Fatal balloon Crash - Carterton

[kiwithrottlejockey]

‘Poor judgement’ led to fatal flight

By MICHAEL DALY - The Dominion Post | 12 NOON - Thursday, 31 October 2013


The path of the balloon and the place where it crashed. — Google Maps.

POOR JUDGEMENT and decision-making contributed to the Wairarapa ballooning tragedy that claimed 11 lives, the Transport Accident Investigation Commission (TAIC) has found.

It had been unsafe for pilot Lance Hopping on the morning of January 7th last year to allow the balloon to descend below the level of power lines, and to remain at a low level while the balloon crossed a paddock.

When collision with the power lines became unavoidable, the pilot should have followed the balloon manufacturer's advice and rapidly descended the balloon, instead of making it climb, the TAIC said.

It also concluded autopsy toxicology results from the 53-year-old pilot showed the result of long-term and recent use of cannabis.

"While it is difficult to say how much each type of use contributed to the result, cannabis is known to affect a person's judgement and decision-making ability," TAIC said.

"Poor judgement and poor decision-making were factors contributing to this accident. The commission found that the pilot's use of cannabis could not be excluded as a factor contributing to his errors of judgement, and therefore to the accident."

"Both long term and recent use of cannabis may significantly impair a person's performance of their duties, especially those involving complex tasks."

TAIC called for significant reform of alcohol and drug regulation across the aviation, rail and marine modes.

Passengers Desmond and Ann Dean, Denise Dellabarca, Johannes Jordaan and Alexis Still, Diana and Howard Cox, Valerie Bennett, Stephen Hopkirk and Belinda Harter died in the crash, along with Mr Hopping.

The TAIC report recommended the introduction of appropriate legislation or rules that would:

❏ prescribe allowable maximum levels of alcohol.

❏ prohibit people from operating an aircraft, vessel or rail vehicle if they were impaired by drugs.

❏ require operators to implement drug and alcohol detection and deterrence regimes, including random testing.

❏ prescribe post-occurrence testing requirements for drugs and alcohol.

The TAIC said it was increasingly seeing more incidents where the use of performance-impairing substances was a feature.

It said a key lesson from the accident was that: "Under no circumstances should operators of transport vehicles, or crew members and support crew with safety-critical roles ever use it."

The second key lesson involved power lines, which were a well recognised critical hazard to hot-air balloon operators.

"Balloon pilots should give them a wide margin and if they ever inadvertently encounter them, they should follow the balloon manufacturers' advice and best industry practice to mitigate the possible consequences," TAIC said.

The tragedy happened on January 7th, 2012, when a Cameron Balloons Ltd hot-air balloon, with 10 passengers and the pilot on board, became entangled in power lines near Carterton shortly after 7.20am.

The balloon had descended to between 5 and 7 metres from the ground as it drifted over a silage paddock, which was bound on two sides by 33-kilovolt power lines with an average height of about 9 metres.

"The balloon was drifting towards the power lines on the far road-end boundary when the wind changed and took it towards power lines closer to the adjacent boundary. The pilot applied the burners to try to out-climb the power lines, but the basket of the balloon became entangled in them," TAIC said.

About 15-30 seconds later there was an intense electrical arcing and fire erupted in the lower part of the basket. One of the balloon's liquefied petroleum gas fuel cylinders was ruptured by the arcing, and escaping fuel intensified the fire.

Two passengers jumped while the basket was still caught on the wires, from a height of about 20m, and they died from their injuries.

Heat from the fire raised the air temperature in the balloon envelope to a point where it broke the wire restraining it. The balloon rapidly rose to between 110 and 150m before the balloon envelope caught fire and collapsed.

The balloon fell to the ground, and the pilot and eight remaining passengers died from their injuries.

Autopsy toxicology tests showed the pilot had levels of THC — an active ingredient of cannabis — of 2 micrograms per litre of blood.

On the balance of probabilities, that level of THC resulted from both longer term and recent use, TAIC said.

"On reviewing the evidence available, it was highly likely that the pilot smoked cannabis on the morning of the flight."

Two witnesses had seen him smoking on the balcony of a shed shortly before the flight.

The pilot was not known to smoke regular cigarettes and his urine tested negative for cotinine, which was normally found in the urine of someone who smoked regular tobacco.

TAIC chief commissioner John Marshall QC told a briefing on the report the commission had investigated six incidents in the past 10 years where people operating aircraft, vessels or rail vehicles, or where people performing functions directly relevant to their safe operation, had tested positive for performance-impairing substances.

Thirty-five people had died in those accidents.

www.stuff.co.nz/dominion-post/news/wairarapa/9346767/Poor-judgement-led-to-fatal-flight

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Related threads:

• Wairarapa balloon tragedy - initial findings

• TAIC InterimReport into Carterton Balloon Accident

• Balloon crash pilot unlicensed

[kiwithrottlejockey]

Download the full report from HERE.

[Dave Homewood]

"The TAIC report recommended the introduction of appropriate legislation or rules that would:

❏ prescribe allowable maximum levels of alcohol.

