Transportation Safety Board of Canada - Aviation Safety Recommendations
TRANSPORTATION SAFETY BOARD OF CANADA
AVIATION SAFETY RECOMMENDATIONS
DATE ISSUED: 27 March 2008
The Honourable Lawrence Cannon, P.C., B.A., M.B.A.
Minister of Transport, Infrastructure and Communities
SUBJECT: Regulation of Passenger-Carrying Balloons
On 11 August 2007 at about 0908 central daylight time,Footnote 1 a FireFly 12B hot air balloon, C-FNVM, attempted a landing in a field adjacent to Birds Hill Provincial Park near the northern outskirts of Winnipeg, Manitoba. The balloon was operated by Sundance Balloons International under Special Flight Operations Certificate (SFOC) 5812-10-36 issued by Transport Canada (TC). One pilot and 11 passengers were on board for a local sightseeing flight of about one hour's duration, originating in the southeast of Winnipeg and terminating in the northeast of Winnipeg.
The flight had been extended beyond Winnipeg as the pilot searched for a suitable landing area. The winds in the landing area chosen were much stronger than anticipated. The balloon touched down and skipped several times. The basket was dragged on its side for about 700 feet and at one point tipped far enough for the burners to strike the ground. When the balloon stopped, the pilot ordered the passengers to evacuate the basket. A propane fuel leak occurred and an intense uncontrolled fire ensued before the evacuation was completed. The pilot and two passengers suffered serious injuries in the intense fire. Four other passengers suffered minor injuries, some with burns. Two of the propane tanks and a fire extinguisher canister exploded, and the basket of the balloon was destroyed by fire. The investigation (A07C0151) is ongoing.
The pilot obtained a weather briefing from the Winnipeg Flight Information Centre before the flight. The briefing indicated that the wind speed for the anticipated duration of the flight would be 120 degrees at 5 knots. The TSB investigation determined that the balloon was landed in winds between 10 and 17 knots.
A balloon is an aircraft as defined in the Aeronautics Act. Some balloon operators use this type of aircraft for hire and reward and are thus a commercial air service and air carrier as defined in the Act. However, although the FireFly 12B and other large balloons can carry up to 12 fare paying passengers, they are not regulated at a level comparable to other commercial operators.
Special Flight Operations Certificates
The carriage of fare-paying passengers in balloons is authorized by TC by way of SFOCs. In order to obtain an SFOC, the applicant must provide basic information, including a list of the balloons to be flown, as well as the registration, make, model, and size. TC then issues the SFOC. The SFOC states that the balloon operator is adequately equipped and able to conduct a safe balloon operation carrying fare-paying passengers. In this specific occurrence, there was no initial inspection of the company by TC to support this statement. The SFOC has no expiry date and there are no audits of the balloon operators as conducted on other air carriers.
TC has indicated that no current list of SFOCs is held nationally or by TC region. TC has issued 89 SFOCs, but does not know which are in use. TC believes that one company accounts for 85 per cent of the business, operating 59 balloons across the country.
TC has indicated that balloon operators could be subject to an inspection by a general aviation inspector once every 10 years. However, TC does not track which operators are active nor where they actually conduct operations.
The accident balloon was manufactured by FireFly Balloons in 2007 and was issued a certificate of airworthiness by TC. The balloon had been modified by a TC-approved Limited Supplemental Type Certificate for the installation of turning vents and changes to the parachute rigging.
The number of balloons currently registered in Canada is 482. Whether used to carry fare paying passengers or not, the balloons are registered privately. Since 01 January 1997, there have been 15 reported accidents involving balloons in Canada. Of these, 12 involved fatalities and/or serious injuries, for a total over the period of 3 fatalities and 26 serious injuries. Three of those 15 accident flights, authorized by an SFOC, involved 31 fare-paying passengers of which there were 2 fatalities and 15 serious injuries. Two of these accidents are currently under investigation as Class 3 occurrences: A07C0151 and A07P0295. Another fatal accident, A01O0200, was investigated as a Class 3 occurrence, but did not involve an SFOC or fare paying passengers.
Unsafe Conditions and Underlying Factors
Section 602.07 of the Canadian Aviation Regulations (CARs) requires operators to follow balloon flight manual (BFM) limitations. The FireFly 12B balloon was certified with an approved BFM dated 20 May 2005. However, the limitations section of the FireFly 12B BFM does not specify wind limitations. The performance section of the FireFly 12B BFM states that the maximum demonstrated wind speed at landing during certification tests was 7 mph. The FireFly 12B BFM normal procedures section has a caution that states "to exercise extreme care when landing at descent rates approaching 500 feet per minute and/or in winds above 7 mph."
Sundance Balloons International had voluntarily produced and maintained an operations manual. The manual was not approved by TC and was general in nature. In some areas, the operations manual lacked clear guidance. For example, the operations manual specified that balloons were not to be operated in surface winds that exceed the manufacturer's limitations as defined by the pertinent BFM and under no circumstances to be operated in surface winds that are, or are likely to become during the flight, greater than 15 knots. The 15-knot surface wind speed was a general limitation selected by the company for all balloon types.
Consequently, since the BFM had no wind limitation, the balloon could be operated in surface wind speeds up to 15 knots, which was significantly greater than the wind speed demonstrated in certification testing. This is a significant safety hazard because higher winds inhibit the deflation of the balloon's envelope, resulting in the basket being dragged over the ground at the wind speed. Landing in high winds increases the risk of passengers spilling out of the basket and the risk of damage to the burners and fuel system. The BFM provides guidance with regard to fuel management during a high-wind landing, but the operations manual does not.
Balloon operators are not regulated under Part VII of the CARs. The upkeep of operations manuals and maintenance manuals, and a requirement to adhere to flight manuals, are recognized means of controlling risks inherent in aviation operations. Balloon operators do not have to maintain operations manuals or maintenance control manuals. Without these approved manuals or specific regulatory standards, operators may not adequately manage risk. Although the SFOC states that "it certifies that the Balloon Operator is adequately equipped and able to conduct a safe balloon operation carrying fare-paying passengers," there is no assurance or verification, either by audit or inspection, that any standards are maintained.
In particular, because balloons are not regulated under Part VII, they fall in the lowest category for priority of inspection in TC's National Cabin Safety Inspection Program. This means that no large balloon carrying fare-paying passengers would be inspected under this program. Further, the placement of balloons in the general aviation category means that no cabin safety standards have been developed for balloons to ensure standardization during certification of new types and of operators engaged in the transportation of passengers. During the examination of a similar balloon basket, it was observed that passengers can reach fuel manifold lines and fuel lines running overhead to the burners, as well as suspension lines. They crouch in proximity to the propane tanks while being dragged during landings. The company manual includes the tank rims as a suitable point to hold onto during landing.
While some commercial balloon operators in Canada have fare-paying passenger loads equal to those of commuter and air taxi operators, their passengers are not assured of the same level of safety and oversight by regulations and standards. The Board is concerned that, without adequate standards and regulations for balloon operators, balloon passenger safety will be compromised. Therefore, the Board recommends that:
The Department of Transport ensure that passenger-carrying commercial balloon operations provide a level of safety equivalent to that established for other aircraft of equal passenger-carrying capacity.
TSB Recommendation A08-01
Assessment Rating: Satisfactory Intent
As the investigation continues, the Board may make further safety recommendations should additional safety deficiencies be identified.
Wendy A. Tadros
on behalf of the Board