Safety recommendation – hot air balloon maintenance

Press Release – Transport Accident Investigation Commission

Apparent anomalies in the maintenance of the hot-air balloon involved in January’s fatal accident near Carterton have led the Transport Accident Investigation Commission (TAIC) to recommend to the Director of Civil Aviation that he make an urgent check …TAIC issues urgent safety recommendation – hot air balloon maintenance

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Apparent anomalies in the maintenance of the hot-air balloon involved in January’s fatal accident near Carterton have led the Transport Accident Investigation Commission (TAIC) to recommend to the Director of Civil Aviation that he make an urgent check of hot air balloon maintainers’ practices and satisfy himself of the airworthiness of New Zealand’s 74 hot air balloons.

TAIC chief commissioner John Marshall QC said “it is too early to say whether maintenance issues actually contributed to the accident, however evidence gathered by our investigators suggests the balloon’s maintenance may not have complied with civil aviation rules. Where an aircraft is not maintained in accordance with those rules then it would not meet the standard for ‘airworthy condition’”. The evidence did not relate to examination of the balloon wreckage, he said.

“Because of concern that these issues might go wider than the balloon lost with 11 lives in January, the Commission last Wednesday (15 Feb 12) issued an urgent safety recommendation (see below) which we are making public today after having given the Director the opportunity to consider it and put in place his response,” Mr Marshall said.

Meanwhile, Mr Marshall confirmed that the Commission would be issuing an interim inquiry report within the next few months. The interim report would aim to describe what happened, ahead of a final inquiry report expected early next year that would analyse why events unfolded as they did, and what might be done in order to reduce the chance of a recurrence.

“The ballooning community and the wider public can be assured that the Commission will, as it has done with this recommendation, call for action to address any significant issue as soon as it is found rather than leaving it to publication of a final report,” he said.

The Transport Accident Investigation Commission is a standing Commission of Inquiry which investigates significant marine, rail and aviation accidents with a focus on improving safety rather than laying blame.

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Inquiry 12-001: Cameron hot air balloon, ZK-XXF, 7 January 2012.
Urgent Recommendation 001/12

Issued on 15 February 2012 under section 9 of the Transport Accident Investigation Commission Act 1990

1. On 7 January 2012 a hot air balloon carrying 11 people caught fire after the balloon’s wicker basket became caught on power lines near Carterton. All 11 occupants died. The Commission opened an inquiry under section 13(1) of the Transport Accident Investigation Commission Act 1990 to determine the circumstances and causes of this occurrence.
2. As a result of the Commission’s inquiries, to date, it believes that some maintenance requirements in the Civil Aviation Rules Part 43 may not have been complied with in respect of this balloon. It found three incidents of non-compliance:
(a) it appears that the manufacturer’s maintenance procedures for the balloon may not have been used to ensure that the appropriate maintenance tasks and procedures were carried out correctly, as required by Civil Aviation Rules 43.53(3)(i) and 43.53(5)-(9) (which deal with performance of maintenance). It appears that the industry is not using the manufacturer’s required “grab test” to test the strength of the material that makes up the balloon envelope (the structure that contains the hot air). Also, there is no record of the results of the required tests, which are relevant to the balloon’s intended purpose;
(b) it appears that the prescribed procedure for inspecting the balloon’s burners and liquefied petroleum gas fuel system was not followed, contrary to Civil Aviation Rule 4353(3)(i) and 43.53(8) (which deals with performance of maintenance); and
(c) the balloon log book did not show that all airworthiness directives applicable to balloons in New Zealand had been assessed, as required by Civil Aviation Rule 43.153(4)(iii) (which deals with review of airworthiness).
3. At this early stage of its inquiry the Commission has not been able to determine whether these non-compliant maintenance practices contributed to the accident in any way. However, where an aircraft is not maintained in accordance with the Civil Aviation Rules then such an aircraft is not considered airworthy (Civil Aviation Rules Part 1 – Definitions). The Commission has also not yet been able to determine whether these maintenance practices are restricted to the balloon involved in this accident or extend to other aircraft, including balloons. In this regard the Commission notes that there are 74 balloons recorded in the New Zealand aircraft register and 7 licensed aviation maintenance engineers approved by the Civil Aviation Authority to maintain these.
4. Notwithstanding this, the Commission believes that the type of non-compliance above is a safety issue, which requires urgent attention. The Commission, therefore, recommends that the Director of Civil Aviation:
(a) conduct an urgent check of all maintenance organisations and licensed engineers approved to maintain hot-air balloons to ensure that their balloon maintenance practices fully comply with Civil Aviation Rules, and
(b) satisfy himself that all New Zealand-registered hot-air balloons are airworthy.

On 17 February 2012 the Director of Civil Aviation Authority responded in part as follows:
I accept the thrust and intent of the recommendations made by the Commission.
I can advise the following:
• The CAA initiated a safety investigation into the maintenance practices associated with balloon ZK-XXF on 15 February 2012

• The CAA investigation will also examine maintenance practices associated with other balloons maintained by the maintenance provider of ZK-XXF

• The CAA investigation will identify any other issues associated with the maintenance practices, and thus airworthiness, of balloons in New Zealand

• The CAA investigation is being undertaken as a matter of urgency, with an initial report from the investigation team due on 29 February in relation to the first bullet point.
The CAA views the issues identified by the Commission very seriously and will act swiftly to address any deficiencies found in maintenance practices that place in doubt the airworthiness of hot air balloons operated in New Zealand. As a consequence of the advice received from the Commission, the CAA has amended the Terms of Reference for its investigation to more expressly address the maintenance and airworthiness issues of all hot air balloons as the third stage of the investigation.

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ENDS

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