Ground operations - Other

What happened

On 10 July 2022, a group of skydivers were preparing for a jump that was to be filmed by an instructor.

At about 0850 local time, the pilot of the Cessna 182 taxied the aircraft to the passenger emplaning area and prepared to hot load[1] the skydivers. The proposed jump had an instructor positioned either side of the student in the doorway and a third instructor located outside the aircraft to capture the groups freefall. The group conducted a practice exit before the instructor filming repositioned themselves in front of the wing strut to show the student where they would be located when they completed the jump.

The pilot, recognising the instructor’s proximity to the spinning propeller, attempted to get their attention. The instructor filming was focussed on the jumpers and took a small step backwards towards the propeller at which point the pilot immediately shut down the engine. The instructor took another step backwards and away from the fuselage of the plane to simulate their own freefall and their hand was struck by the propeller. Although the engine had been shut down, the propeller was still spinning. The instructor received serious injuries to their hand.

Guidance on hot loading

Hot loading is a common practice in skydiving operations. Guidance provided by the Australian Parachuting Federation[2] (APF) to its members in the

The jump pilot faces a greater risk of having someone walk into the propeller than does a pilot working in any other environment.

To mitigate the risk of this happening, the manual suggested that skydivers and staff should approach the aircraft from the rear where possible. Skydivers and instructors were taught to be propeller aware with posters from the APF warning of the dangers associated with spinning propellers. Additional procedures for movement around aircraft were left to the operator. In this instance, the operator’s procedures specified that any task that required a person to be positioned forward of the wing strut was to be conducted on a mock-up airframe or with the engine shutdown.

Regulatory changes

The loading of passengers with engines running and the requirement to brief passengers for this particular activity was previously covered in Civil Aviation Orders section 20.9.5 (CAO). Following CASA’s regulatory framework reform, numerous CAO were incorporated into Part 91—­­­­­General operating and flight rules and Part 138—Aerial work operations, of the Civil Aviation Safety Regulations 1998 (CASR). Part 105 of the CASR set out the operational requirements for aircraft used to facilitate parachute descents. These were in addition to Part 91 which also applied to parachuting operations.

While hot loading was covered in Part 138, there were no regulations that applied to the loading of passengers with engines running during skydiving operations in Part 91 or Part 105. CASA advised the ATSB that while less prescriptive than the previous regulation set, the practice of hot loading would be accepted if certain requirements were met:

CASR 91.055 is of general application and requires the pilot in command to not create a hazard to other aircraft, persons, or property. The hazards of loading passengers while the engines are running are significant and CASA would not see this activity as being able to be safely achieved without creating a hazard unless it was conducted by an operator with the organisational structure and procedures to adequately manage those hazards in the context of the operation.

The APF produced guidance material for parachuting operators with the requirements for safety on the ground contained within a number of manuals, including the Training Operations Manual and the Jump Pilots Manual.

Safety action

The operator advised the ATSB that they have taken the following safety action in response to this accident:

• Banned jumpers from conducting practice exits from the aircraft while the engine is running.
• Mock-up aircraft cabin is planned for refurbishment to facilitate practice exits.
• Ground control officer has been made responsible for supervising the boarding of aircraft
• Safe routes to the loading area have been defined.
• Signage refurbished and placed in prominent areas warning of the dangers associated with propellers.
• Conducted briefings with all regular jumpers and staff about the seriousness of this incident and re-iterated the importance of remaining vigilant in the vicinity of aircraft.

Safety message

Hot loading is a common practice in parachuting operations and the commercial benefits of not shutting down an aircraft’s engines needs to be measured against the increased risk to the proposed activity. Clear and workable procedures are critical in ensuring the risk is reduced to as low as reasonably practicable.

In this accident, the instructor was in a hazard-rich environment completing a task that did not necessitate the engine to be running at the time. In addition to a knowledge and understanding of risks present in the operational environment, crew must be especially vigilant in the vicinity of operating aircraft.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report and allow for greater industry awareness of potential safety issues and possible safety actions.

