ERA14LA347

The pilot's inadequate preflight and inflight planning and improper landing site selection and approach path, which resulted in the balloon contacting powerlines during landing. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of balloon tour operators.

The commercial pilot departed on the hot air balloon tour flight with 6 passengers. After about 1 hour of flight, the balloon approached a town; with about 20 minutes of fuel remaining and about 30 minutes until sunset, the pilot descended the balloon to locate a landing site. He subsequently selected the yard of a residence near an intersection. The pilot initiated a descent, intermittently activating the balloon's burners to maintain the descent path. As the balloon approached the landing site, the envelope contacted powerlines, resulting in an electrical discharge, a shower of sparks, and portions of the powerlines falling onto the ground and a parked vehicle. The balloon sustained thermal damage to the basket, but continued a controlled descent to the intended landing site. Three of the passengers received serious electrical burns as a result of the balloon's contact with the powerlines. The pilot stated that there were no mechanical malfunctions or anomalies with the balloon that would have precluded normal operation. The pilot further stated that he was unfamiliar with the area and was navigating with the aid of a map application on his cell phone. Although the pilot reported that the overflight of the town was the result of a sudden shift in wind direction, given the balloon's departure location and the accident site, the balloon maintained a predominately northerly heading throughout the flight; there was no indication of any variation in wind direction. Based on this information, the pilot should have been able to predict the balloon's flight path with reasonable accuracy both before and after reaching the town and plan a landing site accordingly. Review of satellite imagery for the surrounding area showed several suitable landing fields about 1 ¼ nautical miles north of the accident site. The accident was one of 4 events involving the accident pilot, all of which occurred during low-level operation or confined area landings and resulted in property damage. The events displayed a pattern of poor decision-making which was also exhibited during the accident flight with the pilot's decision to land in a populated area confined by powerlines. Given this history, it is possible that, with a more robust system of oversight and surveillance of balloon operators, the Federal Aviation Administration would have identified the accident pilot as a potential safety risk and taken steps to mitigate this risk.

