in fuel flow, for reasons that could not be determined despite extensive examination, resulted in the engine’s loss of power

Analysis of the engine’s data management system showed that after the power loss, fuel flow did not reduce to zero, but varied between 20 and 16 litres/hour (in conjunction with RPM changes), indicating that fuel starvation did not lead to the power loss.

Further, wreckage examination, flight records and witness reports indicated that there was sufficient fuel on board, and in any tank, to power the engine.

While damage limited examination of the fuel system, no defect was identified that could have led to the fuel flow reduction. The engine was dismantled, examined and all fuel system components were tested and found to function correctly.

The investigation also found that the aircraft was inadvertently fitted with an incorrect engine variant, however, this did not affect the operation of the aircraft or contribute to the power loss.

“This inadvertent fitment, while not contributing to the accident, does underline to maintenance organisations the importance of the correct interpretation of the manufacturer’s type certificate documentation.”

Read the final report: Engine power loss and collision with terrain involving Piper PA 32 300, VH-CWK, near Moorabbin Airport, Victoria, on 22 June 2021

A preliminary report has been released from an ongoing transport safety investigation into the exceedance of a temporary speed restriction by a XPT passenger train in Melbourne.

On the morning of 24 May 2022, a Sydney to Melbourne XPT service travelled over the Moonee Ponds Creek Bridge, in Melbourne’s inner-north, at about 100 km/h.

This was above a 40 km/h temporary speed restriction, placed on the 400 m section, after rough track was reported there the night before.

An investigation is being conducted by the Office of Chief Investigator, Transport Safety, which investigates rail occurrences in Victoria on behalf of the Australian Transport Safety Bureau.

The preliminary report details factual information from the early evidence collection phase of the investigation.

“Travelling south towards Southern Cross Station, the standard gauge and broad gauge tracks run parallel up until Jacana,” Chief Investigator, Transport Safety Mark Smallwood explained.

“However, at Jacana, the standard gauge track, used by interstate trains, diverges from the more direct (16 km) broad gauge route, and takes a longer 27 km route to Southern Cross. To accommodate this longer route, the standard gauge track included a step change in its kilometrage at this point, from 16 km back up to 27 km.”

This effectively meant that trains on the standard gauge line went through two sets of kilometrage markers from 27 km to 16 km, on their way into Melbourne.

“The driver in this incident was told of a speed restriction between 24.4 km and 24.0 km,” Mr Smallwood said.

The driver slowed to below 40 km/h at the first 24.4 km–24.0 km section encountered, but not the second, where the restriction was actually in place.

The investigation will include further review of the track condition that led to the temporary speed restriction, the operation of the train, and the processes and risk controls associated with the establishment of a temporary speed restriction and its communication to drivers.

A final report will be released at the conclusion of the investigation.

“However, should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant parties so appropriate and timely safety action can be taken,” Mr Smallwood said.

Read the preliminary report: Exceedance of temporary speed restriction by XPT train ST21, at Moreland, Victoria, on 24 May 2022

Key points

• Aircraft likely stalled following a retardant drop when flying in hazardous conditions that included windshear and an increasing tailwind;
• Crew very likely did not know that other smaller firefighting aircraft had ceased flying in the area, and the assigned birddog aircraft had turned down the tasking, due to the hazardous conditions;
• Aerial firefighting operations necessarily take place in a high-risk environment, which requires a continued focus on risk mitigation, a responsibility that is shared between the tasking agency and the aircraft operator.

A Lockheed C-130 large air tanker that impacted the ground following an aerial firefighting retardant drop likely aerodynamically stalled when flying in hazardous conditions that included windshear and an increasing tailwind, an Australian Transport Safety Bureau investigation has found.

All three crew on board were fatally injured when the aircraft impacted slightly rising terrain while conducting a climbing left turn away from the drop site at the Good Good fire-ground near Peak View, north of Cooma, in the NSW Snowy Mountains region, on 23 January 2020.

Strong gusting winds and mountain wave activity, producing turbulence, were both forecast and present at the drop site. The fire and local terrain at the fire-ground likely exacerbated these hazardous conditions, the investigation report notes.

“The ATSB recognises the critical importance of aerial firefighting, where aircraft are flown at low altitudes and low airspeeds, often in challenging conditions, in the management and suppression of bushfires in Australia,” said ATSB Chief Commissioner Angus Mitchell.