What happened

On 9 April 2018 at 0700 Eastern Standard Time (EST), the pilot of a Kavanagh G-450 balloon was on final approach to land near Mareeba, Queensland (Qld) with a pilot and 11 passengers on board.

Having received advice by radio from the pilot of a balloon that had already landed, the pilot anticipated a fast landing at approximately 6 kt, descending rapidly after passing over tall trees and stopping before reaching a barbed-wire fence on the downwind side of the paddock.

Before descending, the pilot contacted the ground crew by radio and asked them to provide “weight on” during the landing, to reduce the distance the basket may be dragged before stopping. This is a commonly used strategy in confined landing areas, overcoming the buoyancy of the balloon by adding the weight of the ground crew to that of the balloon and its occupants.

The ground crew moved to the anticipated landing site and waited for the balloon, but rather than remaining at the edge of the paddock, monitoring the balloon’s progress and only moving in once it had passed, one of the ground crew entered the paddock before the balloon arrived.

The ground crew member was walking across the paddock, away from the rapidly descending balloon, but directly in its path, when the pilot shouted a warning. The crew member immediately dropped to the ground and the balloon’s basket passed overhead. The balloon landed safely, and the ground crew member, pilot and passengers were not injured. The other two members of the ground crew remained behind the basket and were not at risk.

If the ground crew member had not heard the shouted warning and responded immediately, the consequences may have been significant. The ground crew member could have been struck by the loaded basket.

The operator’s training manual did not specifically prohibit ground crew members from placing themselves beneath the path of the balloon during landing and the ground crew member, although experienced in performing operational support tasks, was focussed on walking through the long grass and weeds in the paddock, rather than watching the approaching balloon.

Safety action

As a result of this occurrence, the balloon’s operator has advised the ATSB that they have spoken to the ground crew member about the lack of situational awareness and poor risk assessment. The operator intends to amend the company’s training manuals and ensure incidents of this type are covered in the initial and annual emergency procedure checks for all ground personnel.

The company’s Chief Pilot advised all flight and ground crew members of the incident, outlined the expectations when working or walking near balloons in low-level flight, and made the following recommendations:

• Never position yourself in a location where the basket will pass directly overhead. Balloons can be subject to low-level turbulence or last-minute inputs by the pilot (such as venting) and can descend rapidly and unexpectedly.
• When you are close to a balloon in flight, even if it is still attached to the quick release, keep your eyes on the balloon at all times to ensure you know where it is going. Ensure that the balloon does not pass overhead. If it does, react immediately and move to a safe area away from the basket.
• Do not make assumptions on the pilot’s intentions. These may vary from day to day, depending on the circumstances.
• When asked to put weight on during a landing remain off to the side of the basket until it has passed and then move in from behind.

Safety message

The Australian Ballooning Federation's Pilot Training Manual Part 5 "Aerostatics and Airmanship" describes the responsibilities and duties of the pilot and ground crew in detail.

The U.S. Department of Transportation Federal Aviation Administration’s Balloon Flying Handbook is another detailed and valuable resource. In its section on Human Resources, the handbook notes that balloons differ from aircraft in their reliance on unlicensed, non-certified and even first-time volunteers to support ground handling of the balloon.

The handbook goes on to make the point that “while all final decisions and the responsibility for safety still rest with the pilot, this broader than usual safety resource management model recognizes the human resources upon which every pilot relies for safe flight planning and decision-making”.

About this report

Decisions regarding whether to conduct an investigation, and the scope of an investigation, are based on many factors, including the level of safety benefit likely to be obtained from an investigation. For this occurrence, no investigation has been conducted and the ATSB did not verify the accuracy of the information. A brief description has been written using information supplied in the notification and any follow-up information in order to produce a short summary report and allow for greater industry awareness of potential safety issues and possible safety actions.