Balloon's Flight Path Contrary to the pilot's statement, the departure location of the flight, and the accident site location were consistent with the balloon traveling on a predominantly northerly course throughout the 1 hour 15 minute, 7-nautical-mile (nm) flight. Review of satellite imagery of the area showed several fields about 1 ¼ nm north of the accident site located along the balloon's established route of flight. Balloon Manufacturer's Guidance According to the balloon manufacturer's flight manual, section 2.9, LANDING PROCEDURE, when choosing a landing site, the pilot should allow for possible variations in the wind at ground level, and choose a site: (a) Free of obstructions, especially power lines; (b) Overshoot area should also be clear; (c) Field free of crops and animals; (d) If possible, look for upwind shelter to reduce speed; (e) If possible, choose a field with good accessibility for retrieve crew, and minimum inconvenience for the owner. The manual also states: Do not fly into power lines at any cost. If contact is inevitable descend as fast as possible so that the contact of the wires is with the envelope and not with the basket assembly. Shut down the fuel system and vent lines before contact. If the balloon is caught in the wires DO NOT TOUCH ANY METAL PAR'I'S. If possible, remain in the basket until the power is shut off. Never attempt to remove the balloon until the power authority has arrived. Do not allow crew members to make contact between the ground and the basket until the power is shut off. Balloon Flying Handbook The FAA Balloon Flying Handbook (FAA-H-8083-11A), 7-7, "Maneuvering," states, "The balloon is officially a nonsteerable aircraft." Although a hot air balloon has no direct controls for steering, a balloon's flightpath can be indirectly influenced using the burner and parachute valve. The handbook also states: Being knowledgeable of the wind at various altitudes, both before launch and during flight, is the key factor for maneuvering. Maneuvering, or steering, comes indirectly from varying one's time at different altitudes and different wind directions. To initiate a climb, a balloon pilot activates one or more of the balloon's propane fuel burners. Rate of climb is adjusted by the duration and/or frequency of burner activations. Level flight is achieved by executing a series of burns that minimizes changes in vertical velocity. Descent is achieved either by allowing the air in the envelope to cool or by opening the parachute valve to allow hot air to escape. The rate of descent can be increased by leaving the parachute valve open longer or reopening the valve. Rate of descent can be slowed or stopped by activating the burner(s). The FAA Balloon Flying Handbook further states that when contour flying, or during an approach to a landing site, the potential of collision with trees, power lines, and other obstacles is increased. For balloons, landing accidents consistently account for over 90 percent of the total number of accidents in any given year. The most common causal factors for landing accidents include collision with obstructions in the intended landing area. In addition, these accidents account for the majority of injuries to pilots and damage to balloons. Accidents are more likely during landing because the tolerance for error is greatly diminished and opportunities for pilots to overcome errors in judgment and decision-making become increasingly limited, particularly in high wind conditions. Additional Incidents Over the course of the investigation, the NTSB became aware of other incidents with the operator. In October 2004, one passenger received minor injuries when, during landing, the balloon encountered a downdraft. The pilot applied the burners to ascend and overshot the intended landing site. In an attempt to slow the balloon, the pilot brushed the basket through a tree, during which a branch cut the passenger's hand. In October 2011, a witness observed the balloon flying low in the middle of Northborough, Massachusetts. During the flight, the pilot flew below the tops of the surrounding trees and the balloon passed between and struck two houses, which sustained soffit and gutter damage. On September 30, 2013, the pilot landed in the parking lot of a Kmart store in Auburn, Maine. The eight passengers onboard were not injured. The pilot reported to a local media outlet that the flight was going according to plan when an unexpected breeze kicked in around sunset. During the approach to landing, the balloon contacted and damaged a light pole in the parking lot. On September 22, 2015, about 14 months after the accident in Clinton, Massachusetts, the pilot and his six passengers were uninjured when he landed the balloon in the parking lot of a Massachusetts Bay Transportation Authority commuter rail station in Grafton, Massachusetts. The balloon had launched from Shrewsbury, Massachusetts earlier that morning. The pilot advised that, sometime during the flight, the wind conditions changed. He originally tried to land in an open field at Tufts University, but instead landed in the parking lot which was about 1,000 yards northwest of the field. During the balloon's descent, it contacted an overhead guide wire that stretched between two light poles, knocking one pole over and resulting in damage to 3 vehicles. Articles published by local media in Portland, Maine, and Miramichi, New Brunswick, Canada, stated that the pilot's invitations to two separate balloon festivals were rescinded as a result of the open investigation into the Clinton, Massachusetts, accident. NTSB Recommendations On April 7, 2014, the NTSB issued recommendations to the FAA (A-14-11 and A-14-12) to address operational deficiencies in commercial sightseeing (air tour) balloon operations that have resulted in occupant injuries and a fatality. They were derived from the NTSB's investigations of several air tour balloon accidents. The accidents highlighted operational deficiencies in commercial air tour balloon operations, such as operating in unfavorable wind conditions and failure to follow flight manual procedures, that the NTSB considered a result of the lack of oversight relative to similar airplane and helicopter air tour operations. In its recommendations, the NTSB stated that, depending on gondola capacity, balloons can carry more than 20 passengers per flight. Given the various safety deficiencies noted in the NTSB's investigations of the subject balloon accidents, the potential for a high number of fatalities in a single air tour balloon accident is of particular concern if air tour balloon operators continue to conduct operations under less stringent regulations and oversight. Although such an accident had yet to occur in the United States at the time of the issuance of the recommendations, a high-fatality accident occurred in Egypt on February 26, 2013, when a commercial air tour balloon carrying 21 occupants experienced a fire on board, resulting in 19 deaths. On July 30, 2016, about 0742 central daylight time, a Balóny Kubícek BB85Z hot air balloon, N2469L (NTSB Case No. DCA16MA204), crashed into a field after striking high voltage powerlines while landing near Lockhart, Texas. The 15 passengers and pilot onboard were fatally injured. The NTSB determined that the probable cause of this accident was the pilot's pattern of poor decision-making that led to the initial launch, continued flight in fog and above clouds, and descent near or through clouds that decreased the pilot's ability to see and avoid obstacles. Contributing to the accident were (1) the pilot's impairing medical conditions and medications and (2) the FAA's policy to not require a medical certificate for commercial balloon pilots. The investigation further concluded that the FAA's primary method of oversight—sampling balloon operators at festivals and events—does not effectiv