❏ prohibit people from operating an aircraft, vessel or rail vehicle if they were impaired by drugs."

So, umm, right now there's no laws against flying a balloon while drunk or stoned??

[baz62]

Oct 31, 2013 12:22:54 GMT 12 Dave Homewood said:

"The TAIC report recommended the introduction of appropriate legislation or rules that would:

❏ prescribe allowable maximum levels of alcohol.

❏ prohibit people from operating an aircraft, vessel or rail vehicle if they were impaired by drugs."

So, umm, right now there's no laws against flying a balloon while drunk or stoned??

Thats exactly right. There are no laws exactly governing aviation regarding alcohol/drugs as there are for cars. Yes it would be illegal to fly passengers drunk, knowingly putting them at risk but there are no limits set which if tested makes you say hey thats over the limit. One isn't set. It's all part of the requirements to hold an aviation licence, one being a person of good character (or words along those lines.) For example if you had a history of drink driving and then tried to do a PPL it may be declined because of this. But there is no testing of pilots (at least at the smaller level eg: aero clubs) .
It is up to the pilot to decide wether to drink the night before flying and the old rule "8 hours from bottle to throttle" is about it. And even that may not be long enough for some people to still have a measurable amount in their blood.
You can't exactly have checkpoints in the air so it relies on pilots to do the right thing and for others to step up if they think someone is impaired. Unfortunately some have flown drunk and died as a result.

EDIT:
Found the bit in my Air Law book: "It is important to realise that a conviction for any offence relating to alcohol or drugs or a refusal to submit to any test for alcohol or drugs, shall be relevant for determining whether a person is, or remains, a fit and proper person to hold a licence or rating. Such conviction may result in a refusal to grant a licence/rating or to suspend or revoke it."
Thats it. If I were to have a serious aircraft accident I would have to submit to a blood test and then it would be up to a Judge to decide wether the alcohol/drugs found were enough to impair my judgement.
(And no I hadn't been drinking when i bought the Auster! )

[Dave Homewood]

So there have been no regulations and spot checks on commercial operators such as this balloonist, or parachute meat bomb pilots, or sightseeing pilots, etc? What happens if a customer complains a pilot was suspected to be drunk? Is there nothing the cops or CAA can do without laws in place?

[kiwithrottlejockey]

Oct 31, 2013 14:13:47 GMT 12 baz62 said:

Oct 31, 2013 12:22:54 GMT 12 Dave Homewood said:

"The TAIC report recommended the introduction of appropriate legislation or rules that would:

❏ prescribe allowable maximum levels of alcohol.

❏ prohibit people from operating an aircraft, vessel or rail vehicle if they were impaired by drugs."

So, umm, right now there's no laws against flying a balloon while drunk or stoned??

Thats exactly right. There are no laws exactly governing aviation regarding alcohol/drugs as there are for cars. Yes it would be illegal to fly passengers drunk, knowingly putting them at risk but there are no limits set which if tested makes you say hey thats over the limit. One isn't set. It's all part of the requirements to hold an aviation licence, one being a person of good character (or words along those lines.) For example if you had a history of drink driving and then tried to do a PPL it may be declined because of this. But there is no testing of pilots (at least at the smaller level eg: aero clubs) .
It is up to the pilot to decide wether to drink the night before flying and the old rule "8 hours from bottle to throttle" is about it. And even that may not be long enough for some people to still have a measurable amount in their blood.
You can't exactly have checkpoints in the air so it relies on pilots to do the right thing and for others to step up if they think someone is impaired. Unfortunately some have flown drunk and died as a result.

It's actually the same when it comes to driving rail vehicles.

There is no law which specifically says it is illegal to operate a rail vehicle while under the influence of alcohol.

I'm not sure about recreational drugs (I guess one could classify alcohol as a recreational drug), although possession or use of many of those drugs (although not all) are illegal.

However, although being under the influence of alcohol isn't necessarily an offence when operating a rail vehicle, it is a requirement to have a policy on drug and alcohol in the Railway Operating Safety Plan which is required before a Railway Operating Licence is issued to any organisation. And if you move any rail vehicle on rails, then you need a Rail Operating Licence. So if one was to operate a rail vehicle while under the influence of recreational drugs or alcohol, then it becomes a serious discipliniary matter. I cannot speak for other organisations, but I know that KiwiRail specify a ZERO alcohol level, and an effective ZERO level for any recreational drugs.

[Peter Lewis]

I would have assumed that pilots would have more sense.

Any checks on private or small scale operators would in reality be very difficult to enforce.
So you land at Raglan and some guy pops up with a blow-in-the-bag request?

Just to say 'the pilot seemed drunk' well after the event would be very difficult to verify.

My own personal limit on alcohol is nothing within 12 hours of a planned flight. If my ETD is 9am then I won't even have a drink with a meal if it is later than 9pm the previous night.

[baz62]

Oct 31, 2013 14:19:36 GMT 12 Dave Homewood said:

So there have been no regulations and spot checks on commercial operators such as this balloonist, or parachute meat bomb pilots, or sightseeing pilots, etc? What happens if a customer complains a pilot was suspected to be drunk? Is there nothing the cops or CAA can do without laws in place?