“These operations necessarily take place in a high-risk environment, which requires a continued focus on risk mitigation, a responsibility that, in the Australian operating context, is shared between the tasking agency and the aircraft operator.

“As part of this investigation we have sought to understand the risk mitigations in place at the time of the accident, and have identified a number of safety issues that if resolved through actions will further mitigate risks for large air tanker aerial firefighting in the future.”

The investigation details that the C-130 was being operated by Coulson Aviation under contract to the New South Wales Rural Fire Service (RFS).

On the morning of the accident, the RFS State Operations Centre had tasked two large air tankers operating from RAAF Base Richmond, a Boeing 737 and the C-130, to conduct retardant drops at Adaminaby. The 737 departed first, and after conducting a drop at Adaminaby its crew reported that conditions precluded them from returning to the fire-ground.

The investigation notes that the RFS continued the C-130’s tasking to Adaminaby despite an awareness of the extreme environmental conditions and that all other fire‑control aircraft were not operating in the area at the time. (All smaller fire-control aircraft had ceased flying, a ‘birddog’ lead aircraft initially assigned to support the 737 and C-130 had declined the tasking, and the 737 was returning to Richmond, having declined further tasking to Adaminaby.)

This information was not communicated by the RFS to the C-130’s crew.

Instead, the ATSB notes that the RFS relied on the pilot in command to assess the appropriateness of the tasking to Adaminaby without providing them all the available information to make an informed decision on flight safety.

When the C-130 arrived overhead Adaminaby, the crew assessed the conditions were unsuitable and instead accepted an alternate tasking to the Good Good fire at Peak View, about 58 km to the east, which was subject to the same conditions.

Shortly after conducting a partial drop at Peak View, the aircraft commenced a climbing left turn. Following this, climb performance degraded and while at a low height and airspeed, it was likely the aircraft aerodynamically stalled, resulting in the collision with the ground.

The investigation notes that acceptance of the taskings was consistent with the operator’s practices to depart and assess the conditions to find a workable solution rather than rely solely on a weather forecast, which may not necessarily reflect the actual conditions at the fire-ground.

“The investigation found that Coulson Aviation's safety risk management processes did not adequately manage the risks associated with large air tanker operations, in that there were no operational risk assessments conducted or a risk register maintained,” Mr Mitchell said.

“In addition, the operator did not provide a pre-flight risk assessment tool for their firefighting large air tanker crews. This would provide predefined criteria to ensure consistent and objective decision-making with accepting or rejecting tasks, and would take into account elements such as crew status, the operating environment, aircraft condition, and external pressures and factors.”

Separately, the RFS had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision, the investigation found.

The RFS also did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation.

“The responsibility for the safety of aerial firefighting operations has to be shared between the tasking agency and the aircraft operator,” Mr Mitchell said.

“This accident highlights the importance of having effective risk management processes, supported by robust operating procedures and training to support that shared responsibility.”

Mr Mitchell noted Coulson Aviation has taken proactive safety actions in response to the accident, including the introduction of a pre-flight risk assessment tool, a new three-tiered risk management approach, and windshear procedures and training.

Separately, the RFS has committed to undertake a comprehensive review of RFS aviation doctrine and undertake detailed research to identify best practice (nationally and internationally) relating to task rejection and aerial supervision policies and procedures as well as initial attack training and certification.

Mr Mitchell welcomed that commitment but noted the ATSB has issued three safety recommendations to the RFS to take further action to reduce the risk associated with three safety issues identified in the investigation. These concern managing and communicating task rejections, aerial supervision requirements, and initial attack certification.

The ATSB has also issued two safety recommendations to Coulson Aviation. These are to further consider the fitment of a windshear detection system to their C-130 aircraft, and to incorporate foreseeable external factors into their pre-flight assessment tool.

Read the report: Collision with terrain involving Lockheed Martin EC130Q, N134CG, 50 km north-east of Cooma-Snowy Mountains Airport (near Peak View), New South Wales, on 23 January 2020

The Australian Government has launched a new $30 million Automatic Dependent Surveillance Broadcast (ADS-B) rebate program to support more general and recreational visual flight rules (VFR) aircraft owners to install the technology into their aircraft.

ADS-B transmits GPS-derived position data, aircraft identification and other aircraft performance parameters, which can provide pilots near real-time locational data to enhance their situational awareness of other ADS-B equipped aircraft near-by. This can aid self-separation from other aircraft, particularly in non-controlled airspace, helping to reduce the risk of collisions.

