# NTSB ERA14LA347: Colt Balloons 160A, N976TC, Clinton, MA, July 20, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 19, 2014, 20:00 local (Jul 20, 2014, 00:00 UTC) - Place: Clinton, MA - Coordinates: 42.416667, -71.683334 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.4167&lon=-71.6833&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Serious injuries - Injuries: 3 serious, 4 uninjured - Status: Completed, report December 11, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 89713 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA347 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89713/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89713 - Page: https://openairdocs.org/ntsb/ERA14LA347 ## Probable cause The pilot's inadequate preflight and inflight planning and improper landing site selection and approach path, which resulted in the balloon contacting powerlines during landing. Contributing to the accident was the Federal Aviation Administration's inadequate oversight of balloon tour operators. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=2300160), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2300160), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2300160), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2300160), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2300160), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2300160), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Awareness of condition (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=2300160), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Decision related to condition (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=2300160), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md) - [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · FAA/Regulator (probable cause); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-findings/04032015/cases.md?model=2300160), [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/04032015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=2300160), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Enroute: Low altitude operation/event](https://openairdocs.org/ntsb-events/220); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-events/220/sequence.md?model=2300160), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=2300160), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=2300160), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) - [Approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Colt Balloons 160A, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=2300160), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The commercial pilot departed on the hot air balloon tour flight with 6 passengers. After about 1 hour of flight, the balloon approached a town; with about 20 minutes of fuel remaining and about 30 minutes until sunset, the pilot descended the balloon to locate a landing site. He subsequently selected the yard of a residence near an intersection. The pilot initiated a descent, intermittently activating the balloon's burners to maintain the descent path. As the balloon approached the landing site, the envelope contacted powerlines, resulting in an electrical discharge, a shower of sparks, and portions of the powerlines falling onto the ground and a parked vehicle. The balloon sustained thermal damage to the basket, but continued a controlled descent to the intended landing site. Three of the passengers received serious electrical burns as a result of the balloon's contact with the powerlines. The pilot stated that there were no mechanical malfunctions or anomalies with the balloon that would have precluded normal operation. The pilot further stated that he was unfamiliar with the area and was navigating with the aid of a map application on his cell phone. Although the pilot reported that the overflight of the town was the result of a sudden shift in wind direction, given the balloon's departure location and the accident site, the balloon maintained a predominately northerly heading throughout the flight; there was no indication of any variation in wind direction. Based on this information, the pilot should have been able to predict the balloon's flight path with reasonable accuracy both before and after reaching the town and plan a landing site accordingly. Review of satellite imagery for the surrounding area showed several suitable landing fields about 1 ¼ nautical miles north of the accident site. The accident was one of 4 events involving the accident pilot, all of which occurred during low-level operation or confined area landings and resulted in property damage. The events displayed a pattern of poor decision-making which was also exhibited during the accident flight with the pilot's decision to land in a populated area confined by powerlines. Given this history, it is possible that, with a more robust system of oversight and surveillance of balloon operators, the Federal Aviation Administration would have identified the accident pilot as a potential safety risk and taken steps to mitigate this risk. ## Factual narrative Balloon's Flight Path Contrary to the pilot's statement, the departure location of the flight, and the accident site location were consistent with the balloon traveling on a predominantly northerly course throughout the 1 hour 15 minute, 7-nautical-mile (nm) flight. Review of satellite imagery of the area showed several fields about 1 ¼ nm north of the