NTSB Factual Report

History of Flight

On April 15, 1996, at 0749 hours mountain standard time, a Cameron A-210 hot air balloon, nosed over and erupted into flames after being dragged 485.2 feet and becoming inverted while landing in an open field near Phoenix, Arizona. The pilot was completing a local area visual flight rules sight-seeing flight. The balloon, operated by Get Carried Away, Scottsdale, Arizona, was destroyed by the postimpact fire. The certificated commercial pilot and two passengers sustained minor injuries, one passenger sustained fatal injuries, and five passengers sustained serious injuries. One of the seriously injured passengers died on April 28, 1996. Visual meteorological conditions prevailed. The flight originated from an open field at Cave Creek, Arizona, at 0650.

Some of the passengers in the accident balloon told Phoenix Police Department detectives that the they were participating in a General Motors, Chevrolet Division, top 100 dealers award winning trip promotion. The balloon ride was part of the promotional package. The passengers said they were bused from their hotel to the departure site and boarded the accident balloon. Other passengers boarded three other balloons.

After departing on the flight they flew directly to the accident area. In preparation for landing, the pilot briefed the passengers that it was going to be a "breezy, rough landing" and they should crouch down and hold onto something and that the balloon might tip over. One passenger said that the pilot established two landing plans. The first plan was to have the passengers kneeling down as they landed, and the other plan was to have them standing up. The pilot told them to kneel down during the approach for landing.

The balloon approached the landing area from the northeast and touched down beyond the fence line; the balloon did not hit the fence. As the balloon flew over the canal on the approach, the pilot was pulling a "red line" (the red line is used to let out the gaseous air and deflate the envelope). After touchdown, the balloon drug across the ground and the pilot continued to pull on the red line. The basket then tipped onto its side. Moments later, the basket tipped over from its side to inverted.

After the basket was inverted, a passenger said he heard the burners go off and then saw that a "girls hair" was on fire. Other people arrived at the basket and helped the passengers evacuate.

Safety Board investigators interviewed Get Carried Away (hereafter referred to as the company) ground crew chief at the accident site on April 15, 1996. The crew chief said he saw the balloon land and, according to company policy, ran to the balloon and latched onto the balloon as it touched down to help weigh it down and stabilize it. The crew chief attempted to assist the pilot pull the red line as the basket drug along the ground when it "dog housed (the basket became inverted)" about 8 feet before it caught fire.

Two other balloons landed near the accident balloon a few minutes before the accident. Both pilots said that they saw the accident balloon land with the short side of the basket pointed toward the direction of travel. They said that they landed with the short side of the basket pointed in the direction of travel. Both pilots also said that the accident balloon's landing appeared to be normal.

The company's director of operations said that three of the four nylon upright rods broke while inflating the accident balloon on the morning preceding the accident. Three of the four upright rods were replaced with wooden rods. The owner of the company said that a person from the company went to Arizona Hot Air Repair to obtain new upright rods. The owner of the repair station told him that wooden poles would suffice, and that new uprights could be delivered to Get Carried Away before the next morning's flight. The person asked the repair station owner to deliver them in the morning.

The company's director of operations said, however, that the repair station (Arizona Hot Air Repair) owner did not say that the use of wooden poles would suffice. The director of operations attributed the statement to the mechanic who performed the last annual inspection; the mechanic was also one of the pilot's who landed before the accident balloon.

The mechanic said in a telephone interview that it would be better to use wooden poles than no poles at all, even though the flight manual allows the flight to be accomplished without any poles.

On the morning of the accident the repair station owner went to the wrong location to deliver the upright rods. The company's owner said that the uprights were not the correct length for use in their balloon.

The repair station said that on April 14, 1996, he observed the pilot abort the inflation of the accident balloon between 0615 and 0630. At 0730, another pilot from the company (also the mechanic who did the last annual inspection) told him that three of the four flexi-rigid nylon poles had broken earlier during a "hot air inflation." The repair station owner told the pilot/mechanic that he had some flexi-rigid nylon poles at his shop and that he would replace and deliver them to the Jomax site on April 15, 1996, before the flying activities started.

Later that day (April 14, 1996), the company's director of operations called and told him that three flexi-rigid nylon poles had broken. He told the director of operations that he was aware of the situation and that he would bring the poles to the Jomax site the next morning. He also told him that he would cut the poles to the required length, but the director of operations said that he would cut the poles when he received them.

On April 15, 1996, when the repair station owner arrived at the Jomax site, he could not find anyone from the company. Later, he found a company driver and gave him the poles.

The accident coordinates are 33 degrees 44.57 minutes north latitude, and 112 degrees 6.80 minutes west longitude.

Crew Information

The pilot held a commercial pilot certificate with a balloon rating. He did not hold a medical certificate, nor was he required to. Safety Board investigators did not review the pilot's flight hours logbook. The flight hours listed on page 3 of this report were provided by the pilot in the accident report.

According to the accident report, the pilot accrued 1,795 flight hours in balloons, of which 1,768 hours were logged as pilot-in-command. During the preceding 90 days of the accident, the pilot accrued 67 hours as pilot-in-command. The pilot satisfactorily completed the last biennial flight review (BFR) on January 7, 1995. According to federal air regulations, a BFR is valid for 24 calendar months.

Aircraft Information

The FAA aircraft records section show that the balloon was registered to The Hot Air Balloon Company, Phoenix, Arizona. According to Get Carried Away company officials, the company purchased the accident balloon from the registered owner on April 5, 1996. At the time of the accident, the company did not reregister the balloon.

Safety Board investigators did not recover the balloon's maintenance logbooks. According to the company's director of operations, the maintenance logbooks were aboard the balloon. Remnants of the logbooks were not found during the wreckage examination.

