ERA14LA290

The pilot's fall from the balloon’s basket during touchdown in a field for reasons that could not be determined based on the available evidence, which resulted in his fatal injury.

The commercial pilot was conducting a local balloon flight with 10 passengers on board. A ground crewmember reported that he talked with the pilot before takeoff, and he indicated that the pilot did not appear to be unhealthy and that he did not mention feeling ill or that he was having any health-related issues. The passengers reported that, after takeoff, the flight proceeded uneventfully, with the pilot talking to them during the entire flight. The pilot chose to perform a landing in a field and informed the passengers to brace for landing; several of the passengers noted that the wind speed was increasing. Several of the passengers also noted that the descent was steep and that the landing was "hard" or "really hard." The pilot then appeared to lose his balance, and he fell out of the basket and sustained fatal injuries. Although the pilot had several medical conditions and used several medications that could have affected his balance or reaction time and, thus, could have contributed to his fall from the basket, witnesses reported that the pilot appeared healthy and behaved normally before and during the flight. Further, even a fully alert, athletic person could have fallen in the manner described by the passengers. Based on the available evidence, it could not be determined if impairment from any of his medical conditions or the medications he was using to treat them caused the pilot to fall from the basket.

The balloon was equipped with a portable Garmin GPSMap 62s, that records and retains a detailed tracklog consisting of latitude, longitude, date, time, altitude, and derived groundspeed information. The tracklog was downloaded normally and without difficulty via the built-in USB port. The accident flight was recorded, and contained 847 data points which begins with the balloon lifting off the ramp at N47 about 0637, and continue to the balloon coming to rest about 0717:09. A review of the data revealed that with respect to the final portion of the flight, the balloon crossed a road at 282 feet GPS altitude and 11 knots groundspeed. Data showed the balloon steadily descending towards a field with a forward groundspeed of about 10 knots. A copy of the report and downloaded track log as Attachment 1 are contained in the NTSB public docket. The pilot was in two-way communication with members of his ground crew; several passengers reported communication difficulties prior to landing in the field. Pilot Medical Screening/Questionnaire Since operation of a commercial balloon flight does not require a pilot to have a medical certificate, but in light of the facts concerning the accident, the operator was asked postaccident if they would consider medical screening for pilot's used in their operation. Although they indicated they would not perform medical screening, they did include additional information of the pilot application form inquiring about previously diagnosed medical condition and prescribed medication. According to the FAA inspector-in-charge, he did not find a glucose meter or glucose tracking log in the balloon basket, on his person, or in the pilot's car. The inspector did report finding glucose tablets, a package of syringes, Viagra 100MG and Claritin tablets for allergy relief. Further inspection of the pilot's car revealed evidence of contents from a fast food chain restaurant. A postmortem examination of the pilot was performed at the request of the Chester County Coroner's Office. The cause of death was listed as "neck injuries." Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated the results were negative for carbon monoxide and volatiles, and testing for cyanide was not performed. Unquantified amounts of Bupropion, Cetirizine, Desmethylsildenafil, and Sildenafil were detected in the femoral blood and urine specimens, while Rosuvastatin was detected in the liver and urine specimens. An unquantified amount of Bupropion Metabolite was detected in the submitted urine specimen, but it and 7-Amino-clonazepam were not detected the femoral blood specimen. 