Aviation inquiry 12-001:
Hot-air balloon collision with power lines and inflight fire, near Carterton, on 7 January 2012
Final inquiry report – media conference remarks John Marshall QC – Chief Commissioner – Transport Accident Investigation Commission

The Carterton hot air balloon accident was New Zealand’s worst aviation tragedy since Erebus in 1979 and at the time it was the world’s second worst hot-air balloon accident on record.

The Commission’s report is the result of a lengthy and detailed investigation into the causes and circumstances of the accident. Our objective is to avoid something like this ever happening again.

It is not our job to apportion blame or liability and our reports generally cannot be used as evidence in a court of law. The Commission is independent of any other interest, including government and government agencies. We have the powers of a Commission of Inquiry to do our work, and we have used these powers in this case. The preliminary sections of the report, particularly “Conduct of the Inquiry” explain more about our status and the steps taken in this particular inquiry.

The Commission’s findings – which I shall deliver shortly - are drawn out through the analysis section, section 4, of the report, and then drawn together and repeated at section 5. Mr McClelland will take you through most of the topics of analysis shortly, during which he will also outline safety actions that have been taken on some of the safety issues identified, and we will also take questions at the end of our presentation.

In the interim report delivered in May 2012 we noted that post mortem blood tests showed that the pilot had a level of cannabis in his system. The Commission has given considerable attention to this issue and we have made an important recommendation which I shall return to at the end of this presentation. At that stage I will also expand on our findings in relation to that issue.

These are the findings of the Transport Accident Investigation Commission’s “aviation inquiry 12-001, Hot-air balloon collision with power lines and inflight fire, near Carterton, on 7 January 2012” : •The weather conditions were suitable for the balloon flight that morning.

•The pilot allowed the balloon to descend below the level of power lines surrounding a paddock in which he did not intend to land. It could not be determined whether that action was deliberate or not, but it unnecessarily compromised the safety of the flight.

•It was highly likely that the pilot knew the location of the power lines and had seen them before allowing the balloon to descend below their height.

•A last-minute change in wind direction carried the balloon towards power lines that the loaded balloon was probably not capable of outclimbing.

In any event, the pilot exercised poor judgement by attempting to out-climb the power lines, and the balloon collided with them.

•Electrical arcing from the power lines punctured one of the balloon’s LPG fuel cylinders, causing an intense fuel-fed fire that consumed the basket and increased the air temperature in the balloon envelope.

•The pilot’s initial application of the burners caused the balloon to climb. Heat from the basket fire and to a lesser extent 2 of the balloon passengers jumping from the basket increased the balloon’s lift and caused it to break the power line that was restraining it. It then ascended rapidly and fell to the ground once the envelope caught fire.

•Once a collision with power lines is imminent, the recommended action is for the pilot to descend the balloon rapidly. Had he done so there would have been a better chance of survival for the balloon’s occupants.

•The pilot did not have a current medical certificate as required by Civil Aviation Rules. This was unlikely to have contributed to this accident in any way, but it did show a disregard for complying with the rules.

•The pilot had a post-mortem THC blood level of 2 micrograms per litre. This was likely the result of 2 factors: the pilot smoking cannabis shortly before the flight (considered highly likely), and residual THC from his having ingested cannabis over a longer term that redistributed into his blood after he died. It was not possible to determine if either factor contributed more or less to the toxicology result.

•The accident was caused by errors of judgement by the pilot. The possibility that the pilot’s performance was impaired as a result of ingesting cannabis cannot be excluded.

•The long-term and recent ingestion of performance-impairing substances such as cannabis by crew of any transport vehicle is a serious safety issue that needs to be addressed as a matter of priority.

•The regulatory oversight of commercial ballooning in New Zealand was not sufficient to ensure a safe and sustainable industry for the New Zealand public.

•It is a safety issue that a person without any prescribed training, knowledge or medical certificate can take non-paying passengers for a balloon flight.

•The basic design and safety of the balloon were adequate and improvements in the design would not have altered the outcome of this accident.

Those are the findings. Mr McClelland will now take us through the analysis.

Ian McClelland, Investigator-in-Charge
The Flight:
The balloon became airborne at 0638 and climbed steadily to altitude. For the next 30 minutes it operated between about 400 and 600 metres as it drifted slowly around the local area in the light and erratic winds. The calculated flightpath of the balloon is based on a combination of Global Positioning System or GPS data recovered from the wreckage, photographs and eye-witness accounts.

At about 0712, after crossing Somerset Road near State Highway 2, the balloon was descended in preparation for landing. All indications are of the flight preceding normally.

As the balloon was descended the flightpath direction changed and the balloon crossed Somerset Road again as it drifted now in a more north-easterly direction just above tree height.

Approximately 500 metres north-east of Somerset Road, the flightpath changed yet again, and the balloon started drifting back towards Somerset Road. After crossing into what has been referred to as the silage paddock, adjacent to Somerset Road, the balloon descended down to about 5 metres.

