NTSB Factual Report

HISTORY OF FLIGHT

On March 15, 2010, about 1807 mountain standard time, a Head Balloons, Inc., AX9- 118, N3087D, made a hard, bounced, high wind landing in an open field about 5.3 miles north-northwest of Deer Valley Airport, Phoenix, Arizona (DVT). The balloon's basket tipped over during landing. The commercial certificated pilot exited the basket and was seriously injured. One of the three child passengers and both of their parents sustained minor injuries. Several panels in the balloon's envelope were ripped open, and the balloon was substantially damaged. The fare-paying passengers had contracted for their anticipated hour-long sightseeing flight with the balloon’s operator, Arizona Hot Air Balloons, Inc., Phoenix. According to Federal Aviation Administration (FAA) Aircraft Registration Branch personnel, the balloon did not have a valid registration certificate. Its certificate was listed as being in a “pending status.” Visual meteorological conditions prevailed, and no flight plan had been filed. The flight was performed under 14 Code of Federal Regulations Part 91, and it originated from a field in northern Phoenix about 1728.

The pilot elected to terminate the sightseeing flight earlier than planned when the local wind speed increased, and the pilot communicated to her ground crew via radio that she intended to land. The pilot advised the passengers that the landing would likely be hard and would likely involve one or more bounces. She directed the passengers how to position themselves for landing.

The pilot reported to the National Transportation Safety Board investigator that the balloon’s basket bounced back into the air following its initial touchdown. She attempted to open the envelope’s parachute top to expedite the hot air venting process in order to deflate the balloon, but was unable to fully activate it. When the basket touched down the second time, it dragged along the ground and tipped forward.

While the passengers were bent down in the basket, as directed, the pilot attempted to obtain a more substantial grip on the red vent line. The basket was jostling as it passed over small boulders. The pilot stated that she lost her footing when the basket was leaning at a 60-degree forward angle, and she exited the basket. The basket overran her as it dragged in the soil, went across a street, and hit curbs. The balloon finally came to rest upon impacting a roadside gate, which was located about 360 feet east of the initial point of touchdown.

A pilot who was flying in another balloon, and who witnessed the accident, reported that the accident balloon’s (parachute) top did not appear to have been opened during landing. The accident balloon’s envelope did not promptly deflate.

PERSONNEL INFORMATION

The 49-year-old pilot held a commercial pilot certificate for lighter-than-air free balloon. She did not hold an aviation medical certificate; none was required.

The pilot reported that all of her flight time was obtained flying balloons. Her total flight time was 364 hours, of which 12 hours were in the accident balloon’s make and model. During the preceding 90 days, she had flown 12 hours, of which 3 hours were in the accident balloon’s make and model.

AIRCRAFT INFORMATION

Registration and Company Information

According to FAA aircraft registration records, the standard category balloon’s registration certificate had been terminated months prior to the date of the accident when the balloon was sold. The new owner/operator had not completed the required registration procedure by the accident date. Several months after the accident (in July 2010) the FAA issued the new owner a registration certificate.

The private individual (not the pilot), who owned the balloon and the balloon company, informed the Safety Board investigator that he solicited fare-paying passengers for balloon rides in the operation of his business. He used the name “Arizona Hot Air Balloons, Inc.” in his Internet advertisements. The balloon company owner stated that his firm was not, in fact, incorporated.

Balloon Modification, Documentation and Preflight Procedures

In 2004, the Head Balloons, Inc., model AX9-118, serial number 287 (N3087D), was modified pursuant to FAA supplemental type certificate (STC) number SB00463AT, issued in 1994. This STC allowed the use of specific Cameron Balloons’ baskets, burners, and fuel systems with the Head Balloons’ envelope. The FAA reported that a Cameron flight manual supplement was a required part of the STC. The supplement was required to be in the basket, along with the Head balloon flight manual (BFM) during flight.

A balloon repairman had authorized use of Cameron basket part number CB301C-6, serial number 9390, on the Head envelope. This basket part number was authorized for use under the STC, according to the FAA. The FAA coordinator reported that no Cameron flight manual supplement was found in the accident balloon.

According to the FAA approved Head BFM, dated September 30, 1987, the balloon was equipped with a parachute top. In section 2.2.8 of the Head BFM, which addresses normal operating procedures, before the inflation process begins the parachute actuation line and cords are to be checked to insure that they are free of knots and tangles.

