Aviation safety investigations & reports

Ground handling event involving Kavanagh B-400 Balloon, VH-LNB, near Coldstream, Victoria, on 16 March 2019

Investigation number:
AO-2019-014
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final Report

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What happened

On 16 March 2019, two passengers were seriously injured when the basket of a Kavanagh B‑400 hot‑air balloon tipped over during vehicle-assisted deflation.

Prior to the accident, the balloon, operated as a scenic charter flight, landed without incident at a private property near Coldstream, Victoria.

Due to a lack of wind and the large size of the envelope, the crew elected to use the retrieval vehicle to assist by pulling the envelope over (by the crown line) during the deflation.

During this process, with 16 passengers and the pilot on board, the vehicle assisting inadvertently pulled the basket over, seriously injuring two passengers.

What the ATSB found

The ATSB found that the operator had not conducted a risk assessment around the use of a vehicle to assist in the deflation process. Although not required by regulations, the lack of a risk assessment likely left the operator and crew unaware of the risks associated with the vehicle-assisted deflation, and without appropriate procedures to control those risks. Consequently, a communication breakdown between the pilot and vehicle driver led to the basket tipping, and the passengers were unprepared and not in landing positions during the deflation process - increasing their likelihood of injury.

The ATSB also found that the Civil Aviation Safety Authority had not provided guidance to commercial balloon operators concerning the risks associated with vehicle‑assisted deflation. This likely contributed to the limited awareness commercial operators had of the risks associated with vehicle‑assisted deflation. Further, with substantial growth in the number of large, Australian-registered balloons requiring vehicle-assisted deflation, this is an ongoing safety risk.

What's been done as a result

The operator has updated their procedures to reduce the probability of a communication breakdown during the deflation process and is requiring the pilot to instruct passengers to assume landing positions during any vehicle-assisted deflations.

CASA has indicated they will publish an advisory circular, which will include guidance on deflation of hot air balloon envelopes using a vehicle to assist.

The ATSB has released a safety advisory notice (AO-2019-014-SAN-014) to all commercial balloon operators about the risks associated with vehicle‑assisted deflation, as identified in this report.

Safety message

This investigation highlights that gradual changes to operational procedures, while possibly perceived as inconsequential, have the potential to conceal new or emerging safety risks. A thorough assessment of any introduced changes should identify these new risks and allow their mitigation or reduction to an acceptable level.

This investigation also highlights that an increase in the number of aircraft and occupants (passengers and crew) exposed to a hazard has a compounding effect that, in a relatively brief period, can increase the overall risk significantly.

Download final report
[Download  PDF: 688KB]
 
 
Alternate: [Download  DOCX: 799KB]
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

Safety Issues

Go to AO-2019-014-SI-01 - Go to AO-2019-014-SI-02 - Go to AO-2019-014-SI-03 -

Risk management processes

Picture This Ballooning's safety risk management processes and practices were not sufficient to facilitate the identification of key operational risks associated with vehicle-assisted deflation.

Safety issue details
Issue number: AO-2019-014-SI-01
Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation
Status: Closed – Adequately addressed

Vehicle-assisted deflation procedures

Picture This Ballooning did not have any procedures for conducting vehicle-assisted deflation.

Safety issue details
Issue number: AO-2019-014-SI-02
Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation
Status: Closed – Adequately addressed

Guidance on vehicle-assisted deflation risks

The Civil Aviation Safety Authority provided no guidance for operators concerning the risks associated with vehicle‑assisted deflation.

Safety issue details
Issue number: AO-2019-014-SI-03
Who it affects: Commercial Balloon operators that use a vehicle to assist during deflation
Status: Open – Safety action pending
General details
Date: 16 March 2019   Investigation status: Completed  
Time: 0830 EDT   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 5 km NE of Coldstream   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Ground handling  
Release date: 29 June 2020   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Kavanagh Balloons  
Aircraft model B400-440  
Aircraft registration VH-LNB  
Serial number B400-440  
Operator Picture This Ballooning  
Type of operation Ballooning  
Sector Balloon  
Damage to aircraft Nil  
Departure point Private property near Dixons Creek, Victoria  
Destination Private property near Coldstream, Victoria  
Last update 29 June 2020