A study into Australia’s growing hot air balloon sector advises pilots and operators on key areas of focus to improve safety, and recommends the use of a structured Safety Management System to identify and manage risk.

The ATSB conducted the safety study in line with one of its SafetyWatch priorities, Reducing passenger injuries in commercial ballooning operations, and after identifying a serious incident and accident rate in balloon operations around 10 times that of charter operations in aeroplanes and helicopters, on a per flight basis.

ATSB Chief Commissioner Angus Mitchell noted the sector’s overall exposure to risk had also increased recently with an increase in larger balloons, capable of carrying the maximum passenger limit of 24 per flight, on the Australian register.

While no fatal accidents occurred in the sector during the study period, from 2014 to 2022, the study did find ballooning carried a higher risk to fare paying passengers than similar operations in small aeroplanes and helicopters.

“On a per-flight basis, ballooning was more likely to have a serious incident or accident, and more likely to have a passenger injury, than equivalent operations in small aeroplanes and helicopters,” Mr Mitchell said.

Injuries, serious incidents and accidents were more likely to occur during landing than any other phase of flight, the study found.

“Balloons are distinct from other aircraft in that they travel by moving with the wind, with pilots achieving directional control by using differing wind directions at different altitudes,” Mr Mitchell said.

Of the 79 balloon occurrences reported to the ATSB during the study period, 35 cited wind as a safety factor, resulting in 8 serious incidents and 5 accidents.

15 of the occurrences attributed assessing and planning as a safety factor, resulting in 7 serious incidents and 3 accidents.

The study, available here, advises balloon pilots to use all available information sources, including approved Bureau of Meteorology products, to ensure they understand the weather, particularly the wind, and its influence on flight safety.

“Accurate weather assessment is critical for safe go/no-go decisions,” Mr Mitchell continued.

“Pilots should also apply threat and error management by anticipating risks such as powerlines and poor visibility, and prioritising safety over logistical pressures in adverse conditions.”

The study also urges balloon operators to consider implementing a Safety Management System.

“Although not required by legislation for balloon operators, implementing a Safety Management System provides a structured approach to identifying and managing risks,” Mr Mitchell said.

Beaudesert incident a case study

An ATSB occurrence investigation, released alongside the safety study, details an accident involving a large balloon during a morning scenic flight near Beaudesert, Queensland, on 7 July this year.

The final report notes the balloon, with 20 passengers and the pilot on board, encountered fog after clearing a ridge line.

During the approach to land in low visibility, an unexpected low-level wind shift diverted the balloon away from the preferred clear landing area.

The pilot then selected an alternate, unplanned landing site in the final stages of landing and, due to reduced visibility from fog, was unable to see obstacles in the final landing area.

On landing, the balloon basket was carried forward with momentum, skipping several times before coming to a stop. The balloon’s envelope collided with a dead tree during the landing, resulting in minor damage.

“This serious incident demonstrates the unique challenges faced by balloon pilots, dealing with dynamic and changing weather conditions,” Mr Mitchell said.

“It also demonstrates some of the safety steps operators can take to reduce risk.”

The final report notes comprehensive passenger safety briefings meant passengers adopted brace positions before the landing, which likely prevented injury.

“This accident highlights the importance of effective safety briefings and how passengers adopting the correct body position during landing – the most common phase of flight for serious incidents and accidents – substantially reduces the likelihood and severity of injury. 

“We encourage all ballooning operators and pilots to review this material from the perspective of their operations, and consider how they can best ensure the safety of their passengers and aircraft,” Mr Mitchell concluded.

Read the safety study: Safety study into Australian balloon transport operation occurrences from 2014 to 2022

Read the occurrence investigation report: Controlled flight into terrain involving Kavanagh Balloons G-450, VH-FGC, 12 km north-north-west of Beaudesert, Queensland, on 7 July 2025

Confusing markings and lights contributed to several passenger aircraft taking off with less runway remaining than the flight crews had used for performance calculations, during taxiway construction works at Adelaide Airport earlier this year.

From 31 March to 20 May 2025, taxiway construction works took place at Adelaide Airport, an ATSB investigation report details.

Due to the works, the eastern end of the runway was being used as a taxiway, with the start of take-off position for runway 25 (and end of runway 05) displaced 650 m.

For aircraft landing on runway 23, a displaced landing threshold was 508 m beyond the temporary SOT position.

During the works period, 13 occurrences were identified, in both day and night operations, where flight crew mistakenly commenced the take-off on runway 23 from the displaced landing threshold, rather than the temporary SOT position.

“This meant the flight crews of multiple aircraft used performance parameters for a longer runway than was used, increasing the risk of a runway overrun, especially if a high speed rejected take-off had been required,” ATSB Chief Commissioner Angus Mitchell said.

