Recently Released TSB Reports

Recently Released TSB Reports




The following summaries are extracted from final reports issued by the Transportation Safety Board of Canada (TSB). They have been de-identified and include the TSB’s synopsis and selected findings. Some excerpts from the analysis section may be included, where needed, to better understand the findings. For more information, contact the TSB or visit their Web site at www.tsb.gc.ca. —Ed.

TSB Final Report A07P0357—Loss of Control—Collision with Building

On October 19, 2007, at 16:02 PDT, a Piper PA-34-200 Seneca was cleared for takeoff from Runway 08 Right at the Vancouver International Airport destined for Pitt Meadows Regional Airport. The flight was operating under VFR with only the pilot on board. Shortly after takeoff, communications and radar contact were lost. The aircraft collided with a 15-storey residential building in Richmond, about 1.5 NM east-southeast of the departure end of Runway 08R. The pilot was fatally injured. There was no post-impact fire. The aircraft entered a suite occupied by two people; one received serious non-life-threatening injuries, the other received minor injuries. Structural damage to the building was minimal, but there was extensive water damage from the fire suppression system. As a result, hundreds of people were displaced from their homes for extended periods. There were no other reported injuries.

Aircraft flight path depicted over aerial view of Vancouver airport.
Aircraft flight path

Analysis

The identification of the factors that contributed to this accident was hampered by significant destruction of the aircraft and minimal recorded information. Three possible accident scenarios were considered: an intentional act, an equipment problem and pilot response, and pilot incapacitation. These scenarios are analyzed below.

First scenario—an intentional act

The first scenario is that the pilot intentionally flew the aircraft into the building. The pilot’s demeanour, his making of ongoing plans, his concern about the correct operation of the aircraft systems, and the care taken to prepare the aircraft for this flight are inconsistent with such a scenario. The TSB investigation did not reveal any indication to conclude that an intentional effort was made to place the aircraft, or anyone, in jeopardy.

Second scenario—equipment problem and pilot response

The second scenario involves a problem with the aircraft or its configuration that the pilot was unable to resolve during the short flight. Several aircraft systems with the potential to affect aircraft performance during the flight were examined and all but two potential system problems were eliminated. This left the possibility of an autopilot electrical malfunction or an electric pitch trim malfunction.

Because this was the first flight following maintenance on the pitch command function of the autopilot system, it would be unusual for the autopilot to have been engaged at such a low altitude, especially in view of the nature of the original complaint. Component damage prevented complete testing of these systems after the accident, but to the extent these systems could be examined, no anomalies were identified.

Following the accident, the anti-servo trim tab on the stabilator was found to be in a moderate nose-down position and the rudder trim was at full right deflection (left rudder input). It could not be determined if either trim setting was made before or after takeoff. It is possible that the pilot inadvertently omitted the checklist item to check and set either or both trims prior to takeoff. A nose-down trim would require the pilot to exert more back pressure to rotate the aircraft during the takeoff roll and could account for the much higher than normal speed over the departure end of the runway. It could not be determined if the electric power switch for the pitch trim was ON or OFF. There was no pre-takeoff checklist item reminding the pilot to turn the electric trim ON. If OFF, the pilot would have had to either turn it on to regain electric pitch trim functionality, or use the manual trim wheel to adjust the pitch trim. If an electric pitch trim runaway occurred during flight, it could be expected that it would have travelled to its limit (full nose-down position) unless pilot intervention limited the travel.

The pilot’s experience and skill level should have been sufficient to overcome such events and he had previously demonstrated his proficiency at altitude to deal with a faulty pitch command function of the autopilot during recurrent training. It was considered a possibility that degraded cognitive performance may have affected the pilot’s ability to identify, diagnose, and correct an unexpected pitch or rudder trim anomaly while controlling the aircraft’s attitude in the brief time after takeoff and before the collision with the building. However, no evidence of symptoms of reduced cognitive functioning was identified during the investigation.