accident site located along the balloon's established route of flight. Balloon Manufacturer's Guidance According to the balloon manufacturer's flight manual, section 2.9, LANDING PROCEDURE, when choosing a landing site, the pilot should allow for possible variations in the wind at ground level, and choose a site: (a) Free of obstructions, especially power lines; (b) Overshoot area should also be clear; (c) Field free of crops and animals; (d) If possible, look for upwind shelter to reduce speed; (e) If possible, choose a field with good accessibility for retrieve crew, and minimum inconvenience for the owner. The manual also states: Do not fly into power lines at any cost. If contact is inevitable descend as fast as possible so that the contact of the wires is with the envelope and not with the basket assembly. Shut down the fuel system and vent lines before contact. If the balloon is caught in the wires DO NOT TOUCH ANY METAL PAR'I'S. If possible, remain in the basket until the power is shut off. Never attempt to remove the balloon until the power authority has arrived. Do not allow crew members to make contact between the ground and the basket until the power is shut off. Balloon Flying Handbook The FAA Balloon Flying Handbook (FAA-H-8083-11A), 7-7, "Maneuvering," states, "The balloon is officially a nonsteerable aircraft." Although a hot air balloon has no direct controls for steering, a balloon's flightpath can be indirectly influenced using the burner and parachute valve. The handbook also states: Being knowledgeable of the wind at various altitudes, both before launch and during flight, is the key factor for maneuvering. Maneuvering, or steering, comes indirectly from varying one's time at different altitudes and different wind directions. To initiate a climb, a balloon pilot activates one or more of the balloon's propane fuel burners. Rate of climb is adjusted by the duration and/or frequency of burner activations. Level flight is achieved by executing a series of burns that minimizes changes in vertical velocity. Descent is achieved either by allowing the air in the envelope to cool or by opening the parachute valve to allow hot air to escape. The rate of descent can be increased by leaving the parachute valve open longer or reopening the valve. Rate of descent can be slowed or stopped by activating the burner(s). The FAA Balloon Flying Handbook further states that when contour flying, or during an approach to a landing site, the potential of collision with trees, power lines, and other obstacles is increased. For balloons, landing accidents consistently account for over 90 percent of thetotal number of accidents in any given year. The most common causal factors for landing accidents include collision with obstructions in the intended landing area. In addition, these accidents account for the majority of injuries to pilots and damage to balloons. Accidents are more likely during landing because the tolerance for error is greatly diminished and opportunities for pilots to overcome errors in judgment and decision-making become increasingly limited, particularly in high wind conditions. Additional Incidents Over the course of the investigation, the NTSB became aware of other incidents with the operator. In October 2004, one passenger received minor injuries when, during landing, the balloon encountered a downdraft. The pilot applied the burners to ascend and overshot the intended landing site. In an attempt to slow the balloon, the pilot brushed the basket through a tree, during which a branch cut the passenger's hand. In October 2011, a witness observed the balloon flying low in the middle of Northborough, Massachusetts. During the flight, the pilot flew below the tops of the surrounding trees and the balloon passed between and struck two houses, which sustained soffit and gutter damage. On September 30, 2013, the pilot landed in the parking lot of a Kmart store in Auburn, Maine. The eight passengers onboard were not injured. The pilot reported to a local media outlet that the flight was going according to plan when an unexpected breeze kicked in around sunset. During the approach to landing, the balloon contacted and damaged a light pole in the parking lot. On September 22, 2015, about 14 months after the accident in Clinton, Massachusetts, the pilot and his six passengers were uninjured when he landed the balloon in the parking lot of a Massachusetts Bay Transportation Authority commuter rail station in Grafton, Massachusetts. The balloon had launched from Shrewsbury, Massachusetts earlier that morning. The pilot advised that, sometime during the flight, the wind conditions changed. He originally tried to land in an open field at Tufts University, but instead landed in the parking lot which was about 1,000 yards northwest of the field. During the balloon's descent, it contacted an overhead guide wire that stretched between two light poles, knocking one pole over and resulting in damage to 3 vehicles. Articles published by local media in Portland, Maine, and Miramichi, New Brunswick, Canada, stated that the pilot's invitations to two separate balloon festivals were rescinded as a result of the open investigation into the Clinton, Massachusetts, accident. NTSB Recommendations On April 7, 2014, the NTSB issued recommendations to the FAA (A-14-11 and A-14-12) to address operational deficiencies in commercial sightseeing (air tour) balloon operations that have resulted in occupant injuries