This is the height of the basket above ground level.

As the balloon continued across the silage paddock there was a wind shift, with the balloon now flying in a more southerly direction towards a farm house near the paddock boundary. Shortly after the pilot was heard to call out “Duck down”. This is the first indication that something was wrong.

The basket was then seen to catch underneath the 33 000 kilovolt power line - lifting 2 of the wires as it continued to climb and slide along the power line and over a farm track. There was an arcing as an electrical circuit was made between the 2 wires and the metal in the basket. This included one of the fuel cylinders, resulting in a small hole, allowing fuel to escape under pressure and generate an intense fire. The balloon continued to climb from a combination of the sustained use of the burners before the basket caught on the wires, and the heat from the fire directly under the mouth of the envelope. Two of the occupants escaped the advancing fire by jumping overboard.

The reduction in weight did not however alter the eventual outcome with the wire parting and the ballooning climbing rapidly to about 150 m before falling to the ground.

The Accident Site:
The radio calls made by the pilot indicate he was preparing to land somewhere around the Somerset Road area. However, in light wind conditions the direction of the breeze can change often, and so pilots need to be flexible in selecting a suitable paddock to land in. The silage paddock was not considered to be the intended landing area for 4 main reasons: Firstly, the basket was not orientated for landing.

Secondly, there were several rows of sprinklers operating in the paddock and it would have been unwise to let either the balloon envelope or the passengers get wet.

Thirdly, the passengers were not in their braced landing positions in preparation for landing.

And fourthly, if this was the intended landing area, the pilot would likely have advised the ground crew as part of their radio conversation made a few minutes before striking the power line.

There were numerous suitable landing areas further on and ample fuel available to continue flying for at least another 45 minutes.

A question therefore is, why stay at low level?

The pilot may have wanted to stay with the southerly drift and continue heading south across Somerset Road. He may also have wanted to land immediately after crossing Somerset Road. We will never know the exact reason. Regardless, it was not safe practice to descend and stay at low level below the height of the power lines as the balloon continued across the paddock.

Power lines:
Therefore a second question is, did the pilot see the power lines?

Wires are a well-known hazard when flying at low level and account for the majority of balloon injuries. They are numerous and can be difficult to detect.

However, pilots are trained to look for wires and the pilot of the balloon was both experienced in flying balloons and very familiar with the local area. He was also aware of the dangers of power lines, having been involved in a collision with a power line some 12 years previously.

The pilot had landed in the Somerset Road area before. He had also crossed the power line he later struck only a few minutes before the accident when the flightpath changed about 500 m from Somerset Road.

As the balloon crossed the silage paddock the poles running both along Somerset Road and the adjacent farm track were easily visible.

For these reasons the inquiry determined that the pilot was highly likely to have both aware of the power lines and seen them as he entered and flew at low level across the paddock.

The Balloon:
The inquiry could not identify any fault with the balloon that would likely have contributed to the accident.

The inquiry raised concerns about the general maintenance of this and other balloons. An urgent safety recommendation was made to the Director of Civil Aviation to address this issue before the start of the various balloon fiestas around the country.

Because of the small number of balloons, the CAA had relied on industry expertise to help ensure balloons were correctly maintained. While appearing to be a simple aircraft, balloons nevertheless, need to be maintained in strict accordance with the prescribed rules and procedures.

The resulting safety actions by the CAA addressed the initial safety concerns.

The Commission later became aware of an Aviation Related Concern or ARC relating to balloon maintenance. I will talk more on this shortly.

Pilot Performance:
The pilot was an experienced balloon pilot, having accumulated over 1000 flying hours during some 15 years of commercial ballooning. He was aware of the Civil Aviation Rules for maintaining a current commercial pilot licence, including the requirement for a current medical certificate.

He had also received a reminder from his medical examiner confirming his medical certificate was about to expire.

The inquiry could find no reason why he had allowed his medical certificate to lapse and subsequently fly 9 commercial flights over the next 6 weeks leading up to the accident. He was reportedly healthy and the gout was unlikely to have prevented him from maintaining his medical certificate.

The CAA’s investigation of the Aviation Related Concern filed against the pilot in February 2010 found nothing that would have prevented the pilot holding an aviation document. It was not possible to say whether a more rigorous follow-up of the concern by CAA would have prevented this accident.

What was identified was the need for prompt and robust handling of ARCs to identify potential safety issues as early as possible. The CAA has acted upon this and other concerns raised in the report and initiated a range of safety actions.

Safety Actions:
I have already talked about balloon maintenance and the related urgent safety recommendation made. As a result a CAA safety inspection team visited the 5 maintenance providers approved to work on balloons. This has resulted in a range of actions and an improvement in the standard of maintenance and documentation.