Therefore, the investigation concluded that it is unlikely there was any system malfunction that could not have been readily overcome by the pilot.

Third scenario—pilot incapacitation

The third accident scenario involves the possibility of an acute medical event resulting in pilot incapacitation. The pilot was diagnosed with several cardiovascular risk factors, making an acute cardiovascular decompensation a possibility. An equally plausible possibility is an acute neurological event (such as a seizure or stroke). The routine medical examination did not detect impairment of cognitive processes or other neurological functions; therefore, further testing was not conducted.

The normal and loud engine operating sounds provided an indication of normal engine and propeller operation, which was confirmed by post-accident examination. High-engine power available from both engines would have contributed to reducing the angle of descent. A conscious pilot would have likely made some effort to correct the descent, to manoeuvre away from the building, or to communicate with air traffic services.

Demonstration showed that it is extremely unlikely for an unconscious pilot to have collapsed onto the control wheel and to have caused the loss of control resulting in the unchecked descent. Therefore, the change from a climb to a descent due to unconsciousness could be the result of two possibilities: the pilot being unable to maintain overriding control input in response to an anomalous pitch trim condition, or a less likely scenario of the pilot making an autonomic electric pitch trim command during the transition toward unconsciousness. In either case, it follows that the aircraft was accelerating in a descent because it had not achieved the airspeed corresponding to the pitch trim position. The erroneous pitch trim setting was not successfully addressed, and before the aircraft could achieve the corresponding speed and level off or resume a climb, it descended below the height of the building and collided with it.

The pilot had pre-existing health risk factors, making it possible that he suffered an acute medical event resulting in incapacitation and a loss of control of the aircraft. The investigation concluded that this is the most plausible scenario.

Photo showing impact damage with building.
Impact damage

Findings as to causes and contributing factors

  1. The pilot had pre-existing health risk factors, making it possible that he suffered an acute medical event resulting in incapacitation and a loss of control of the aircraft.
  2. With the pitch trim at an inappropriate setting, the aircraft accelerated in a descent below the height of the building and collided with it.

Findings as to risk

  1. Non-disclosure of medical symptoms or chronic conditions to civil aviation medical examiners (CAME) bypasses some of the safety benefit of examinations and may pose a risk of incapacitation while flying and, as such, a risk to public safety.
  2. TP 13312 does not address the complete range of conditions that may be affected by age, does not include significant advances since 2001, and does not cover the age range above 74. The guidelines, therefore, are of limited value in assisting CAMEs to detect all pilots with age-related medical risk factors.

Other findings

  1. There is no evidence to suggest that the pilot intentionally flew the aircraft into the building.
  2. The manufacturers and designers of equipment containing memory devices may not consider their potential use for accident investigation purposes.

TSB Final Report A08W0001—Runway Overrun

On January 4, 2008, a Jetstream 3212 was landing at Fort Smith (CYSM), N.W.T., following an IFR flight from Edmonton, Alta. While landing on Runway 29, at 15:02 MST, the aircraft rolled off the end of the runway and stopped 367 ft from the threshold and 60 ft to the left of the runway centreline. There was about 18 in. of snow in the overrun area. Damage was limited to the number two propeller. There were no injuries to the 2 pilots and 16 passengers.

Analysis

When the visual approach slope indicator system (VASIS) became visible, the aircraft was above the optimum glide path for a touchdown in the first 1 000 ft of the runway. In the attempt to regain the glide path, the pilot allowed the airspeed to increase to at least 20 kt above landing reference speed (Vref). By the time the aircraft decelerated to a speed allowing a firm touchdown, a considerable portion of the runway was overflown. The remaining 3 400 ft would have been sufficient for the aircraft to stop on a bare, dry runway after a touchdown at, or near, Vref; however, at a higher touchdown speed on a runway with a Canadian Runway Friction Index (CRFI) of 0.18 or 0.34, stopping in this distance could not be assured. Conservative CRFI charted landing distances are designed to cue flight crews to consider aircraft performance options for landing. Reference to CRFI charts prior to the approach would likely have prompted the crew to consider rejecting the landing when the airspeed and height profile exceeded normal parameters.

