2012 Carterton hot air balloon crash

2012 Carterton hot air balloon crash

250 px ZK-XXF, the balloon that crashed
Accident summary
Date	7 January 2012, 07:22 NZDT (18:22, 6 January UTC)
Summary	Pilot error causing power line contact and onboard fire
Site	Clareville, near Carterton, New Zealand
Passengers	10
Crew	1
Fatalities	11 (all)
Survivors	0
Aircraft type	Cameron A-210 hot air balloon
Aircraft name	Mr Big
Operator	Early Morning Balloons Ltd
Registration	ZK-XXF
Flight origin	Carterton, New Zealand
Destination	Carterton, New Zealand

On 7 January 2012, a scenic hot air balloon flight from Carterton, New Zealand, collided with a high voltage power line while attempting to land, causing it to catch fire, disintegrate and crash just north of the town, killing all eleven people (ten passengers and the pilot) on board.

An inquiry into the accident by the Transport Accident Investigation Commission (TAIC) concluded that the balloon pilot made an error of judgement when contact with the power lines became imminent, trying to out-climb the power lines rather than using the rapid descent system to drop the balloon quickly to the ground below. Toxicology analysis of the balloon pilot after the accident tested positive for tetrahydrocannabinol (THC), suggesting he may have been under the influence of cannabis at the time of the crash, which ultimately led to the error of judgement. It was the sixth accident in ten years the TAIC had investigated (the TAIC also investigates marine and rail accidents) which involved key people testing positive for drugs or alcohol, and it has called for the Government to enact stricter measures in regards to drug and alcohol use in the aviation, marine and rail industries.

The crash was the deadliest air disaster to occur in mainland New Zealand since the July 1963 crash of New Zealand National Airways Corporation Flight 441 in the Kaimai Ranges, and the deadliest crash involving a New Zealand aircraft since the November 1979 crash of Air New Zealand Flight 901 into Mount Erebus. As of January 2015 it is the third-deadliest hot air balloon disaster on record after a 2013 balloon crash in Egypt that killed 19 people, and the 1989 crash in the Northern Territory, Australia that killed 13.

Background

The balloon was a Cameron A-210 model, registered ZK-XXF and named Mr Big. The envelope was manufactured in the United Kingdom in 1997, and was initially used in the United Kingdom before being purchased and imported into New Zealand by Early Morning Balloons Ltd in 2001. The basket and burner system, capable of carrying ten passengers plus pilot, were manufactured in 1989 and were previously used with a Thunder and Colt 160A envelope before the envelope was retired at the end of its useful life

The balloon took off at 6:38 am from its launching area in Carterton, a town of 4100 people in north-eastern Wellington Region, on a 45-minute scenic flight over the Carterton area, carrying ten passengers. The Masterton-based pilot was one of New Zealand's most experienced balloon pilots, with more than 10,000 hours flying time, and was the safety officer for the "Balloons over Wairarapa" hot air balloon festival, held annually in March around the Carterton and Masterton area. The ten passengers were all from the greater Wellington Region: two husband-and-wife couples from Masterton and Wellington, a couple from Lower Hutt, a boyfriend and girlfriend from Wellington, and two cousins from Masterton and Paraparaumu. At the time, the weather was clear, with sufficient light and little wind. Data collected from weather stations at six nearby vineyards confirmed that the wind was mostly calm with occasional gusts up to 11.4 kilometres per hour (7.1 mph) from the north-east.

Crash

File:2012 Carterton HAB crash map.png

The approximate final route of the balloon. The red star indicates where the balloon first came into contact with the 33 kV power line (the faint grey line from the east), while the red circle is where the balloon wreckage was found.

The accident occurred around 7:20 am, when the balloon was attempting to land after completing a partial figure-8 flight pattern over the Carterton area. The pilot had indicated to the chase team he was likely to land near Somerset Road, a rural through road just north of Carterton in the locality of Clareville. At first the balloon was heading north-east over Somerset Road, around 700 metres east of the road's intersection with State Highway 2. Around 400 metres north of Somerset Road, the balloon reversed direction and headed back towards the road. The two chase vehicles, carrying some of the family members of the passengers, positioned on the road ready to assist with the landing.

Eyewitnesses saw the balloon climb and drift east towards a ten-metre high 33,000-volt power line running perpendicular to the road, one of the two lines that connected the Clareville zone substation, which supplied Carterton and the surrounding rural area, to the national grid at Transpower's Masterton substation. The pilot was heard shouting "duck down" as the balloon came in contact with the power line around 85 metres from the road. One of the conductor wires was caught over the top of the pilot's end of the basket, and the pilot attempted to get the balloon to climb, but the tension of the wire prevented it rising and instead the balloon slid along the conductor. Around 20 seconds later, electrical arcing occurred as the balloon caused a phase-to-phase short circuit, tripping the line and causing the 3800 properties supplied by the Clareville zone substation to lose power. The arcing caused one of the four liquefied petroleum gas bottles supplying the burners to rupture, and a fire subsequently started.