A balloon pilot participating in the flight of four balloons told investigators that he accomplished the last annual inspection on April 3, 1996. He said that there were no deferred maintenance discrepancies when he completed the annual inspection.

According to Cameron Balloons drawings CB 1006, issue I (April 2, 1996) and CB532, only nylon or lexan rods are permitted. The A-210 Cameron Balloon Flight Manual allows the balloon to be flown without any upright rods installed. If the upright rods are not installed, the pilot will use a different landing technique. That is, on touchdown, the pilot will push the burner assembly forward. The pilot must adopt this landing technique for flights without any nylon flexi poles installed.

The referenced drawings, all of which are proprietary data, are not normally available to any balloon operator. The prohibition of the use of any replacement upright rods not made with nylon or lexan material is not specifically noted in the A-210 maintenance or flight manual.

The flight manual, section 1, General, page 1-3, states, in part, ". . .For appearance and safety, fuel hoses, suspension cables and nylon flexi-rigid poles are optionally enclosed together in a padded suede sleeve. . . ." Section 4, Normal Procedures, states, in part, ". . .As with all parts of the balloon system, these fittings must not be altered, replaced, or substituted except in conformance with the type design. . . ."

The Cameron parts catalog specify which upright rods can be installed. The maintenance manual does not address installation of the upright rods.

The Cameron Balloons on-site representative said that the company considers the pilot techniques used during an anticipated "breezy or high wind" landing to be the same as an anticipated "hard landing." During a high wind landing, the flight manual states, in part, ". . .If possible, the pilot should turn off the fuel tank shut-off valves before touch-down, and at least turn off the pilot light(s) at the burner. . . ."

According to the Cameron Balloons on-site representative, the basket ground alignment is at the pilot's discretion. Most pilots land with the long side of the basket pointed toward the direction of travel. Some pilots told Safety Board investigators that they will land with the short side of the basket aligned parallel to the ground path during anticipated high wind landings.

Fire

The balloon erupted into flames shortly after becoming inverted. A pilot from another landing balloon attempted to extinguish the fire with his fire extinguisher, but without success. Phoenix Fire Department personnel responded to the accident and arrived about 0900. The fire extinguished itself by the time they arrived.

Wreckage and Impact Information

The crash site is located in an open field near Happy Valley Road and Highway 17. A north-south wire fence separates the open field from a canal. The on-scene investigation revealed the balloon touched down about 63.3 feet southwest of the fence. Ground skid marks show the balloon touched down with the basket skids parallel to the ground. The skid marks were intermittently interrupted two times and continued until reaching 421.9 feet beyond the initial touchdown point. (See the Photographic Wreckage Diagram herein this report)

The ground scars changed to a solid scrape mark and continued to the main wreckage area, about 68.8 feet. The basket and its associated components were found, inverted. The four fuel tanks and the burner assembly were found beneath the basket frame. Some of the fuel lines separated from their respective attach points.

The envelope was destroyed by the postimpact fire.

Safety Board investigators examined the wreckage at National Air Transport, Inc., Phoenix, Arizona, on April 16, 1996. The parties listed on page 5 of this report participated in the wreckage examination.

Two fuel manifolds were installed: one on the exterior wall of the pilot compartment toward side C connecting tanks 3 & 4 (see basket drawing herein this report) and the other on the interior wall of the pilot compartment toward side A connecting tanks 1 & 2).

Tanks 2 & 3 were being used for the vapor feed to the pilot lights. The pilot valve on tank 2 was found in the "on" position and was connected to the vapor hose. Tank 3 vapor valve was found in the "on" position, but was not connected to the vapor hose; the vapor hose sustained fire damage.

The liquid hoses were connected to the master fuel tanks.

The pilot light valves at the burner assembly was found fused in the "on" position. The main blast valves were found in the "off" position and were not fused. The whisper and crossover valves sustained fire damage. Investigators were unable to determine their position (on/off).

The left burner (the closest to side D) exhibited extensive fire damage. The left side of the burner frame appeared to have sustained more heat damage than the right side.

The basket frame was bent upward at side B. When placed in a horizontal position, side B was lower than side D. One of the four basket frame top sockets that held the poles were damaged; the top edge was bent inward. Safety Board investigators removed charred wood remnants from both of the basket top sockets along side C of the basket. All four basket suspension stainless steel cables and carabiners were found connected and intact.

Medical and Pathological Information

Toxicological examinations were not performed on the pilot, nor were they requested.

Tests and Research

The main fuel line was examined at the National Transportation Safety Board's Materials Laboratory, Washington, D.C. The examination showed that the line separated from the fuel manifold due to fire damage.

The current flight manual (FAA Approved: January 15, 1989) for the A-210 balloon, section 4, normal procedures contains a warning admonition that states:

Additions or modifications to the basket, burner, envelope, or instruments, or installation of unapproved equipment, may create a hazard which could result in injury or death. Before undertaking any maintenance or modification not specifically documented in the Maintenance Manual under Preventive Maintenance, contact Cameron Balloons for guidance. (See also Appendix H: PREVENTIVE MAINTENANCE)

According to the factory representative, this caveat is placed in the flight manual for current balloons and was not distributed to the registered owners of earlier models. Since this accident, Cameron Balloons has sent a letter to all registered owners that contain the referenced warning admonition.

Additional Information

The wreckage, except the main fuel line, was released to Get Carried Away director of operations on April 16, 1996. The main fuel line was returned to Get Carried Away on May 8, 1996.

NTSB Probable Cause

the pilot's failure to follow the flight manual procedure by not turning off the burner's pilot shutoff valves. Factors relating to the accident were: the installation of improper (unapproved wooden) upright rods by company maintenance personnel, subsequent failure of the upright rods, and the manufacturer's unclear information concerning the replacement parts.