If a customer suspected the pilot drunk I'd hope he would A: Not go up with him/her and B:Report them to either the Business management or Police. But you are right, as far as I know there are no spot checks done although perhaps the big boys like Air New Zealand etc do?

[baz62]

Oct 31, 2013 14:38:40 GMT 12 Peter Lewis said:

I would have assumed that pilots would have more sense.

Any checks on private or small scale operators would in reality be very difficult to enforce.
So you land at Raglan and some guy pops up with a blow-in-the-bag request?

Just to say 'the pilot seemed drunk' well after the event would be very difficult to verify.

My own personal limit on alcohol is nothing within 12 hours of a planned flight. If my ETD is 9am then I wont eve have a drink with a meal if it is later than 9pm the previous night.

yep that's good practice.

[jonesy]

I'm all for random Drug & Alcohol testing in these industries, its relevant in most primary industries already and is easy to carry out. At the mine sites over here in W.A its a daily occurrence, approx 1 in 40 randomly picked is the ratio I think. Sure, it wont catch every person who "partakes" but the threat of being caught (and almost effectively ending your career at worst) certainly makes people change their lifestyle.
Its actually part of my job to do these tests every day. Most participants are cool with it, but I'm sick of the smell of other peoples urine!! (And thats not how we test it!)

[flyinkiwi]

Twelve hours bottle to throttle is my rule as well. Flying is hard enough without impairing your ability.

[haughtney1]

Alcohol and drug spot checks do happen in NZ, certainly for foreign airline crews, generally they are administered by the airline concerned and contracted out to a third party to ensure impartiality, they generally take place in the hotel before you launch off to the airport etc.
NZ is one of those funny regulatory environments where the concept of self policing was seen as adequate, given the limited amount of aviation activity taking place. The rise of higher risk and adventure type aviation activity however has introduced a completely new group of individuals and pressures for the regulator to deal with. Using professional skydivers in NZ that I know as an example, I'd be very surprised if there wasn't a trace of THC in most of their bloodstreams.
Regarding alcohol, my own personal limit is 18 hours (my company rule is 12, and the regulation states 8), and it also means for me, I'm happy to have a couple of beers...or a glass of wine with dinner, not half a bottle of black label...
If you can't abide by the rules (such as they exist) or are unable to get through the day without a tipple....then aviation in any form isn't for you.

[Dave Homewood]

I have tried drinking for 18 hours but seldom manage it. 16 is about my limit.

[haughtney1]

I have tried drinking for 18 hours but seldom manage it. 16 is about my limit.

Hahaha..wiping the coke 0 off my screen and out of my nose.......

[lesterpk]

Thats what you get for drinking Coke Zero.

Here in our business we have a CASA approved DAMP (Drug and Alcohol Management Plan) which means any client or CASA or my own company can come into my workplace and request a brethtest and a urine sample. Its happened twice so far in just over 2 yrs. Once by a client and once by the company.

[Peter Lewis]

So how, exactly, do you preflight drug/alcohol test at 6am an owner/operator who is about to ascend from a remote rural paddock?

[Dave Homewood]

I think the more important area where this needs to be monitored is clearly the tourism sector such as parachute organisations, balloonists, pleasure flights, scenics, etc that take paying tourists (local and overseas) up as a business. They are responsible not just for themselves and the lives of their passengers but the livelihoods of the business owners, and for the reputation of the New Zealand tourism and aviation industries.

This one balloonist has made himself, the balloon ride industry and NZ as a whole look pretty bad at different levels simply because of his own nasty habits and poor discipline. had a body been monitoring this more closely he may have been sorted out properly last time he was caught drunk/stoned flying and his flight was grounded! 11 people might be still alive because of it.

[lumpy]

Nov 1, 2013 19:26:29 GMT 12 haughtney1 said:

Regarding alcohol, my own personal limit is 18 hours (my company rule is 12, and the regulation states 8)If you can't abide by the rules (such as they exist)

So your personal views on alcohol rules when flying , are vastly different to your views on speed when driving , ie , follow the rules " such as they exist ". Guess which one is most likely to kill you ?
Sorry in advance , not trying to be confrontational - just food for thought .

[delticman]

Flying Squad?

[jonesy]

Nov 1, 2013 21:20:17 GMT 12 Peter Lewis said:

So how, exactly, do you preflight drug/alcohol test at 6am an owner/operator who is about to ascend from a remote rural paddock?

Surely they issue flight plans? I'm not completely sure of how their system works, but what could happen is a governing body could organise random tests and subcontract to local providors. I was on a course with a chap who does forestry workers, he has a 4WD that tows a modified horse float (has certified testing booth set up inside it)and just turns up on site anywhere, anytime when directed. It cant be that difficult to organise, just takes a bit of time and effort then it pretty much runs itself. Doesnt even have to be directly before flight even. Random ones in the workplace are just as effective.
My opinion? Theres no place for workers under the influence in ANY industry where you are responsible for other people's well-being. Simple as that.