In Australia, all aircraft operating under instrument flight rules (IFR) are required to be fitted with ADS-B, with its fitment to aircraft operating under VFR voluntary.

To increase the uptake of ADS-B in VFR aircraft, the government is now providing a 50% rebate of the purchase cost of eligible ADS-B devices and, where applicable, the installation, capped to $5,000. Low-cost portable ADS-B devices will also be eligible for the grant.

“Ensuring the safety of our pilots, other aviation workers, passengers and those on the ground is of the utmost importance each and every time a plane takes off, which is why the funding of this technology will make a huge positive impact,” Infrastructure, Transport, Regional Development and Local Government Minister Catherine King said in announcing the scheme.

The rebate program, which opened on 12 August 2022, directly responds to calls from industry to encourage the uptake of ADS-B technology to realise its many benefits.

“The ‘see and avoid’ principle has known limitations, and the use of ADS-B with a cockpit display or an electronic flight bag application showing traffic information greatly improves a pilot’s situational awareness and enhances the safety of their flight,” Australian Transport Safety Bureau Chief Commissioner Angus Mitchell said.

“ATSB transport safety investigators can also use ADS-B data to help build a detailed picture and better understanding of an aircraft’s flight path* and performance in the lead up to an incident or accident, which can lead to better safety outcomes for the aviation community.”

The precise positional data available from ADS-B can also assist in managing life-saving search and rescue (SAR) operations undertaken by the Australian Maritime Safety Authority (AMSA).

“ADS-B data is another valuable tool used for SAR operations in Australia which helps to improve our ability to save lives,” AMSA’s Chief Executive Officer Mick Kinley said.

“For aircraft in distress, that are equipped with ADS-B, AMSA’s Joint Rescue Coordination Centre Australia will use the aircraft’s ADS-B data to refine a distress location and provide enhanced traffic conflict data in a search area that may involve multiple SAR aircraft.”

The ADS-B rebate program will be open until 31 May 2023 or until funding is exhausted, whichever occurs first.

For more information, including on how to apply, visit https://business.gov.au/grants-and-programs/automatic-dependent-surveillance-broadcast-rebate-program(Opens in a new tab/window).

* The above Google Earth image was generated by ATSB transport safety investigators using ADS-B data to show the flight path of Bell UH-1H helicopter, registered VH-UVC, which lost of control and collided with water 5 km south-west of Anna Bay, New South Wales, on 6 September 2019 (AO-2019-050).

An Australian Transport Safety Bureau investigation preliminary report has detailed that an Airbus A350 passenger aircraft was about to be pushed back for departure from Brisbane Airport before it was observed that covers were still in place on its pitot probes.

Aircraft are fitted with pitot probe covers when parked at Brisbane Airport to prevent mud wasps building nests within and blocking their pitot probes, which are used to measure air pressure to calculate airspeed.

The preliminary report on the 27 May 2022 occurrence, released to provide timely information to industry to highlight the importance of pitot probe covers being removed, notes that an aircraft refueller on an adjacent bay observed the pitot probe covers were still in place when the aircraft appeared ready for pushback.

“A known hazard at Brisbane Airport, mud wasps can rapidly build nests in aircraft pitot probes,” noted ATSB Director Transport Safety Dr Michael Walker.

“An aircraft being cleared to commence taxiing and then commence take-off with all pitot probe covers still fitted is a serious event.”

Two maintenance contractor ground crew engineers – a licensed aircraft maintenance engineer (LAME) supervising an inexperienced aircraft maintenance engineer (AME) – had been assigned to conduct scheduled receipt, dispatch, certification, and maintenance duties for the Singapore Airlines A350 aircraft during a two-hour turnaround at Brisbane.

As pushback approached, the covers remained in place until an aircraft refueller, working at an adjacent bay, observed them and alerted the supervising LAME.

The pitot covers were then removed two minutes before expected departure, and pushback occurred shortly afterwards.

As part of its investigation, to date the ATSB has interviewed the LAME, AME and the refueller, and reviewed airport security video, which did not show that the required final walk-around of the aircraft was conducted by either the LAME or the AME prior to dispatch.

“From here, the investigation will include examination of flight crew pre-flight inspection procedures, engineering final walk-around procedures, and induction training procedures,” Dr Walker said.

“It will also examine the engineers’ training records, policies and procedures around fatigue and change management, and more security video recordings.”