0.051 ug/mL was detected in the urine specimen, while 51 mg/dl and 248 mg/dl Glucose was detected in the vitreous and urine specimens, respectively. The femoral blood specimen was not suitable for Hemoglobin A1C analysis. A copy of the toxicology report is contained in the NTSB public docket. According to the NTSB Medical Officer's factual report, the 47 year old male pilot in this balloon accident had diagnoses of type 1 diabetes, depression, and high cholesterol. His blood and tissue toxicology tests showed evidence of use of bupropion, cetirizine, sildenafil, and rosuvastatin. In addition, his urine tested positive for a metabolite of clonazepam. Bupropion is an antidepressant used to treat depression and help patients quite smoking, often marketed with the names Wellbutrin and Zyban. It carries two warnings: 1) a dose dependent risk of seizures; and 2) may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). Cetirizine is a sedating antihistamine used to treat allergy symptoms and is available over the counter, also commonly named Zyrtec. It carries a warning that it may cause drowsiness. Sildenafil is a prescription drug used to treat erectile dysfunction, commonly known as Viagra. Rosuvastatin is a cholesterol lowering agent available by prescription and commonly marketed as Crestor, and 7-amino-clonazepam is a metabolite of clonazepam, which is described above. The pilot's aviation medical certificate had expired in 2010 and he was not required to have a valid medical certificate to pilot a balloon on a commercial flight with 10 passengers. A copy of the NTSB Medical Officer Factual Report is contained in the NTSB public docket. According to the Federal Aviation Administration inspector-in-charge (FAA-IIC), the basket came to rest upright in a field located at 40 degrees 09 minutes 50.40 seconds North latitude and 075 degrees 32 minutes, 22.14 seconds West longitude. That location consisted of an open field of newly planted corn field. Further inspection of the accident site revealed the basket came to rest about 96 feet after the first observed ground contact location. There was no reported damage to the basket or envelope; the top rail of the basket and a side of the basket was noted to have dirt adhering to it. The FAA-IIC reported there was no restraining belt/harness installed in the pilot's compartment. According to the operator, the balloon's fuel supply had 50 percent remaining. A surface observation weather report taken at Heritage Field Airport (PTW), at 0654, or approximately 22 minutes before the accident indicates the wind was from 310 degrees at 8 knots, the visibility was 9 statute miles, and clear skies existed. The temperature and dewpoint were 14 and 10 degrees Celsius, respectively, and the altimeter setting was 30.14 inches of Mercury. The accident site was located about 170 degrees and 4.5 nautical miles from PTW. A copy of the weather report and record from PTW is contained in the NTSB public docket. The pilot, age 47, held a commercial pilot with lighter-than-air free balloon limited to hot air balloons with airborne heater issued July 25, 2006. He also held a private pilot certificate with airplane single engine land rating issued November 26, 2004. His last third class medical certificate was issued on March 16, 2009, and was not valid for any class after March 31, 2010. His last flight review in accordance with 14 CFR Part 61.56 occurred in the accident balloon on May 25, 2014; the flight duration was reported to be 1.0 hour. A review of the pilot's blue ribbon airman file revealed his commercial pilot certificate was suspended 75 days for operating an unairworthy balloon during revenue flights. The suspension began on November 30, 2007, and ended on February 12, 2008. Subsequently on November 5, 2009, he underwent a re-examination flight with FAA, and was approved to exercise the privileges of his commercial pilot certificate. According to the National Transportation Safety Board (NTSB) Pilot/Operator Aircraft Accident/Incident Report submitted by the operator, the pilot's total lighter than air time was 570 hours. A review of the pilot's pilot logbook that contain entries from December 29, 2013, to the last entry dated June 4, 2014, revealed he logged a total time of approximately 44 hours (excluding record keeping errors), of which approximately 10 hours were in the accident balloon. He logged 28 and 19 hours in the last 90 and 30 days, respectively. The pilot's father provided NTSB the results of blood testing that was performed on April 5, 2014. The results were forwarded to the NTSB's Medical Officer for Review. The balloon was manufactured in 2011 by Cameron Balloons US, as model Z-225, and was designated serial number 6630. It was equipped with a "Delta II" basket, which had 5 burner tanks and pilot compartment in the middle; the maximum occupant capacity is 12. Review of the maintenance records revealed the balloon was last inspected in accordance with an annual inspection on August 15, 2013; the total time at that time was recorded to be 244 hours. The balloon had accumulated 94 hours since the inspection at the tim