Two of the passengers jumped from the balloon to avoid the fire, falling ten metres to their deaths below. As the fire intensified, it caused the air inside the balloon to heat and force it to rise. Eventually, the conductor wire on the power line snapped, sending the balloon shooting upwards. The fire soon engulfed the whole balloon, and 150 metres in the air, the envelope disintegrated, causing the balloon to fall towards the ground, with the wreckage landing in a field just south of Somerset Road, around 600 metres east of the SH2 intersection.

Emergency services were on the scene within seven minutes but, shortly after they arrived, ambulance staff found that all eleven people had died at the scene, and this was later confirmed by police. The bodies of the two people who jumped from the balloon were located 200 metres (700 ft) from the crash site.

Aftermath

It took two days until 9 January to remove the last victims' bodies from the crash site. All eleven victims' bodies were taken to Wellington Hospital to be formally identified,.

The wreckage was examined at the scene, before being packed into a shipping container and transported to the TAIC's secure workshop in Wellington.

Power to the Carterton area was restored shortly after the crash using the remaining subtransmission line and spare capacity in the 11,000-volt distribution network until the damaged line was repaired. The damaged power line conductors were removed from the scene for examination.

Investigation

The Transport Accident Investigation Commission (TAIC) opened an inquiry to investigate the cause of the accident and to recommend any safety improvements in relation to the accident. The New Zealand Civil Aviation Authority was responsible for looking into any occupational health and safety and regulatory matters relating to the crash, while the United Kingdom's Air Accident Investigation Branch was contacted by the TAIC in case inquiries needed to be made in relation to the Bristol-based balloon manufacturer. The investigations could take up to a year to complete.

On 15 February 2012, the TAIC released an urgent safety recommendation after investigators found apparent anomalies in the maintenance of the crash balloon. The recommendation to the Civil Aviation Authority recommended that they urgently check the maintenance practices and airworthiness, especially in relation to the inspection of burners, fuel systems and envelopes, and maintenance record-keeping, of the other 74 hot air balloons registered in New Zealand.

The TAIC released its interim report on the accident on 10 May 2012. Examination of the wreckage showed electrical arcing on the basket and one of the four propane cylinders, consistent with a power line strike. Details about the maintenance and record-keeping of the balloon were released. The most recent inspection had occurred on 14 September 2011, with several errors made in the records and inspection. The inspection report erroneously recorded the type certificate as B2GL, which is applicable to Cameron Balloons United States for serial numbers 5000 and higher – ZK-XXF was manufactured in the United Kingdom and was serial number 4300, so the correct type certificate was BB12. It also recorded the basket and burners as being of Cameron Balloons, not as being of Thunder and Colt. Anomalies were also identified in the maintenance logbook, including incorrect identification of the basket and burners, no record of four airworthiness directives, and no entry regarding the use of the gas bottles. The maintenance provider was also found to be using outdated versions of the Flight and Maintenance Manuals, using the 1992-released Issue 7 rather than the current Issue 10, and that the maintainers had tested the strength of the envelope by hand, rather than the prescribed method of using a spring gauge to measure actual strength.

Toxicology analysis of the balloon pilot found evidence of tetrahydrocannabinol (THC), indicating cannabis use. The report was the second fatal aviation incident report released by the TAIC in two days in which crew members tested positive for cannabis, following on from the release of the final report into the 2010 New Zealand Fletcher FU24 crash, in which two of the skydiving instructors killed in the crash tested positive for cannabis.

In February 2013, a report by the Civil Aviation Authority on the crash was released to The Dominion Post newspaper under the Official Information Act. The report found that the pilot's medical certificate had expired six weeks before the crash and he should have not been piloting a commercial aircraft. It also found that neither the rapid deflation system nor the parachute valve, which would have allowed for a rapid controlled descent, had been deployed despite there being sufficient time to do so, and passengers were not briefed in their emergency use.

In April 2015, the findings of coroner Peter Ryan were revealed to the public. In the report, he described the accident as "entirely preventable" and caused by "a significant error of judgement" by the pilot. Although there was no proof the pilot had used cannabis before the flight, statements from people who knew him, as well as post-mortem forensic tests, revealed that he was a weekly cannabis user and the long term effects of using the drug could have had an "effect on his perception and thinking".

Ryan also commented on issues with regards to safety standards in the industry, commenting on the "lack of enforcement" for mandatory drug and alcohol tests.

See also

• List of New Zealand disasters by death toll

External links

• ASN Wikibase Occurrence # 141667. Aviation Safety Network