ERA13LA212

NTSB accident investigation · Cameron Balloons US Z-225 · Chester Springs, PA · April 21, 2013

Accident · Serious injuriesLimited investigationFinal report
Date
April 21, 2013, 07:35 local (11:35 UTC)
Place
Chester Springs, PA
Injuries
3 serious, 7 minor, 1 uninjured
Damage
Minor damage
Phase of flight
Landing
Aircraft
N65625Cameron Balloons US Z-225
Defining event
Landing: Hard landing
Weather
Visual (VMC) · Day
Status
Completed · report December 11, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Safety recommendations
Yes
FAA report
20130421005859A
Case key
86702

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's failure to extinguish the burner pilot lights prior to a hard landing in windy conditions.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Wind: high windEnvironmental issues › Conditions/weather/phenomena · Effect on operationCameron Balloons US Z-225: 1 caseAll aircraft: 112 casesProbable cause
TerrainEnvironmental issues › Physical environment · Contributed to outcomeCameron Balloons US Z-225: 1 caseAll aircraft: 267 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

During an approximate 1-hour balloon flight, the wind increased as the pilot was preparing to land. The pilot preferred to land on asphalt, but missed several landing spots due to the wind and elected to land on the mowed lawn of a residence. Just prior to landing, the pilot instructed the passengers how to brace themselves and added that the landing was going to be rough due to the wind. The balloon subsequently contacted trees just prior to touchdown. As the balloon touched down on the lawn, the gondola tipped on its side and passengers were jostled about and out of the gondola. During which, one of the passengers or the pilot likely inadvertently contacted the burner switch, which caused a propane flash and burned three of the ten passengers. When asked about why the pilot flames on the burners were still on during the landing, the pilot replied that the pilot flame is usually extinguished on smaller balloons prior to landing. Larger balloons, such as the accident balloon, have three burners and it takes some time to extinguish the pilot flames as it is not just a matter of moving a switch. Review of a flight manual for the accident balloon make and model revealed that the normal procedures for approaching to land, instructed the pilot to shut off the pilot light connection just before touchdown in high winds. Review of the flight manual emergency procedures for preparation for a hard landing, instructed the pilot to extinguish the pilot flames by closing the pilot light valves at the burners or by disconnecting the vapor hose quick disconnects at the tanks.

Factual narrative

On April 21, 2013, about 0735 eastern daylight time, a Cameron Balloons US Z-225, N65625, operated by U.S. Hot Air Balloon Team, sustained minor damage during a collision with trees and hard landing near a residence in Chester Springs, Pennsylvania. The commercial pilot and six passengers incurred minor injuries, while three passengers were seriously injured and one passenger was not injured. The local sightseeing flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the flight that departed Pottstown Municipal Airport (N47), Pottstown, Pennsylvania, about 0635. The pilot reported that he obtained a weather briefing prior to the accident flight, which departed about 30 minutes behind schedule. The departure and flight were uneventful; however, as he was preparing to land, the wind increased. The pilot attempted to land on a mowed lawn, but the balloon contacted trees just prior to the lawn. As the balloon touched down on the lawn, the gondola tipped on its side and a propane flash occurred. Several of the passengers reported that the flight departed about 30 to 60 minutes late due to a dead battery in one of the supporting ground vehicles. One passenger added that the pilot was in a hurry to takeoff as he was concerned about the increase in wind speed as the morning progressed. Two of the passengers stated that the pilot mentioned it was weird that they were the only balloon flying that morning. After flying for approximately 1 hour, the pilot wanted to land on asphalt; however, he had missed several landing spots and elected to land on grass. Just prior to landing, the pilot instructed the passengers how to brace themselves and added that the landing was going to be rough due to the wind. Passengers further stated that during the touchdown and tipping, the occupants were jostled about and out of the gondola. One passenger added that during which, something or someone fell on the burner switch, which caused a propane flash and burned three of the passengers. The other passenger injuries were described as scrapes, bruising, or muscle soreness as a result of the impact with trees and subsequent hard landing. Two of the passengers that received burns were a husband and wife, with the husband's burns more severe and to the face and head. The husband stated that during the hard landing, before the burner flash, he was yelling for someone to turn the pilot flames off. The husband and wife also reported that after the accident, the pilot asked them if they wanted him to drive them to the hospital or call 911. They both replied that they would like to be driven to the hospital. The husband later stated that he was in shock at the time and in retrospect, an ambulance would have been a better option for faster medical treatment. Several other passengers stated that once everyone was in a van, there was an approximate 5 to 10-minute delay in departingfor the hospital while the pilot conferred with ground crew. One passenger stated that during that time, the pilot was pushing dirt with his feet into ground scars created by the hard landing. During a telephone interview, when asked about the wind conditions, the pilot stated that the wind was 4 to 5 knots when he launched on the accident flight and he normally would not launch if the wind was 10 to 12 knots or greater. When asked about why the pilot flames on the burners were still on during the landing, the pilot replied that the pilot flame is usually extinguished on smaller balloons prior to landing. Larger balloons, such as the accident balloon, have three burners and it takes some time to extinguish the pilot flames as it is not just a matter of moving a switch. Review of a flight manual for the accident balloon make and model revealed: "…Maximum Demonstrated Surface Wind: The maximum surface wind speed during launch and landing during FAA type certification flight tests were: For Launch 10 mph For Landing 15 mph These wind speeds are not an operating limitation..." Review of the flight manual normal procedures revealed: "…Approach to Land… Pilot light connection…shut off or popped quick release connection just before touchdown in high winds..." Review of the flight manual emergency procedures revealed: "…Preparation For a Hard Landing… Extinguish the pilot flames(s) by closing the pilot light valves(s) at the burner or by disconnecting the vapor hose quick disconnect(s) at the tanks(s)…" Heritage Field (PTW), Pottstown, Pennsylvania was located about 5 miles east of the departure point and 10 miles north of the accident site. The recorded wind at PTW, at 0554, was from 340 degrees at 7 knots. The recorded wind at 0654 was from 350 degrees at 3 knots. The recorded wind at 0754 was from 350 degrees at 9 knots, gusting to 14 knots, varying from 280 degrees to 020 degrees.

Aircraft

Registration
N65625
Reported as
Cameron Balloons US Z-225
Category
Balloon
Serial number
6630
Built
2011
Airframe hours
141
Damage
Minor damage
Fire
On-Ground
Flight
Other work use · Part 91
Operator
U.S. Hot Air Balloon Team
Registered owner
Morning Star Visions
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 22, 2012
Departed
N47 · Pottstown, PA
Destination
N47 · Pottstown, PA

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Minor
Certificate
Commercial
Last flight review
March 17, 2013
Flight hours
2,978 total · 450 in this make and model · 10 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 9 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
37 °F, dew point 21 °F
Altimeter
30.55 inHg
Observed at
PTW, 10 nm away

Docket · 10

The files NTSB released with the investigation on September 25, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N65625 · 1

Matched to the same aircraft by N-number and date.