The parachute top is used to deflate the balloon during landing. In section 2.5.2 of the balloon’s landing procedures, the Head BFM states that when landing in moderate or strong wind the parachute top must be held open by maintaining tension on the actuation line until the balloon is deflated.

METEOROLOGICAL INFORMATION

Weather information available to the pilot indicated that at the Phoenix Sky Harbor Airport after 1700, the wind speed was forecast to be variable at 3 knots. Temporarily between 1700 and 2000, it was forecast to be 5 knots.

The closest airport to the accident site is DVT, elevation 1,478 feet mean sea level (msl). It is located about 5.3 miles south-southeast (153 degrees, magnetic) from the accident site. About 14 minutes before the accident, at 1753, DVT reported wind from 310 degrees at 4 knots, 10 miles visibility, and a clear sky. One hour later, the wind speed had increased to 8 knots.

A pilot flying in another balloon observed the accident balloon during its landing. The pilot reported that the local wind speed had increased in the area minutes prior to the accident. The pilot estimated that the wind speed was 12 knots.

WRECKAGE AND IMPACT INFORMATION

The FAA reported that the balloon initially touched down at 33 degrees 45.743 minutes north latitude by 112 degrees 06.763 minutes west longitude. It came to a stop after dragging along uneven terrain over rocks, crossing a street, impacting a curb, and colliding with a crossing gate.

The accident site elevation is about 1,560 feet msl. The magnetic bearing and distance from the initial point of touchdown to the gate is about 68 degrees and 360 feet.

TESTS AND RESEARCH

The FAA inspectors who examined the balloon reported observing two registration certificates in the basket. One certificate bore registration number N9534R, and the other certificate bore number N3087D.

The pilot subsequently reported to the Safety Board investigator that the accident could have been prevented if she had possessed a more complete working knowledge of the balloon’s “Smartvent” deflation mechanism and had utilized it. The Cameron BFM associated with N9534R lists a “Smartvent” system as part of its designed fast action deflation system, which is combined with a parachute venting/deflation system.

The accident Head Balloon’s envelope in fact was not constructed with a “Smartvent.” The Head Balloon incorporates another type of rapid air deflation system, which is similar to the patented Smartvent system, according to the Phoenix-based balloon repairman who examined the accident balloon.

FAA inspectors reported to the Safety Board investigator that they observed a deflation activation line, which was connected to a portion of the rapid vent system inside the Head envelope, was incorrectly rigged. The line was found secured to a ring with a knot, located near the top of the envelope. The line was supposed to have been routed through the ring. The knot on the activation line secured the line to the ring. This event would have inhibited the pilot’s efforts at venting the balloon by pulling on the line, and it rendered the rapid deflation system partially ineffective.

FAA inspectors further reported that during the pilot’s required preflight inspection of the balloon’s venting system, the deflation activation line’s rigging should have been inspected. During the inspection, the deflation system would not have performed correctly, and the visually apparent improper rigging should have been corrected prior to flight.

The Safety Board investigator’s examination of the Head BFM (provided by the operator) revealed that it did not include the FAA approved supplement, dated October 21, 2008. In pertinent part, section 1.12 of this supplement states that helmets are required for all occupants on board and must be worn during emergency procedures. The Head BFM “strongly” recommends that helmets be worn when landing if the wind speed is 10 miles per hour, or greater. In section 4.1 of the operator’s Head BFM, the maximum demonstrated surface wind for landing was listed as 5 miles per hour.

Additionally, the operator’s Head BFM did not contain appendix 1, which addresses operation of the parachute top balloon’s optional auxiliary vent line, called a Quick Vent. The Quick Vent (red webbing) is utilized for faster deflation of the balloon upon landing.

ADDITIONAL INFORMATION

The passenger who arranged for the balloon ride reported to the Safety Board investigator that she had located the balloon company after observing the company’s advertisement on the Internet.

The passengers reported they had not been offered use of safety helmets. One of the passengers sustained a head injury upon exiting the balloon's basket.

NTSB Probable Cause

The pilot’s improper preflight inspection of the balloon’s rapid deflation system, which resulted in its inhibited functionality during landing.