The ATSB report notes the initial notice to airmen (NOTAM) released at the start of the runway works used inconsistent terminology and did not refer to the SOT markings being used.

For one of the reported occurrences, it was also identified that air traffic control did not challenge two incorrect readbacks of displaced threshold instead of displaced runway end by the flight crew.

One safety issue consistently identified across the occurrences was that lights and markings in use during the construction works were confusing, despite being in accordance with the standards specified in the relevant Civil Aviation Safety Regulations.

“The relevant manual of standards for aerodromes did not recommend or provide standardised options for movement area guidance signs, or other visual aids, to draw flight crews’ attention to the temporary SOT position, especially when that position was distant from a displaced threshold, and not coinciding with a taxiway or runway intersection,” Mr Mitchell explained.

“This investigation highlights how visual cues for the SOT position may be more difficult to identify than those for aircraft landing on a displaced threshold.”

Mr Mitchell noted the Australian standards for aerodrome signs, markings and lighting are based on the International Civil Aviation Organization (ICAO)’s existing standards, but do not include conspicuous visual cues for a displaced start of take-off position. The next amendment of the relevant ICAO Annex will incorporate construction signage, including for a temporary start of take-off position and stating the take-off run distance available.

The Australian Civil Aviation Safety Authority plans to consider inclusion of this signage in future amendments to the aerodrome manual of standards.

“It remains essential for pilots to review all available information before flight, to understand the visual cues necessary to identify both the threshold and SOT positions,” Mr Mitchell said.

“However, runway safety during runway works requires a system-wide approach, including flight crew, airport and aircraft operators, air traffic service providers, and regulators.”

Read the final report: Multiple runway events during aerodrome works at Adelaide Airport, South Australia, 31 March to 20 May 2025

A Cessna 206 triggered an air traffic control terrain alert after conducting a visual flight rules take-off from Archerfield close to last light, an ATSB short investigation report details.

On 24 July 2025, the Cessna 206G was preparing for a training flight under instrument flight rules from Archerfield to Rockhampton. On board was an instructor and a pilot under training for a private instrument rating.

An instrument flight rules (IFR) flight plan was submitted with a departure time of 1730, prior to last light at 1739. CTAF procedures were in place after the Archerfield tower had closed at 1700.

However, the take-off occurred seven minutes later than planned, just two minutes prior to last light, and the instructor elected to conduct a visual flight rules departure, instead of an IFR departure.

This meant when last light occurred shortly after take-off, the aircraft was below the 2,900 ft minimum altitude when it left the circling area, triggering a minimum safe altitude warning at Brisbane Centre ATC.

ATC requested the pilots expedite their climb to at least 3,000 ft, which they did. The flight then continued without further incident.

“Despite the IFR plan, the instructor elected to conduct the VFR Northern departure instead of conducting an IFR departure,” ATSB Director of Transport Safety Stuart Macleod said.

“While it was feasible that the aircraft would reach the required minimum altitude before last light based on their flight plan departure time of 1730, take-off actually occurred 7 minutes later than what was flight planned.”

Mr Macleod said the incident highlights the importance of planning, particularly around times of day when rules change, such as the transition from day to night.

The final report notes the instructor opted for a VFR departure for the IFR flight because they believed it was the preferred method for Brisbane ATC traffic management.

In line with this, during the investigation the ATSB became aware of a potential conflict point over Archerfield Airport, for IFR departures from Archerfield and IFR arrivals into Brisbane Airport runway 01R.

“IFR arrivals to Brisbane runway 01R pass overhead Archerfield at 3,000 ft, which is the same altitude ATC needs IFR departures from Archerfield to climb to in the circling area before departing, creating a potential traffic conflict point for ATC to manage,” Mr Macleod explained.

“This concern is understood by the parties involved, and a project is underway to develop a procedural instrument departure from Archerfield Airport.”

Read the final report: Flight below minimum altitude involving Cessna 206G, VH-ARS, 6 km north-west of Archerfield Airport, Queensland, on 24 July 2025

A mustering pilot was uninjured in a tail strike accident in a Robinson R22 after they immediately applied the correct tail rotor failure technique, as had been included in a recent proficiency check, an ATSB final report details.

The helicopter was one of two being used for mustering cattle on a property in eastern Northern Territory on 1 July 2025 when, as it was working an animal towards a holding yard, the animal baulked and turned away from the mustered direction.

“With limited time to react, the pilot attempted to stop the animal changing direction but, with a tailwind present, did not anticipate the additional power required to flare the helicopter,” ATSB Director of Transport Safety Dr Stuart Godley said.

The helicopter descended in a tail low attitude before the tail rotor struck the ground.