and a fatality. They were derived from the NTSB's investigations of several air tour balloon accidents. The accidents highlighted operationaldeficiencies in commercial air tour balloon operations, such as operating in unfavorable wind conditions and failure to follow flight manual procedures, that the NTSB considered a result of the lack of oversight relative to similar airplane and helicopter air tour operations. In its recommendations, the NTSB stated that, depending on gondola capacity, balloons can carry more than 20 passengers per flight. Given the various safety deficiencies noted in the NTSB's investigations of the subject balloon accidents, the potential for a high number of fatalities in a single air tour balloon accident is of particular concern if air tour balloon operators continue to conduct operations under less stringent regulations and oversight. Although such an accident had yet to occur in the United States at the time of the issuance of the recommendations, a high-fatality accident occurred in Egypt on February 26, 2013, when a commercial air tour balloon carrying 21 occupants experienced a fire on board, resulting in 19 deaths. On July 30, 2016, about 0742 central daylight time, a Balóny Kubícek BB85Z hot air balloon, N2469L (NTSB Case No. DCA16MA204), crashed into a field after striking high voltage powerlines while landing near Lockhart, Texas. The 15 passengers and pilot onboard were fatally injured. The NTSB determined that the probable cause of this accident was the pilot's pattern of poor decision-making that led to the initial launch, continued flight in fog and above clouds, and descent near or through clouds that decreased the pilot's ability to see and avoid obstacles. Contributing to the accident were (1) the pilot's impairing medical conditions and medications and (2) the FAA's policy to not require a medical certificate for commercial balloon pilots. The investigation further concluded that the FAA's primary method of oversight—sampling balloon operators at festivals and events—does not effectively target the operations that pose the most significant safety risks to members of the public who choose to participate in commercial balloon sightseeing activities. As a result of this investigation, the NTSB classified Safety Recommendations A-14-011 and -12 as "Closed—Unacceptable Action/Superseded," and made the following new safety recommendation to the FAA: Analyze your current policies, procedures, and tools for conducting oversight of commercial balloon operations in accordance with your Integrated Oversight Philosophy, taking into account the findings of this accident; based on this analysis, develop and implement more effective ways to target oversight of the operators and operations that pose the most significant safety risks to the public. The balloon envelope and basket were manufactured in 1989. The balloon was powered by 2 propane burners, and had a basket capacity of 9 occupants. The balloon's most recent annual inspection was completed on May 28, 2014. At the time of the accident, the balloon had accrued about 711.1 total hours of operation.On July 19, 2014, about 2000 eastern daylight time, a Colt Balloons 160A, N976TC, contacted powerlines in Clinton, Massachusetts. The balloon received minor damage. The pilot and three passengers were uninjured, and three passengers were seriously injured. The local sightseeing flight was operated by Damn Yankee Balloons under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which departed from a field in Shrewsbury, Massachusetts, about 1845. The pilot stated that the accident flight was the second flight that day. After meeting the passengers and ground crew at the departure location, he provided the passengers with a safety briefing that included all aspects of the flight, including the risks involved and the flight procedures and timeline. While the pilot conducted the safety briefing, his ground crew assembled the balloon. The pilot then performed a preflight inspection before inflating the envelope. The passengers boarded, and the pilot conducted a second preflight inspection before launching. According to the pilot, after launch, the balloon climbed to about 1,000 ft above ground level (agl) and traveled 170°-180° (southbound) at a groundspeed of about 5 knots. About 1 hour into the flight, the balloon passed over a reservoir, then the wind "shifted" and the balloon began approaching the town of Clinton. Witness photographs captured images of the balloon as it traveled over the reservoir between 50 and 100 ft agl. One witness reported that the balloon's basket was "skimming the water." The pilot reported that he approached the town at an altitude of 100 ft agl in preparation for landing should an adequate landing site appear. Shortly thereafter, he saw a large side yard next to a house at an intersection. He initiated a descent using the balloon's burners intermittently to maintain the proper descent path. Photographs showed the balloon approaching the landing site about 50 feet agl. According to the pilot, as the balloon approached the landing site, the basket skid (attached to the bottom of the basket), contacted the top wire of a set of electrical wires perpendicular to the balloon's flight path. The balloon continued forward, causing the top wire to contact another wire; a large arc and flash ensued. The balloon then continued its descent to the landing site, where it touched down normally. Video footage