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ASN Wikibase Occurrence # 205821
Last updated: 24 January 2019
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Date:08-FEB-2018
Time:7:15 LT
Type:Silhouette image of generic BALL model; specific model in this crash may look slightly different
Kavanagh B-350
Owner/operator:Go Wild Ballooning
Registration: VH-EUA
C/n / msn: B350-368
Fatalities:Fatalities: 0 / Occupants: 16
Other fatalities:0
Aircraft damage: Minor
Category:Accident
Location:near Yarra Glen, VIC -   Australia
Phase: En route
Nature:Domestic Non Scheduled Passenger
Departure airport:Glenburn
Destination airport:Chateau Yering
Investigating agency: ATSB
Narrative:
During landing, the balloon bounced twice and landed hard. Seven of the 16 occupants were taken to hospital, some with serious injuries (4).

ATSB final report :

Findings:

From the evidence available, the following findings are made with respect to the hard landing involving the balloon, registered VH-EUA, that occurred 6 km east-north-east of Yarra Glen, 8 February 2018. These findings should not be read as apportioning blame or liability to any particular organisation or individual. Safety issues, or system problems, are highlighted in bold to emphasise their importance.

A safety issue is an event or condition that increases safety risk and (a) can reasonably be regarded as having the potential to adversely affect the safety of future operations, and (b) is a characteristic of an organisation or a system, rather than a characteristic of a specific individual, or characteristic of an operating nvironment at a specific point in time.

Contributing factors:

• During the flight, the balloon encountered a wind change that substantially altered the direction and speed of the balloon and subjected the occupants to moderate turbulence.
• The most recent local balloon forecast was inadvertently not made publicly available, and other forecast information available to the pilot did not accurately state the timing of the wind change.
• The Bureau of Meteorology did not have a procedure to ensure that a recording of the local weather forecast for balloon operations in the Melbourne area was correctly uploaded and accessible to balloon pilots. [Safety issue]
• The pre-flight safety briefing provided to the passengers was ineffective in ensuring that all passengers understood the required landing position to use in the event of an emergency landing.
• Although the operator had procedures for conducting a verbal safety briefing prior to flight and had safety briefing cards available, its risk controls did not provide assurance that all passengers would understand the required procedures for emergency landings.

More specifically:

- safety briefing cards were not routinely made available to passengers prior to or during flight
- safety briefing cards for non-English speaking passengers did not include diagrams to help communicate important information
- the procedure for safety briefings did not require passengers to physically demonstrate that they understood the required landing position
- the procedure for safety briefings did not require the pilot and ground crew to crosscheck that a safety briefing had been conducted prior to departure. [Safety
issue]

Other findings
Following the sudden wind change, the pilot decided to land immediately rather than continue flight over rising and heavily vegetated terrain. Given the existing situation, this decision meant that a hard and fast landing was likely to occur.

See full report and safety issues and actions below -->

Sources:

https://www.ndtv.com/world-news/7-injured-in-australia-hot-air-balloon-crash-1810010
___________________________________________

https://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-016/

Accident investigation:
cover
  
Investigating agency: ATSB
Status: Investigation completed
Duration: 8 months
Download report: Final report


Images:



Revision history:

Date/timeContributorUpdates
08-Feb-2018 07:00 Chieftain Added
08-Feb-2018 08:41 Iceman 29 Updated [Time, Aircraft type, Location, Nature, Embed code, Narrative]
08-Feb-2018 08:42 Iceman 29 Updated [Aircraft type, Embed code]
08-Feb-2018 08:44 Iceman 29 Updated [Operator, Other fatalities]
08-Feb-2018 10:41 Iceman 29 Updated [Embed code, Narrative]
08-Feb-2018 18:22 Pineapple Updated [Time, Aircraft type, Registration, Cn, Operator, Other fatalities, Location, Source, Embed code, Narrative]
09-Feb-2018 12:02 Iceman 29 Updated [Time, Embed code]
30-Oct-2018 12:36 Iceman 29 Updated [Source, Embed code, Narrative, Photo]
30-Oct-2018 12:43 Iceman 29 Updated [Departure airport, Destination airport, Damage, Narrative, Photo]
30-Oct-2018 18:35 harro Updated [Source, Accident report, ]

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