The R22 subsequently began to rotate and the pilot, assessing there was a tail rotor failure, reduced the throttle to decrease the torque, and increased the collective to cushion the aircraft onto the ground.

The pilot estimated that the helicopter had completed 2 or 3 full rotations, and still had some rotation when the right skid made contact with the ground, causing the helicopter to roll over to the right. 

The main rotor blades then impacted the ground and the helicopter came to a stop on its right side, resulting in substantial damage.

“The pilot had recently conducted a proficiency check which included simulated tail rotor failures,” Dr Godley said.

“This likely allowed them to react quickly, and correctly apply the emergency technique, avoiding a more serious accident.”

The pilot was able to exit the helicopter, uninjured, once it came to a rest, and later stated that their wearing of a flight helmet had prevented a head impact during the accident sequence.

“Aerial mustering is a high-risk activity involving low flying, often near obstacles, powerlines and stock,” Dr Godley concluded.

“This accident highlights the benefit of recent emergency training, which in this case likely helped the pilot to react to the tail rotor failure with the correct technique before the helicopter became uncontrollable.”

Read the final report: Tail rotor strike involving Robinson R22 Beta II, VH-HGE, 58 km north‑west of Anthony Lagoon, Northern Territory, on 1 July 2025

An ATSB final report details how features of the airport runway and taxiway contributed to three separate misaligned take-off incidents before first light from Perth Airport’s runway 06.

On 12 June 2023, a Virgin Australia Boeing 737-800 entered Perth’s runway 06 via taxiway V from the south, the investigation report details. As the aircraft turned onto the runway, the crew inadvertently went past the centreline and aligned with the left-hand runway edge lighting.

After this, in two occurrences on 10 August 2023 and 4 April 2024, a Cessna Conquest 441 charter aircraft also entered runway 06 via taxiway V, but from the north. It also turned beyond the centreline, aligning with the right-hand runway edge lighting.

No damage was reported in the first incident involving the 737. During the take-off roll, the crew identified they were misaligned, and manoeuvred to the centreline, continuing the take-off and flight to Sydney without further incident.

During the second incident, the Cessna 441 pilot detected an impact with the aircraft and returned to land in Perth. Subsequent inspection found no aircraft damage, but several damaged runway edge lights.

In the third incident, the Cessna 441 pilot – a different pilot to the prior occurrence but in the same aircraft – heard an unusual noise, but believed it originated from outside the cabin, so continued their take-off and flight to Southern Cross. A runway inspection later that morning found several damaged runway edge lights and, after returning to Perth, the pilot identified minor damage to the aircraft’s right engine propeller.

ATSB Director Transport Safety Kerri Hughes said in all three incidents there were common contributing factors that increased the risk of misaligned take-offs.

“All three occurred before first light, exacerbated by factors specific to runway 06/24, which unlike Perth’s main runway, does not have centreline lighting,” Ms Hughes noted.

“There was also an unlit and unmarked pavement area on each side of the runway, making it appear wider, and the lead-on lights from taxiway V continued across the taxiway to the other side, meaning there was limited guidance when taxiing to the runway centreline.”

After the first two occurrences, Perth Airport submitted a notice to Airservices Australia requesting an update to the Aeronautical Information Publication to highlight the misaligned take-off risk on runway 06. This update was made effective in November 2023.

The airport has also painted chevrons on the extra pavement on either side of runway 06 to delineate this area from the useable runway.

Ms Hughes noted one factor specific to the first incident involving the 737, was the flight crew reported their attention was diverted to completing pre-take-off tasks and their take-off clearance, while lining up on the runway.

Following that occurrence, Virgin Australia revised its before take-off procedure to reallocate tasks earlier in the taxi to reduce flight crew workload during line-up.

The airline also added caution notes to its Perth Airport supplementary port information about centreline misidentification on runway 06, and developed case studies involving this event, which were incorporated into non-technical skills training.

The operator involved in the latter two occurrences, Western Sky Aviation, distributed notices to its flight crew, including strategies to check runway alignment prior to take-off.

“The features of airport runways and taxiways can vary, and at times the combination of these features can increase the risk of runway misalignments,” Ms Hughes said.

“This can be exacerbated at night-time, when the amount of visual information available is markedly reduced. These reduced visual cues can affect pilots even when they are familiar with an airport.”

The ATSB’s final report also encourages pilots to report any circumstances where they believe they may have conducted a misaligned take-off, to limit the risk to their aircraft and others subsequently using the same runway.

“This would also allow aerodrome operators to identify any trends or emerging misaligned take-off hotspots, and consider mitigations,” Ms Hughes concluded.

Read the final report: Misaligned take-off occurrences on runway 06 at Perth Airport, Western Australia