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Picture This Ballooning Kavanagh B-350 Hot Air Balloon hard landing…
Picture This Ballooning Kavanagh B-350 Hot Air Balloon hard landing 31/12/2021
Nature of the System
System parts
Kavanagh B-350 balloon - registered VH-BSW - serial no: B350-399
Envelope
Double T-partitioned basket with 32 rope handles
4 passenger compartments
Three burner system
3 propane fuel tanks
Lite Vent deflation system
Rotation vents on side of envelope
33.7 meters tall
28.7 meters widest point
Ground crew members
Assist with pre flight preparations
Meet balloon at landing point to assist with post flight requirements
Retrieve passengers from landing point
Passengers
16 passengers permitted to be onboard
Pilot
Pilot held commercial flight license (balloon)
Significant balloon piloting experience
3000 hours of flying
300 hours in the Kavanagh B-350 balloon
Pilot had completed 26 hours of flight time in the prior 90 days
18 hours flying the Kavanagh B-350 balloon
System Life Cycle
Commissioning
Kavanaugh Balloons supply Kavanagh B-350 to Picture This Ballooning
Picture This Ballooning order Kavanagh B-350 from Kavanaugh Balloons
Construction
Kavanagh Balloons B Type, B-350, 24 Gore balloon
Registered VH-BSW
Serial no: B50-399
Operations
Balloon used for scenic flights throughout the Melbourne, Yarra Valley, Daylesford and Ballarat region in Victoria
Maintenance
Kavanaugh Balloon's maintenance manual states that routine maintenance should be conducted regularly on all system parts.
Balloon parts to be stored under cover and out of direct sunlight between flights
Scheduled inspections should be carried out at periods of 100 hours of service or twelve calendar months, whichever occurs first
Fire extinguishers inspected every 6 months
Log books to be completed upon servicing and inspection
Decommissioning
Balloon is destroyed
Attachments cut off
Control lines removed and cut from valve system in the top of the Envelope
Identification marks and tags removed
Balloon placed in landfill
People
Pilot
Pilot indecisive with alternate landing location
Experienced pilot with over 3000 hours of flight time
Pilot rejected various possible landing areas, deeming them too difficult for passenger retrieval logistics and removal of balloon from site
16 passengers on board
Two passengers adopted a deep squat position during landing, causing serious leg injuries
Workplace
Work environment
16 persons permitted to travel in basket
Preventing persons from having space to enact safe brace position for hard landing situation
Relationships with surrounding landowners
good relationships imperative for continued flight operations
Trying to avoid inconveniences to landowners
Attempting to land only in areas where landowners have approved
Weather
Stong wind speeds
Management
Information Transfer
Pre-flight briefing not completed in entirety
Pressure due to time restraints
Assumed comprehension of procedures
The importance of safe landing positions were not understood by all passengers
Pilot did not have knowledge of fences present in landing path
Job Design
Responsibility for choice of landing site fell with pilot
Pilot chose to opt seek a more convenient landing location for post light logistical reason
Map of land sites out of date, pilot was not aware of additional fences in flight path at chosen landing spot
What happened?
Hot air balloon carrying 16 passengers takes off at 5:47am from Glenburn
42 minutes into flight, pilot is alerted of increasing winds near to intended landing area
Pilot assesses several alternate landing options over the following 17 minutes
Pilot rejects several landing fields due to post landing logistical and operational difficulties
Basket is tipped over and dragged 30-40 meters along ground before coming to halt
Strong winds turn balloon west, away from intended landing site
Pilot instructs passengers to take up landing position
Balloon begins to descend
Pilot determines new landing spot
Pilot pulls parachute vent for 10 seconds to descend for landing
Balloon begins to descend faster than expected
Pilot unable to slow balloons descent speed
Balloon basket contacts ground but begins rising again
Pilot pulls rip line, opening the vent to deflate the balloon
Pilot intends touchdown over nearby fence
Pilot notices another fence running across landing path
Pilot holds rip line to maintain a height of 40ft to clear fences
Pilot resumes pulling rip line
Balloon descends at rapid pace
Balloon lands hard at 6:48am 2km south of Lilydale Airport
Two passengers obtain serious leg injuries
Why it happened
Maximum number of occupants meant insufficient space to adopt specified landing brace position for reducing the risk of injury
Strong wind speeds caused pilot to lose control of speed multiple times during descent
Preflight safety briefing was not completed in its entirety due to time pressures
Landing field contained fences not previously known by pilot
Pilot maneuvering to avoid powerlines
Landing site presented high risks in prevailing wind conditions
References
Australian Transport and Safety Bureau, 2022. “Pre-flight briefing emphasised after balloon hard landing”, viewed 8th September 2022,
https://www.atsb.gov.au/media/news-items/2022/balloon-hard-landing/?fbclid=IwAR2I0Jp-w8r7362LS_WUVAEMwGGcCrOjJK8do8V_Nilc2wBay1WBXnwzGf4
Australian Transport Safety Bureau, 2022. “Hard Landing involving Hard landing involving Kavanagh Balloons B-350, VH-BSW, 2 km south of Lilydale Airport, Victoria on 31 December 2021”, Aviation Safety investigations and Reports, viewed 8th September 2022,
https://www.atsb.gov.au/publications/investigation_reports/2022/aair/ao-2022-003/
Kavanaugh Balloons Australia PTY LTD, 2019. “Hot Air Balloon Maintenance Manual”, issue 4 (8), viewed 8th September 2022,
https://www.kavanaghballoons.com.au/_files/ugd/49cd93_6723d3ce4afc450091012cd601eda85c.pdf
Kavanaugh Balloons, 2022. “B-350 Standard Features”, viewed 8th September 2022,
https://www.kavanaghballoons.com.au/_files/ugd/49cd93_e5c327d3fa484b81ae46bfd9bfd6787b.pdf
Kavanaugh Balloons, 2022. “Design”, viewed 8th September 2022,
https://www.kavanaghballoons.com.au/design
Kavanaugh Balloons, 2022. “Support”, viewed 8th September 2022,
https://www.kavanaghballoons.com.au/techsupport
Picture This Ballooning, 2022. “Safety”, viewed 8th September 2022,
https://www.picturethisballooning.com.au/safety