LAX05LA135

NTSB accident investigation · Cameron Balloons A-210 · Marana, AZ · April 13, 2005

Accident · FatalLimited investigationFinal report
Date
April 13, 2005, 06:45 local (13:45 UTC)
Place
Marana, AZ
Injuries
1 fatal, 3 serious, 7 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N210EWCameron Balloons A-210
Weather
Visual (VMC) · Day
Status
Completed · report August 29, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20050413007279A
Case key
61299

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 failure of the flying pilot to attain a proper climb rate and maintain an adequate clearance from rising terrain. Also causal was the commercial pilot's inadequate supervision of the flight and his delayed remedial action.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterClimb
Terrain condition - rising
Proper climb rate - not attainedCopilot/second pilotCause
Clearance - not maintainedCopilot/second pilotCause
Remedial action - delayedPilot in commandCause
Supervision - inadequatePilot in commandCause

Analysis

The balloon collided with boulders located atop a hill, fatally injuring a passenger. After a normal departure on the for-hire sightseeing flight, the pilot transferred control authority to a crewmember who held a private pilot certificate. The purpose of the control transfer was to help the crewmember obtain more practice hours and log pilot-in-command time. He was additionally receiving instruction from the commercial pilot. As the balloon approached rising terrain the crewmember continued the ascent up to about 1,000 feet above ground level (agl). The pilot said the balloon began a gradual descent and the crewmember reacted by manipulating all the burners to produce maximum lift. The balloon's basket impacted a boulder on the peak of the hill and bounced upward. The balloon again collided with another boulder and subsequently became airborne, clearing the peak of the hill. After maneuvering the balloon over power lines, the pilot landed. A passenger reported that the balloon continued to gain altitude continuously as it proceeded toward the mountain. In the cumulative 2 minutes prior to impact, the passenger noted that the balloon did not appear to increase in altitude, and he assumed that the pilot was going to attempt to maneuver around the approaching peak. He stated that during the flight's duration only one burner was operating at a given time, with the exception of just seconds before the impact when the pilot instructed the other crewmember to "turn on both burners." The passenger said that the two burners appeared to be operating. He added that the balloon's altitude never appeared to reach higher than the top of the hill, and the flight path consisted of a continuous accent up the mountain. Safety Board investigators reviewed an atmospheric sounding of the area around the time of the accident. The data did not support any thermals and no clear air turbulence was identified at the accident altitudes. The wind profile indicated calm surface winds, defined as below 10 knots. No defined mountain wave pattern was identified. A post accident examination of the balloon found no anomalies or discrepancies with the envelope, basket, or burners. Regulations restrict private pilots from being pilot-in-command during commercial operations with fare-paying passengers; however, a private pilot can be the pilot-in-command if a commercial pilot is providing instruction.

Factual narrative

History of flight

On April 13, 2005, about 0645 mountain standard time, a Cameron Balloons A-210, N210EW, collided with boulders located atop the foothills in Marana, Arizona. Thunderbird Adventures was operating the balloon under the provisions of 14 CFR Part 91. The commercial pilot, a second crewmember, and five passengers sustained minor injuries; three passengers sustained serious injuries; one passenger was fatally injured. The balloon sustained substantial damage. The local area sightseeing flight departed Marana about 0615. Visual meteorological conditions prevailed, and a flight plan had not been filed.

During a telephone conversation with a National Transportation Safety Board investigator, the pilot reported that after making a normal departure, he maneuvered the balloon in a level attitude toward a series of hills to the west. He had followed this flight path many times prior. As he approached the hills on a heading of 300 degrees, he noted that the balloon appeared to be encountering a downdraft. He manipulated all the burners to produce maximum lift in an effort to counteract the downward force, which he attributed to be a result of either a rotor wave or downdraft. The balloon's basket impacted a boulder on the peak of the hill and bounced upward. The balloon again collided with another boulder and subsequently became airborne, clearing the peak of the hill. After maneuvering the balloon over power lines, the pilot landed; the balloon incurred substantial damage to the basket.

A Safety Board investigator interviewed the crewmember, a private pilot, who was aboard the balloon during the accident. He stated that a normal flight the operator provides to passengers consists of a departure from Marana, followed by an ascent over the foothills located to the west of the town. After clearing the terrain, the pilot gives a tour of the valley, and pending wind conditions, decides where to land. The accident flight departed from the Coyote Moon Health Resort and Spa about 0615, in light wind conditions. After lifting off, the balloon ascended about 300 feet per minute, until reaching about 600 feet above ground level (agl), where the pilot configured the balloon in a level attitude. The crewmember added that due to the residential neighborhood below, they always fly at a minimum altitude of 500 feet agl, until reaching the unpopulated foothills, about a mile to the west.