Findings as to causes and contributing factors

  1. The descent profile on final approach was above the optimal approach path for a landing in the runway touchdown zone. The aircraft landed about 3 400 ft from the end of the runway, which afforded insufficient distance to stop on the slippery runway surface.
  2. The airspeed during the approach and touchdown was significantly higher than that recommended. This higher speed and the tailwind contributed to the aircraft landing at a point on the runway which afforded insufficient distance to stop.
  3. The application of reverse thrust and maximum wheel braking was delayed until aerodynamic drag slowed the aircraft from the touchdown airspeed of 120 kt to 90 kt. The ground roll during that time consumed runway surface available for active braking.
  4. Reference to CFRI charts prior to the approach would likely have prompted the crew to consider rejecting the landing when the airspeed and height profile exceeded normal parameters.
  5. Prior to the landing, runway maintenance removed a light layer of snow and the previously-applied sand. This resulted in a very low coefficient of friction on the runway that was not measured or reported to the flight crew.

Artist’s representation of runway overrun.
Aircraft final position 60' from centreline and 367' past runway threshold

Safety action taken

The company instituted an enhanced pilot training program emphasizing crew resource management, conducting stabilized approaches, decision making regarding go-arounds, and airspeed control on approaches. In addition, quick reference charts featuring required landing distance were placed in company Jetstream cockpits, and required landing distance was to be included in pre-landing briefings.

TSB Final Report A08W0173—Aerodynamic Stall—Impact with Terrain

On August 17, 2008, a Cessna 337 was conducting an aerial fire patrol and wildlife survey with the pilot and a biologist on board, approximately 15 NM west of Beaverlodge, Alta. At 14:37 MDT, the pilot lost control of the aircraft during a low-level turn. The aircraft descended steeply through trees, skidded, and came to rest at the edge of a beaver pond. The aircraft was substantially damaged and the pilot was fatally injured. The biologist, who was seated in the front right seat, sustained serious injuries. The emergency locator transmitter (ELT) did not activate; however, locating the aircraft and survivor was facilitated by the global positioning system tracking equipment installed in the aircraft and the monitoring software used by the client’s flight-following personnel.

Helicopter wreckage being examined by TSB investigators.

Other factual information

The primary mission was to conduct a fire patrol. In addition, a Trumpeter Swan cygnet survey was to take place in certain areas, with a wildlife biologist assigned to the flight. Because the cygnets hide in the vegetation, biologists need to get quite close in order to make an accurate count. Wildlife surveys of this nature require the aircraft to be operated at lower altitudes and slower speeds than fire patrols, and it is not unusual for the aircraft to be at tree top height. Speeds and altitudes were always at the pilot’s discretion, and it was not unusual for the stall warning horn to sound during these operations. The company operations manual (COM) did not specify training or standard operating procedures for low-altitude wildlife surveys. The only reference to low-altitude flying was contained in the safety training practices section of the COM, which stated that any training shall not be conducted below 500 ft AGL or in the vicinity of wildlife.

Companies contracted for this survey work had to meet the following aircraft specifications and air crew qualifications: for twin-engine aircraft, the pilot shall have 1 200 hr total flying time with 100 hr multi-engine, 200 hr pilot-in-command (PIC), and at least six months operational experience. While the occurrence pilot met the multi-engine and PIC experience requirements, he did not possess 1 200 hr total flying time, nor did he have six months of operational experience.

The COM requires that all flights or series of flights must be authorized, before departure, by the operations manager or the chief pilot, as applicable. Operational control of a flight was delegated to the PIC by the operations manager, who retained responsibility for the day-to-day conduct of flight operations. In the event that a new requirement for a flight develops when operating away from base, the PIC has the authority to release the aircraft. The pilot did not communicate to the chief pilot that the occurrence flight would involve a low-level wildlife survey.