The ATSB has previously highlighted the risks of pitot probe covers not being removed prior to departure with its investigation into a March 2018 incident where an Airbus A330 took off from Brisbane with covers still in place, meaning the flight crew were faced with unreliable airspeed indications.

That ATSB investigation (AO-2018-053) identified safety factors across a range of subjects including flight deck and ground operations, aircraft warning systems, air traffic control, aerodrome charts, and risk and change management.

“The loss of airspeed data due to mud wasp ingress can occur even after brief periods, and the use of pitot probe covers for aircraft turnarounds at Brisbane is largely an effective defence,” Dr Walker said.

“However, as that earlier ATSB investigation identified, their use introduces another risk, which is the potential for aircraft to commence a take-off with pitot probe covers still fitted.”

Read the preliminary report: Flight preparation event involving Airbus A350-941, 9V-SHH, Brisbane Airport, Queensland, on 27 May 2022

Read the final report: Airspeed indication failure on take-off involving Airbus A330, 9M-MTK Brisbane Airport, Queensland, 18 July 2018

Key points:

• Two passengers sustained serious injuries during the hard landing of a hot-air balloon during a Yarra Valley scenic flight;
• The passengers had received an incomplete pre-flight briefing, probably resulting in them adopting a deep squat position during the hard landing, contributing to their injuries;
• Despite deteriorating wind conditions, the pilot rejected several suitable landing fields to avoid possible post landing logistical and operational difficulties, and eventually conducted a hard landing in a field to avoid contact with powerlines.

An ATSB investigation into a hard landing of a commercial hot air balloon in which two passengers sustained serious injuries highlights the importance of pre-flight briefings being completed and understood by all passengers.

On 31 December 2021, a Kavanagh B-350 balloon with 16 passengers and a pilot on board took off from near Glenburn, just north of Victoria’s Yarra Valley, for a planned one-hour scenic charter flight.

About 42 minutes later, the balloon pilot learned via a radio call that the wind was increasing near the intended landing area at Yarra Glen. Over the next 17 minutes, with the wind increasing, the pilot assessed multiple landing options before making an approach to land in a field.

During the approach the pilot manoeuvred the balloon to clear a fence before descending rapidly to avoid contact with nearby powerlines, and then landing hard. The basket then tipped onto its side and dragged for 30-40 metres. Two passengers sustained serious leg injuries.

The ATSB’s investigation found that, just prior to the landing, three passengers adopted a deep squat position.

“This was not in accordance with the prescribed pre-flight passenger safety briefing,” ATSB Director Transport Safety Stuart Macleod said.

“However, not all required actions were completed during the pre-flight briefing, probably due to time pressure and the pilot’s assumption that all passengers would understand an abbreviated briefing.”

“This incomplete briefing probably resulted in these three passengers adopting an inappropriate deep squat position prior to the hard landing, causing two of them to be seriously injured.”

Mr Macleod said the hard landing is a clear reminder for balloon pilots and operators of the importance of the pre-flight briefing being thorough and clearly understood.

“The pre-flight briefing is critical in ensuring passenger preparation, particularly as opportunities to reinforce that information during the flight may be limited.”

The investigation found that although wind conditions were deteriorating, the pilot rejected several suitable landing fields to avoid post-landing logistical and operational difficulties.

“While some landing options may not be ideal due to the impact on landowner relations, or the ease of access to the site after landing, pilots are reminded to prioritise occupant safety over such considerations, when faced with deteriorating wind conditions,” Mr Macleod said.

With safe landing sites progressively reduced as the flight continued, the balloon was landed in a field which presented high risks in the prevailing windy conditions.

The field contained fences, had powerlines downwind, and was the last landing field known to the pilot along the balloon’s track.

“The landing was complicated by the balloon descending faster than intended, bouncing off the ground back into the air, and then due to manoeuvres to clear fences,” Mr Macleod noted.

“These factors, in combination with the prevailing winds and nearby powerlines, led to the pilot descending the balloon rapidly from an excessive height, resulting in the hard landing.

“While undesirable, the hard landing was the safer option instead of risking contact with the power lines. However, hard landings still increase the risk of pilot and passenger injury.”

Although not contributing to the passenger injuries, the investigation also found that the maximum number of passengers that the balloon operator allowed to be carried on the balloon meant that there was insufficient room in the basket for passengers to adopt the backwards-facing landing position specified in the operator's procedures.

Read the final report: Hard landing involving Kavanagh Balloons B-350, VH-BSW 2 km south of Lilydale Airport, Victoria, on 31 December 2021