Aviation safety investigations & reports

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

Investigation number:
AO-2022-003
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase

Final

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What happened

On 31 December 2021, a Kavanagh B-350 hot-air balloon, registered VH BSW and operated as a scenic charter flight by Picture This Ballooning (PTB), was being prepared near Glenburn, north of the Yarra Valley, Victoria, with one pilot and 16 passengers. The pilot conducted a pre-flight safety briefing and departed shortly after, intending to land near Yarra Glen.

About 42 minutes into the planned 1‑hour flight, the pilot received a report that the surface wind near the landing area was increasing. The pilot assessed multiple landing options over the next 17 minutes while the wind was increasing. The pilot then made an approach to a landing field and the balloon landed hard with 2 passengers seriously injured.

What the ATSB found

The ATSB found that the pilot rejected several suitable landing fields to avoid possible post‑landing logistical and operational difficulties. This progressively reduced the safe landing sites available to the pilot.

The field in which the pilot decided to land contained fences not previously known to the pilot, powerlines downwind, and no known landing sites further along the balloon's track. This landing site presented high risks in the prevailing windy conditions.

The landing was complicated by the balloon descending faster than intended, bouncing off the ground back into the air, and then manoeuvres to clear fences. These factors, in combination with the prevailing winds and nearby power lines, led to the pilot descending the balloon rapidly from an excessive height resulting in the hard landing.

The investigation also found that all required actions of the pre-flight passenger safety briefing were not completed, probably due to time pressure and the pilot’s assumption that all passengers would understand an abbreviated briefing. The incomplete briefing probably resulted in 2 passengers adopting a deep squat position during the hard landing, causing their injuries.

The ATSB further identified 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 them to adopt the landing position specified in the operator's procedures to reduce the risk of injury.

What has been done as a result

The balloon operator has reduced the maximum number of passengers that the balloon can carry to ensure that all passengers can achieve the required backwards facing landing position. The operator is also reviewing maximum passenger capacities on all of its balloons.

Safety message

This accident demonstrates the importance of passengers adopting the correct body position during landing to reduce the likelihood and severity of injury. The pre-flight briefing is critical in ensuring passenger preparation, particularly as opportunities to reinforce the information during flight may be limited. Pilots should use all available resources (such as, passenger demonstrations and safety briefing cards) to ensure that each passenger understands the landing position and its importance. Further, commercial balloon operators are reminded to ensure that all passengers can physically achieve the required landing positions to reduce the risk of injury.

When faced with deteriorating wind conditions, pilots should prioritise occupant safety in the selection of a landing field. This reduces the risk of a hard landing or accident. Post flight logistical or operational considerations are of secondary importance.

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[Download  PDF: 1.34MB]
 
 
 

The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Glossary

Sources and submissions

Australian Transport Safety Bureau

Summary

The Australian Transport Safety Bureau (ATSB) is investigating a hard landing involving Kavanagh Balloons B-350, registered VH-BSW, that occurred 2 km south of Lilydale Airport, Victoria on 31 December 2021.

While landing in windy conditions, the balloon initially touched down in a field before the pilot decided to manoeuvre the balloon over the fences of adjacent fields to land. While landing, the balloon’s basket was dragged about 30 metres before coming to rest, resulting in serious injuries to two of the 16 passengers on board.

As part of the investigation, ATSB investigators will examine weather data, operator procedures, and interview the pilot and relevant witnesses.

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 safety action can be taken.

Safety Issue

Go to AO-2022-003-SI-01 -

Passenger brace positions

The maximum number of passengers that the balloon operator allowed to be carried meant that there was insufficient room in the basket for them to adopt the landing position specified in the operator's procedures to reduce the risk of injury.

Safety issue details
Issue number: AO-2022-003-SI-01
Status: Closed – Adequately addressed
General details
Date: 31 December 2021   Investigation status: Completed  
Time: 0650 AEST   Investigation level: Defined - click for an explanation of investigation levels  
Location   (show map): 2 km south of Lilydale Airport   Investigation phase: Final report: Dissemination  
State: Victoria   Occurrence type: Hard landing  
Release date: 18 August 2022   Occurrence category: Accident  
Report status: Final   Highest injury level: Serious  

Aircraft details

Aircraft details
Aircraft manufacturer Kavanagh Balloons  
Aircraft model B-350  
Aircraft registration VH-BSW  
Serial number B350-399  
Operator PICTURE THIS BALLOONING PTY. LTD.  
Sector Balloon  
Damage to aircraft Nil  
Departure point Glenburn, Victoria  
Destination Yarra Valley, Victoria  
Last update 18 August 2022