The wreckage trail indicated the aircraft had struck the trees in an approximately 40° left-wing-low attitude, about 40 ft AGL. The trees were estimated to be 35 to 50 ft tall and up to 12 in. thick. The tree swath indicated the descending flight path angle was approximately 45°. The aircraft had skidded and tumbled approximately 80 ft across the shoreline after initial impact with the ground. It came to rest on a small peninsula of land that jutted into the pond. The total length of the wreckage trail, from first tree impact to where the aircraft came to rest, was approximately 136 ft. Aircraft damage indicates that the majority of the impact forces were to the left side of the aircraft.

Analysis

The steep descent through the trees, short wreckage trail, low groundspeed, and steep angle of bank point to a loss of control at low altitude due to aerodynamic stall.

Due to the low altitude, the pilot would have been unable to recover in time to avoid impact with the trees. The biologist in the right seat survived due in part to the aircraft striking a fairly soft terrain feature (marshy swamp) after decelerating through several trees and impacting primarily on the left side of the aircraft. Survivability for the pilot could have been enhanced had he been wearing head protection in the form of a helmet.

Search-and-rescue efforts were delayed because the ELT, though fully functioning, was not able to transmit because the antenna leads were severed during the impact sequence. The GPS tracking system yielded a position that was instrumental in finding the aircraft and surviving biologist before dark.

The operator’s COM and standard operating procedures did not address the risks associated with low-level flight. Additionally, the company allowed a pilot to command who did not meet the client’s requirements. Operational control was insufficient to mitigate the risks associated with low-level flight, and as a result, the pilot entered into an operational situation that exceeded his abilities.

Findings as to causes and contributing factors

  1. The pilot had not been provided with sufficient guidance and training pertaining to low-level aerial surveys; consequently, the pilot’s handling of the aircraft was not consistent with safe operations in the low-level environment.
  2. The pilot flew the aircraft at low air speed, an angle of bank in excess of 50°, and a high-density altitude; this resulted in an aerodynamic stall.
  3. The low altitude of the aircraft prevented recovery from the stall prior to striking the trees.

Finding as to risk

  1. Having pilots operate aircraft at low altitudes without specific guidance and training increases operational flight risk.

TSB Final Report A09Q0003—Controlled Flight into Trees

On January 6, 2009, at 04:46 EST, a Piper Cherokee PA-28-140 took off from the Québec/Jean Lesage International Airport, Que., on a night VFR flight to the Saint John Airport, N.B., with the pilot and 3 passengers on board. Approximately 20 min later and about 38 NM east of Québec, the pilot informed the Québec terminal control unit that the flight was encountering a snow shower. Thirty-six sec later, the Québec terminal controller lost radio contact with the aircraft. About 3 min later, the aircraft disappeared from the radar screen. Shortly after, the aircraft struck the southwest slope of the Massif du Sud Mountain, Que. The emergency locator transmitter (ELT) activated on impact. The aircraft was located at 09:06 EST. The aircraft was destroyed, but there was no post-impact fire. The pilot and front seat passenger were fatally injured. The two rear seat passengers sustained serious injuries.

Findings as to causes and contributing factors

  1. The pilot undertook a night VFR flight while there was a risk of encountering instrument meteorological conditions (IMC).
  2. During the night flight, the pilot inadvertently entered snow showers and lost visual reference with the ground before crashing in controlled flight.
  3. The accident occurred at night, when it is harder to avoid bad weather and to see unmarked obstacles.
  4. It is likely that the pilot did not use the VFR navigation chart to navigate and, as a result, did not know the exact position of the aircraft or the elevation of the terrain in the area.
  5. The aircraft altitude was not corrected to compensate for the low outside temperature. As a result, the true altitude of the aircraft was approximately 500 ft lower than the indicated altitude, thus reducing the safety margin needed to avoid obstacles and the terrain.
  6. Although the effects of cocaine on performance in aviation have not been studied, its known effects indicate that the pilot’s use may have contributed to this accident.