The CAA is introducing a private pilot licence rating for balloon pilots and also an instructor rating. In April this year, the CAA issued a new flight test standards guide for commercial balloon pilots. The new qualifications and documents should provide for better training and standardisation of balloons pilots.

The introduction of the new Rule Part 115 for Adventure Aviation will also allow for improved management of balloon operators and activities.

The CAA has initiated a range of actions concerning the receiving, coordination, management, resource allocation and record keeping of ARCs.

While there will no doubt continue to be the occasional minor or frivolous report, the revised system should be more responsive to genuine concerns being raised and initiating appropriate action.

One of those safety concerns is substance abuse. Chief Commissioner Marshall will continue.

John Marshall QC
The Commission found that the accident was caused by errors of judgement made by the pilot. There were three: 1. Descending below the power lines in a paddock in which we do not believe he intended to land.

2. Attempting to out-climb the power lines as the wind took the balloon towards them.

3. Not following the recommended course and making an emergency descent once contact with the power lines was imminent.

It is totally unacceptable for anyone in a safety-critical transport role, such as a pilot, to be working while impaired by a substance, whether legal or not.

Cannabis has both short and long term impact on judgement depending upon the person, the quantity, and the frequency of use.

The pilot was a cannabis user; cannabis was found in post-mortem samples, and based on the evidence of witnesses who saw him smoking, and on the toxicological evidence, the Commission considered it highly likely he smoked cannabis before the flight.

The two witnesses who saw the pilot smoking shortly before the flight gave evidence to the Commission, and their observations were consistent. The pilot was not a tobacco smoker, and his urine tested negative for the marker of tobacco.

The expert toxicologist engaged by the Commission advised that the level of 2 micrograms per litre of THC which was found in the pilot’s blood sample, strongly suggested recent use of cannabis on the morning of the accident.

The toxicology report from the Institute of Environmental Science and Research was to the same effect.

The Commission’s expert toxicologist also concluded that QUOTE “cognitive impairment at or around the time of the accident, and its contribution to the cause of the accident, cannot be excluded, given the carry over effect of cannabis” END QUOTE.

Having considered all the evidence, the Commission found that the accident was caused by errors of judgement by the pilot, and the possibility that the pilot’s judgement was impaired by the use of cannabis cannot be excluded.

The Commission also believes that the use of cannabis, or other performance impairing substance by anyone in a safety critical role in the transport industry is a serious safety issue that needs to be addressed as a matter of priority.

The Commission has investigated six occurrences in the last 10 years where persons operating aircraft, vessels or rail vehicles, or where persons performing functions directly relevant to the safe operation of these, have tested positive for performance-impairing substances. Thirty-four people have died in these accidents. While substance impairment may not have been a cause, its presence and potential to be so is a matter of real concern to the Commission. There are also many more accidents, including fatalities, which do not reach our threshold for inquiry and are investigated by other agencies.

There have been some positive developments. In November last year the Minister of Transport approved a new rule requiring adventure aviation operators to: “Establish a drug and alcohol programme for monitoring and managing the risks relating to the use of any drug, or consumption of alcohol by…any person…whose work directly affects the safety of an adventure aviation operation."

Operators were required to have this drug and alcohol programme in place by mid-March this year. This should give increased confidence in the adventure aviation industry and help reduce the risk of a recurrence.

Also many, particularly larger transport organisations in New Zealand, such as KiwiRail and Air New Zealand have introduced drug and alcohol management programmes that would appear to go a long way towards meeting the Commission’s recommendation.

The Commission has previously made recommendations to the appropriate government agencies concerning drugs and alcohol. These recommendations remain open. We have – in essence – rolled them up and restated them in a single recommendation today.

The Commission is calling for legislation or rules across the aviation, rail and marine sectors – including recreational boating – that:

1. set maximum limits for alcohol

2. prohibit people operating aircraft, vessels or rail vehicles if they are substance impaired

3. require operators to implement drug and alcohol detection and deterrence regimes, including random testing

4. prescribe post-occurrence testing requirements for drugs and alcohol.

We note that the Ministry of Transport has commissioned research on the question of developing a post-occurrence testing regime, and the Ministry sees the results of any such study as being necessary to inform whether limits should be set, and detection and deterrence regimes put in place.

The Commission has not formally considered the Ministry’s response as it was received just a few days ago, however I would observe that maximum limits and testing for alcohol and drugs, including random testing, is accepted practice in road transport in New Zealand, and in other modes in other jurisdictions. I would also observe that accidents such as this one – in addition to the personal tragedy and community impact - can affect New Zealand’s reputation, and have economic impacts that extend well beyond those immediately involved.

The Commission has done its job of a conducting an exhaustive, independent inquiry to find out what caused the Carterton tragedy.

Substance impairment has again been highlighted as an issue. We have made yet another recommendation. It is time for public debate and action.

As I said at the beginning, it our objective to ensure that something like this never happens again.

ENDS

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