AVIATION Reports - 2007 - A07C0151

2.0 Analysis

The forecast obtained by the pilot indicated suitable weather for the planned flight that was flight-planned to land by about 0830. The forecast winds would not have exceeded the BFM demonstrated wind speed of 7 mph until 1000 and would not have reached the limit of 15 knots specified in the company operations manual until 1200. However, the conditions changed more rapidly than forecast. After lift-off, the pilot was made aware that the wind speed at the Winnipeg Airport was 10 knots on initial contact with tower at 0746. Within one minute, the tower made a transmission on the same frequency including the information that the wind was gusting to 15 knots. While the BFM performance section indicated that the balloon had only been demonstrated to 7 mph in certification testing and the normal procedures section indicated that extreme care should be exercised while landing at wind speeds in excess of this speed, there was no wind speed limit specified in the limitations section of the BFM. Consequently, the balloon could be flown to a wind speed set by the company. The speed set in the company operations manual was a wind speed of 15 knots, more than twice the wind speed demonstrated in certification testing.

Upon receipt of information from the tower indicating that the weather forecasts were not correct and that the operations manual limit had been reached, the pilot continued over open areas of the city until 0824, at which time he indicated an intention to land some distance further away. Although the wind had quickly and unexpectedly reached the limit specified in the operations manual, there was no indication that the pilot attempted to land at the earliest opportunity.

The number of attempts to land indicates that the wind speed made the landing difficult to position or control. The hard landing procedure, outlined in the BFM, required the fuel valves to be closed and ignition systems to be turned off to reduce the risk of fire and explosion. The absence of readily accessible quick shut-off valves precluded the pilot from turning off the fuel after the balloon was on the ground, although he attempted to do so.

The pilot attempted to deflate the balloon envelope quickly and was unable to do so effectively even though the rigging was functional, resulting in a dragged landing of some 700 feet. The extended drag distance increased the risk of injury to the passengers and damage to the basket. The wind speed at the accident site could not be measured, but was likely between the wind speed of 15 knots recorded at the Winnipeg Airport and the 19-knot wind speed that was recorded near the accident site. Therefore, the company operations manual wind speed of 15 knots was too high to ensure a short drag distance while deflating the envelope after landing.

Although the SFOC states that "it certifies that the balloon operator is adequately equipped and able to conduct a safe balloon operation carrying fare-paying passengers," this statement was based solely on the licensing of the pilot and certification of the balloon. The SFOC did not trigger any audit or inspection cycle and in fact relegated the balloon to a status similar to that of privately registered general aviation aircraft. In practice, TC did not know which operators were active or the operator's actual area of operations. TC's National Cabin Safety Inspection Program would not have resulted in a balloon cabin safety inspection. Additionally, there was no requirement for passenger restraint or personal protective equipment. There was no requirement for approved manuals or specific regulatory standards. Consequently, there was no equivalent level of safety for balloon air carriers comparable to other commercial operators.

During the accident sequence, the fuel supply lines had pulled out of their fittings at the burner manifolds and, because the fuel system was not turned off, released liquid propane in the vicinity of the pilot lights, resulting in the fire and subsequent explosion.

The maximum operating pressure of the fuel system indicated that the fuel lines and fittings should have been able to withstand pressures up to 400 psi. Tests conducted by the TSB Engineering Laboratory on the exemplar hoses manufactured by Sundance Balloons International and used to connect the seventh inflator tank revealed that the fuel lines began leaking at the crimped sleeve fittings at 150 psi and, therefore, did not meet the airworthiness standards.

The following TSB Engineering Laboratory Report was completed:

LP 080/007 - Burner System Examination

This report is available from the Transportation Safety Board of Canada upon request.

3.0 Conclusions

3.1 Findings as to Causes and Contributing Factors

1. The flight continued even though the winds exceeded the maximum demonstrated winds listed in the balloon flight manual and were at the upper wind limit specified in the company operations manual.
   
   
2. The fuel system was not shut down as recommended in the balloon flight manual procedures for a hard landing even though a hard landing was likely.
   
   
3. Because the balloon was not deflated quickly, the basket was dragged for some 700 feet and the integrity of the burner support structure was lost.
   
   
4. As the basket was dragged across the ground, the fuel line fittings were pulled out at the burner manifolds and liquid propane was released in the vicinity of the pilot lights, resulting in the fire and subsequent explosion.

3.2 Findings as to Risk

1. There was no mandated requirement for passenger restraint or personal protective equipment to reduce injury during a dragged landing.
   