Aircraft wreckage in heavily wooded area.

Findings as to risk

  1. The pilot undertook an extended night flight at the end of the day, with a planned return flight the same day. As a result, the pilot ran the risk of fatigue that may have led to degradation of performance.
  2. The time of arrival at the Saint John Airport, N.B., did not allow for spare time. Consequently, the pilot likely felt pressured to complete the flight in a timely manner.
  3. The pilot undertook a flight with a gyroscopic heading indicator that was in all likelihood defective, rendering navigation at night over a dark landscape difficult.
  4. The aircraft was not carrying adequate survival equipment. As a result, the survivors were exposed to the risk that their physical condition would deteriorate further before rescue personnel arrived.

Other findings

  1. The aircraft was overloaded, and the use of the two rear seats was not in compliance with the aircraft certification and flight manual. As a result, the aircraft performance was reduced.
  2. The time that passes between the collection and the analysis of blood and urine samples and the method of storage during the interval can have an impact on the effectiveness of an investigation.

TSB Final Report A09C0087—In-Flight Fire

On June 15, 2009, a Bell 204B helicopter, with two crewmembers onboard, was being used to bucket water in support of firefighting operations at Easterville, Man. During a water pickup, there was an electrical burning odour followed by the illumination of a fuel boost pump caution light. The crew aborted the water pickup and transitioned back to the ground staging area approximately 100 m away. The pilot landed the helicopter, shut off the engine, fuel, and electrics, and the crew quickly exited. Flames emanated from the right side of the engine cowling area, the fire spread quickly, and within minutes the helicopter was completely engulfed. The community fire truck was called and arrived within five minutes of the occurrence. The crewmembers were not injured, but the helicopter was completely destroyed. The accident occurred during daylight hours at 17:27 CDT.

Photo of helicopter with engine on fire.
Helicopter showing fire emanating from the engine area

Findings as to causes and contributing factors

  1. Electrical arcing occurred in an engine electrical harness in the area of the oil cooler blower compartment and the aft electrical compartment wall. The exact cause of the wire arcing could not be determined.
  2. The initial electrical arcing likely breached a nearby fuel line, which led to the rapid propagation of the fire and the total destruction of the helicopter.

Other findings

  1. The pilot’s timely decision to terminate the flight and the aircraft’s proximity to a suitable landing site facilitated a successful landing.
  2. The location of the fire would not initially have produced conditions that would have activated the engine fire caution system.

TSB Final Report A09Q0111—Controlled Flight into Terrain

On July 17, 2009, a float-equipped Bell 206L helicopter was on a VFR flight from Kangirsuk to Kangiqsujuaq, Que. The pilot and an aircraft maintenance engineer were on board the helicopter. Approximately 44 NM from the destination, with reduced visibility and a low ceiling, the aircraft diverted from the direct route and proceeded north towards the shore of the Hudson Strait. The helicopter was flying at a low altitude and at low speed. At a little less than a mile from the coast, the aircraft traversed an arm of the sea in a valley. Within the next minute, at 14:34 EDT, the helicopter in controlled flight struck the north rock wall of the valley. The aircraft was destroyed by impact forces and both occupants were fatally injured. The helicopter was found six days later.

Photo of wrecked helicopter in Northern Quebec’s treeless mountains.

Analysis

The pilot had never flown in Northern Quebec. It was also likely his first experience flying in an area under the influence of an Arctic maritime climate. His practical experience did not enable him to fully appreciate the difficulties to be encountered in flight.