of the accident showed that the pilot engaged the burner several times as the balloon approached the landing site. Subsequent footage showed the balloon descending toward the landing site. As it descended, the envelope contacted the three uppermost powerlines, resulting in an electrical discharge, a shower of sparks, and portions of the powerlines falling onto the ground and a parked vehicle. The balloon then continued in a controlled descent to the landing area. After the balloon landed, the ground crew and others who had stopped torender assistance helped the passengers egress from the basket. Three of the passengers received serious electrical burns as a result of the balloon's contact with the powerlines. The pilot stated that he decided to land in the town because the balloon had about 20 minutes of fuel remaining, and that sunset would occur in about 30 minutes. He also stated that he was unfamiliar with the area, and reported to law enforcement personnel that he was navigating with the use of a map application on his cell phone. In his written statement to the NTSB, he suggested that the accident may have been prevented with a steeper approach to the landing site. The 2052 recorded weather at Fitchburg Municipal Airport (FIT) Fitchburg, Massachusetts, located about 9 miles northwest of the accident site included wind from 090° at 3 knots, visibility 10 statute miles, clear skies, temperature 22°C, dew point 17°C, and altimeter setting of 30.23 inches of mercury. The pilot held a commercial pilot certificate with a rating for lighter-than-air balloon, and private pilot privileges for airplane single-engine land. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on September 14, 2012. He reported 4,388.9 total hours of flight experience, of which 2,708.2 hours were in lighter-than-air balloons. Examination of the balloon envelope and basket by an FAA inspector revealed that the outside of the wicker basket had been scorched on one side and that both burner support covers on that side of the basket displayed thermal damage. ## Aircraft - Registration: [N976TC](https://openairdocs.org/aircraft/N976TC), registered now, S/N 1482US (OpenAirDocs) - Reported make and model: COLT BALLOONS 160A - Registry model: [Colt Balloons 160A](https://openairdocs.org/model/colt-balloons-160a) (registry code 2300160) (OpenAirDocs) - Category: Balloon - Serial number: 1482US - Year built: 1989 - Airframe hours: 711 - Engines: none - Damage: Minor damage - Flight: Other work use, Part 91 - Operator: Young Derald E - Registered owner: Young Derald E - Airworthiness certificate: Standard, Balloon - Last inspection: Annual, May 28, 2014 - Departed: NONE, Shrewsbury, MA - Destination: Clinton, MA - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: none; commercial; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review August 15, 2013; seat: none; restraint: none; flight hours: 4,388.8 total, 2,708 in this make and model, 24 in the last 90 days, 16.7 in the last 30 days, 3.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 63 °F - Altimeter: 30.23 inHg - Observed at: FIT, 8 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20140719014539A](https://openairdocs.org/incident/20140719014539A), Jul 19, 2014: Colt Balloons Ltd 160A, Clinton, MA, Minor damage. On July 19, 2014 at approximately 2000 hours, [privacy data omitted] was operating his balloon with six passengers on board for a sight seeing flight,… ## Docket (9 files) The files NTSB released with the investigation on November 21, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89713. 30.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 942 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458297&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statements and Interview Summaries (item 2, .PDF, 667 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458298&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Master.PDF - Excerpts from Balloon Flight Manual (item 3, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458299&FileExtension=.PDF&FileName=Excerpts%20from%20Balloon%20Flight%20Manual-Master.PDF - Weather Reports and Records - KFIT METARs (item 4, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458300&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20-%20KFIT%20METARs-Master.PDF - Weather Reports and Records - US Naval Observatory Sun and Moon Data (item 5, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458301&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20-%20US%20Naval%20Observatory%20Sun%20and%20Moon%20Data-Master.PDF - Satellite Images of Accident Area as Provided by FAA (item 6, .PDF, 775 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458302&FileExtension=.PDF&FileName=Satellite%20Images%20of%20Accident%20Area%20as%20Provided%20by%20FAA-Master.PDF - Investigation Photographs (Courtesy of FAA) (item 7, .PDF, 20 photos, 26.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458303&FileExtension=.PDF&FileName=Investigation%20Photographs%20(Courtesy%20of%20FAA)-Master.PDF - Witness Videos (Shelf Item) Courtesy of FAA (item 8, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458304&FileExtension=.PDF&FileName=Witness%20Videos%20(Shelf%20Item)%20Courtesy%20of%20FAA-Master.PDF - Excerpts from Public Media (item 9, .PDF, 514 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458305&FileExtension=.PDF&FileName=Excerpts%20from%20Public%20Media-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.