   
2. Balloon air carrier operations do not have the same degree of regulatory oversight as other air carriers. There may not be an equivalent level of safety for balloon air carriers comparable to that of commercial operators.
   
   
3. Exemplar fuel supply hoses manufactured by Sundance Balloons International, one of which was used to connect the inflator tank, did not meet the required airworthiness standard.
   
   
4. The company operations manual maximum wind speed of 15 knots was more than twice the wind speed demonstrated in certification testing. This was too high to ensure a short drag distance while deflating the envelope after landing.

4.0 Safety Action

On 27 March 2008, the Board released two recommendations to Transport Canada as follows:

While some commercial balloon operators in Canada have fare-paying passenger loads equal to those of commuter and air taxi operators, their passengers are not assured of the same level of safety and oversight by regulations and standards. The Board is concerned that, without adequate standards and regulations for balloon operators, balloon passenger safety will be compromised. Therefore, the Board recommends that:

The Department of Transport ensure that passenger-carrying commercial balloon operations provide a level of safety equivalent to that established for other aircraft of equal passenger-carrying capacity. (Interim recommendation A08-01, issued March 2008)

Assessment Rating: Satisfactory Intent

While some commercial balloon operators in Canada have fare-paying passenger loads in the range of those of commuter and air taxi operators, their passengers are not assured of the same level of safety and oversight by regulations and standards. The inability to quickly shut off the fuel supply during landing or in an emergency increases the risk of a fire and/or explosion, compromising balloon passenger safety. Therefore, the Board recommends that:

The Department of Transport ensure that balloons carrying fare-paying passengers have an emergency fuel shut-off. (Interim recommendation A08-02, issued March 2008)

Assessment Rating: Satisfactory Intent

Transport Canada Response to A08-01

To address the subject of the level of equivalent safety of passenger-carrying commercial balloon operations, Transport Canada is conducting a risk assessment of commercial passenger-carrying balloon operations. This study will address the special flight operations certificate process and commercial passenger-carrying balloon operation oversight. Once the review is complete, should regulatory changes be required, Notice of Proposed Amendments will be developed and submitted to the Canadian Aviation Regulation Advisory Council for consultation.

Board Assessment of the Response to A08-01

Transport Canada's written response to the recommendation indicates that it intends to conduct a risk assessment and determine an appropriate means of addressing the issue of commercial passenger-carrying balloon operations. This study will address both the special flight operations certificate process and commercial passenger-carrying balloon operation oversight.

Once the review is complete, regulatory changes will be proposed should they be considered necessary. However, the Board believes that, Transport Canada's proposed review and regulatory amendment process will not yield any specific course of action that, in the short term, would reduce or eliminate the deficiency identified in Board Recommendation A08-01.

The response is assessed as "Satisfactory Intent".

Transport Canada Response to A08-02

To address the subject of the proposed emergency fuel shut-off for balloons carrying fare-paying passengers, Transport Canada is conducting a risk assessment to determine whether regulatory or non-regulatory solutions would be appropriate to address this issue. Once the review is complete, should regulatory changes be required, Notice of Proposed Amendments will be developed and submitted to the Canadian Aviation Regulation Advisory Council for consultation.

Board Assessment of the Response to A08-02

Transport Canada's response to the recommendation indicates that it intends to conduct a risk assessment and determine an appropriate means of addressing the issue of the proposed emergency fuel shut-off for balloons carrying fare-paying passengers. Once the review is complete, regulatory changes will be proposed should they be considered necessary. However, the Board believes that, Transport Canada's proposed review and regulatory amendment process will not yield any specific course of action, in the short term, that would reduce or eliminate the deficiency identified in Board Recommendation A08-02. The response is assessed as "Satisfactory Intent".

Next TSB Action

The Board will continue to monitor the safety of passenger-carrying balloon operations and will follow up Transport Canada's response in conducting its risk assessment process.

This deficiency file is assigned an "Active" status.

This report concludes the Transportation Safety Board's investigation into this occurrence. Consequently, the Board authorized the release of this report on 20 August 2008.

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1.   All times are central daylight time (Coordinated Universal Time minus five hours).

2.   FAA Advisory Circular 43.13-1B (Acceptable Methods, Techniques, and Practices - Aircraft Inspection and Repair), Chapter 8, Section 2, Paragraph 8-31.

3.   The FAA Balloon Flying Handbook, FAA-H-8083-11, also recommends this action.