Knowledge of the topography of the Northern Quebec coastline would lead to the conclusion that the multitude of steep-sided arms of the sea makes VFR flight hazardous in reduced visibility. Further, understanding the meteorological characteristics of the region would lead to the realization that the fog in this region is advection fog formed over the ocean that affects the coastal regions. Considering these two elements, a westward diversion should be made to move away from the coast to bypass the areas of reduced visibility.

Before taking off from Kuujjuaq, the pilot obtained weather information to plan the flight. He reviewed the weather information available at the Kuujjuaq flight service station (FSS) and got a verbal description of the weather along the planned flight route from the operator’s base in Goose Bay. Based on this information, he delayed the flight about two hours.

The pilot appears to have based his decision to take off from Kuujjuaq essentially on the reported visibility at Kangirsuk and Kangiqsujuaq. The hourly observations at 08:00 EDT, 09:00 EDT, and 10:00 EDT at Kangirsuk and Kangiqsujuaq reported visibility exceeding the minimum visibility required by the CARs to make the flight. In addition, the trend suggested by these observations gave reason to believe that the weather was gradually improving. Visibility at Kangirsuk had indeed improved from ½ SM to 1½ SM, and at Kangiqsujuaq from 5 to 12 SM. Moreover, the weather at Kuujjuaq was good. Also, the drizzle, fog and low cloud reported at Quaqtaq would not delay the flight to Coral Harbour.

For an undetermined reason, the pilot did not call the flight information centre (FIC) at Québec to request a printout of the graphic area forecast (GFA). Because the pilot could have obtained weather information from the Internet, it cannot be stated without a doubt that he did not check the GFA before going to the airport. However, if he had done so, especially being an airline pilot, he would have easily seen that the GFA for the region called for visibilities of ¼ SM to 2 SM in mist/fog and ceilings of 100 to 200 ft between Kangirsuk and Kangiqsujuaq in the coastal area and over the Hudson Strait. Also, by analyzing the GFA he would have seen that the mist was clearing over the land to the west of the shoreline. Given his qualifications, the route he elected to fly and the diversion route he chose, it is unlikely that the pilot checked the GFA on the Internet.

Illustration of Quebec GFA weather chart.
This is the GFA available prior to takeoff from Kuujjuaq, Que.

According to the information relayed to the pilot, visibility at Kangirsuk had increased from ½ SM to 15 SM and the ceiling from 200 ft AGL to a few clouds at 600 ft AGL in the previous three hr. Further, the information he received from the Goose Bay base before taking off from Kangirsuk indicated VFR conditions at all the airports where the aircraft was to stop. Consequently, the pilot’s decision to continue the flight was reasonable and consistent with his knowledge of the situation.

The GPS data indicate that the flight to Kangiqsujuaq was normal until 44 NM from destination. Because the aircraft was flying at low altitude and high speed, there is reason to believe that the ceiling was low but that visibility was not a hindrance to pilot navigation. However, at that point the helicopter diverted from the direct route and proceeded north towards the coast. By all indications, the pilot diverted due to reduced visibility.

The pilot had three options when he diverted. First, he could land and wait for conditions to improve. Once on the ground, he could call the Goose Bay base to request a weather update and select a better diversion route. Because the weather was not as the pilot had anticipated, and with the benefit of hindsight, that would have been the most reasonable decision. Given the pilot’s experience in flying with little or no visibility, it is possible that GPS gave him greater confidence when he encountered poor weather conditions.

Second, the pilot could have diverted west and proceeded farther inland. There is reason to believe that if the pilot had checked the GFA before taking off from Kuujjuaq, he would have chosen that option. The rolling terrain was suitable for low-level flight, and the area of mist/fog was clearing to the west. A thorough analysis of the full weather picture and the planned route would have enabled the pilot to choose that option.

The third option—diverting towards the coast—was the least likely to succeed due to the precipitous coastal terrain and the misty conditions moving inland from Hudson Strait. Because of this, the helicopter headed towards an area where the mist/fog was thickening over terrain that was not suitable for low-level flight. Evidence of this can be seen in the decrease in groundspeed and height of the aircraft above the terrain.

