Aviation safety investigations & reports

Hard landing involving Kavanagh B-350 hot-air balloon, VH-EUA, 6 km ENE of Yarra Glen, Victoria on 8 February 2018

Investigation number:
AO-2018-016
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

Download final report
[Download  PDF: 2.22MB]
 

What happened

On 8 February 2018, a Kavanagh B-350 hot-air balloon, registration VH-EUA, operated by Go Wild Ballooning, departed Glenburn, Victoria for a scenic charter flight with a pilot and 15 passengers on board. About 45 minutes into the flight, over the Yarra Valley, the balloon experienced a sudden wind change with associated turbulence. The pilot decided to land immediately rather than continue over rising and heavily vegetated terrain. The resulting landing was hard and fast and 11 passengers were injured, with four of them receiving serious injuries.

What the ATSB found

The ATSB found that information about the sudden wind change was not available to the pilot prior to the flight. In particular, the most recent local balloon forecast (provided in a recorded telephone message) was inadvertently not publicly available, and other forecast information available to the pilot did not accurately state the timing of the wind change. The ATSB identified a safety issue with the procedure used by the Bureau of Meteorology to confirm the local weather forecast for balloon operators in the Melbourne area was correctly uploaded and therefore available.

Although some passengers were provided with a safety briefing prior to boarding the balloon, the operator’s normal safety briefing for passengers post boarding was not conducted. In addition, the briefing prior to boarding was not effective in ensuring all passengers understood the required landing position to use in the event of an emergency landing. The ATSB identified a safety issue with the operator’s risk controls for ensuring safety briefings were conducted, and that passengers understood the briefing and the availability and content of its safety information cards.

What's been done as a result

The Bureau of Meteorology has commissioned a new system and modified its procedures for providing local weather briefings to balloon operators in the Melbourne area. This new recording system automatically uploads the recording to the automated telephone service.

The operator has implemented a procedure that all passengers are required to demonstrate the landing position after boarding the aircraft. In addition, the operator has implemented procedures for all pilots to share wind and weather conditions to optimise safe and suitable launch sites in addition to conducting more regular checks of nearby aerodrome weather information.

Safety message

Pilots are reminded that good command judgement is required for all operations when actual weather conditions do not appear as forecast.

In relation to the emergency descent and landing, this accident highlights the importance of operators briefing balloon passengers about what to do in an emergency and the landing position. Proper preparation for landing is shown to reduce the likelihood and severity of injury, and operators should ensure that passengers understand the instructions provided. It is recommended that all passengers should board the basket and practice the position they should adopt for landing. This allows the operator to determine any misunderstanding prior to flight.

It is also recommended that safety information cards, with diagrams, be readily available to help communicate important safety information, particularly to people from a non-English speaking background.

Download final report
[Download  PDF: 2.22MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Media

Download VIDEO: ATSB Final Balloon VH-EUA Yarra Glen Patrick Hornby [MP4 227.64MB]

Download AUDIO: Grab 1: Balloon VH-EUA Patrick Hornby [MP3 224KB]

Download AUDIO: Grab 2: Balloon VH-EUA Patrick Hornby [MP3 230KB]

Download AUDIO: Grab 3: Balloon VH-EUA Patrick Hornby [MP3 190KB]

Download PDF: Transcript VH-EUA download [PDF 211KB]

To download, click the link, then right-click and select Save As.

Copyright in material obtained from other agencies, private individuals or organisations, belongs to those agencies, individuals or organisations and should be credited accordingly.

General details
Date: 08 February 2018   Investigation status: Completed  
Time: 0705 AEDT   Investigation phase: Final report: Dissemination  
Location   (show map): near Yarra Glen (Bleases Lane)   Investigation type: Occurrence Investigation  
State: Victoria   Occurrence type: Hard landing  
Release date: 30 October 2018   Occurrence class: Operational  
Report status: Final   Occurrence category: Accident  
  Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Kavanagh Balloons  
Aircraft model B-350  
Aircraft registration VH-EUA  
Serial number B350-368  
Operator Go Wild Ballooning  
Type of operation Ballooning  
Sector Balloon  
Damage to aircraft Minor  
Departure point Glenburn, Vic.  
Destination Chateau Yering, Vic.  
Last update 03 December 2018