The accident occurred just under 1 NM from the coast while the aircraft was traversing a valley. The GPS data indicate an increase in speed and a loss of altitude after the northbound aircraft flew over the summit of the south wall of the valley. It is possible that the pilot was not aware of his geographical position. If that was the case, he did not know he was about to traverse a valley. The need to maintain visual references therefore led the pilot to follow the downward slope in conditions of reduced visibility. Taking into account his speed, the pilot was unable to avoid the north wall of the valley.

Findings as to causes and contributing factors

1. The pilot continued the flight in adverse weather in an area where he was unfamiliar with the topography and the associated local weather systems.

2. In reduced visibility, the pilot diverted towards the shore of the Hudson Strait—a location where the weather was deteriorating and where the precipitous terrain was unsuitable for low-altitude flight. Consequently, the helicopter struck a rock wall in controlled flight in adverse weather.

3. Although not a requirement, specific training on the particular characteristics of this region would have enabled the pilot to fully appreciate the difficulties to be encountered in flight.

TSB Final Report A10O0137—In-Flight Fire and Precautionary Landing

On July 14, 2010, a hot air balloon launched at approximately 19:25 EDT from Carleton University, Ottawa, Ont., for a local flight. On board were the pilot and 12 passengers. While over the city at approximately 700 ft AGL, the balloon encountered turbulence. The pilot initiated a descent with the intention of executing a precautionary landing. The balloon’s rate of descent increased unexpectedly, and the pilot had to light all 3 burners to arrest the descent. During this time the lower portion of the balloon’s envelope collapsed into the path of the burner flame. Some of the lower envelope panels caught fire, but self-extinguished once the flame was removed. The balloon’s basket struck the tops of some trees, and then the balloon climbed to approximately 1 000 ft AGL. The pilot then executed another descent to land. The balloon struck trees during the landing, and subsequently came to rest in a residential area of Ottawa at about 20:00 EDT.

Illustration of hot air balloon during a fire occurrence.
Artist impression of occurrence as the balloon came to land near a soccer field

Findings as to causes and contributing factors

  1. The flight encountered localized turbulence that prompted the pilot to initiate a precautionary landing. A high sink rate developed during this initial landing attempt requiring the pilot to use maximum available power to arrest the sink rate.
  2. During this descent, the bottom of the balloon envelope came into contact with the burner flame, igniting some of the panels. As the balloon climbed in response to the influx of hot air, the pilot turned the burners off, which allowed the balloon envelope material to self-extinguish.
  3. During the second landing attempt, the pilot was concerned about controlling the balloon in the turbulence and the condition of the balloon envelope. This influenced the decision to land in the residential area rather than prolong the flight to a more suitable site.

Findings as to risk

  1. Without the same degree of regulatory oversight as other aircraft of equal passenger-carrying capacity, there may not be an equivalent level of safety for balloon operations.
  2. The pilot did not define the emergency nature of the precautionary landing to ATS and declined emergency assistance. This could have delayed emergency response.
  3. Without adequate information on balloon operations, emergency response units may not take appropriate steps to safeguard passengers, the public and property.
  4. With the absence of specific emergency procedures for balloon landings, there is a risk that passengers may be injured because they were not properly prepared for landing.

Other finding

  1. The balloon envelope material self-extinguished, as designed, when no longer in the direct influence of the burner flame.

Safety action taken

Transport Canada

As reported on page 33 of ASL Issue 3/2011, the article titled “Update on Passenger-Carrying Commercial Balloon Operations in Canada” advised industry that a Civil Aviation Regulation Advisory Council (CARAC) working group was formed at the CARAC Technical Committee meeting of November 2010. The purpose of the “Balloons with Fare-paying Passengers Working Group” is to make recommendations on how to best provide an adequate level of safety to the public involved in sightseeing activities. 

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