The crewmember further stated that as the balloon continued toward the hills, just south of Rattlesnake Pass, everything seemed normal. As the balloon came in closer proximity to the hilly terrain, he noted that the burners were configured for maximum lift, but the balloon did not climb. The balloon impacted a rock on top of a hill, which offset the basket from the envelope. The basket collided with an addition rock causing injuries to himself and the occupants inside the basket. The balloon floated to the west side of the hill and the pilot landed.

In a written statement the pilot reported that after departing the resort, the balloon ascended to about 500 feet agl. He transferred control authority to the crewmember about 5 minutes into the flight. About 1/2 mile before reaching the rising terrain, the crewmember continued the ascent up to about 1,000 feet agl. The speed increased to about 15 knots and the balloon was100 feet higher than the peak of the upcoming hill. The balloon leveled off and began a gradual decent. The pilot took authority and activated both burners. The balloon continued in the decent with no reaction to the burners. The basket impacted the rising terrain twice.

A passenger reported that after departure, as the balloon continued to gain altitude, he kept his attention fixated on the scenery below. An estimated 2 1/2 minutes prior to the balloon impacting the side of a hill, he recalled a woman passenger asking the pilot what altitude the balloon was flying at. After consulting the handheld global positioning system (GPS) onboard, the pilot reported a cruising altitude of 2,500 feet. Another 30 seconds passed and an additional passenger again queried the pilot as to the altitude the balloon was operating, at which time he confirmed the balloon was still at 2,500 feet. Seconds before the balloon impacted, the pilot instructed the other crewmember to "turn on both burners."

In the cumulative 2 minutes prior to impact, the passenger noted that the balloon did not appear to increase in altitude, and he assumed that the pilot was going to attempt to maneuver around the approaching peak. He stated that during the flight's duration only one burner was operating at a given time, with the exception of just seconds before the impact (just after the pilot directed the crewmember to turn on both burners) he noted that the two burners appeared to be operating. He added that the balloon's altitude never appeared to reach higher than the top of the hill, as the flight path consisted of a continuous accent up the mountain.

During a telephone interview with a Safety Board investigator, a resident of Marana, who is also a pilot, stated that she witnesses the operator conduct sightseeing flights almost every morning. The operator regularly maneuvers over her house at an altitude of 50 feet agl, before reaching the foothills to the west where it ascends over the mountain if enough altitude is gained, or continues though a pass in the hills. On numerous occasions she has observed the balloon landing on fields below the hill (including her property), which she thought was a result of the balloon not obtaining enough altitude prior to reaching the rising terrain. The morning of the accident, she again saw the balloon cross over her house about 50 feet agl, and ran outside to communicate to the pilot that he is flying too low. She thought the low operations were an invasion of her privacy, as the balloon was at such an altitude that the occupants could look through her windows. She added that several months prior to the accident, she contacted the Federal Aviation Administration to file a complaint against the operator, at which point no action was taken.

The global positioning system (GPS) coordinates for the first impact point were: 32 degrees 21.948 minutes north latitude by 111 degrees 08.735 west longitude, and an estimated 2,465-foot mean sea level (msl)

Aircraft information

The balloon was a Cameron Balloons A-210, serial number 3134. The manufacturer reported the envelope was built in 1994. The pilot reported that the balloon had a total time of 234 hours at the time of the accident. The last annual inspection was preformed 68 hours prior to the accident, on August 26, 2004.

A representative from Cameron Balloons US, stated that the manufacturer of the accident balloon was not his company, but rather Cameron Balloons LTD, which is their sister company in the United Kingdom. An external inspection revealed that the balloon's components were also manufactured by different companies. The basket was manufactured by Ultra Magic; Thunder and Colt manufactured the burners, the tanks were a mix of ones manufactured by Thunder and Colt, as well as Ultra Magic. He stated that the combination of such components all being from different manufacturers is quite common and did not believe that it was a safety issue.

Meteorological information

At 0655, the aviation routine weather report (METAR) at Tucson International Airport, located 25 miles southeast of the accident site, was reporting winds from 140 degrees at 9 knots. The pilot stated that during the accident, the wind was from 120 degrees at 10 knots, gusting to 15 knots, with a downdraft present.

Safety Board investigators reviewed the 1200Z sounding that was launched within the hour and within 25 miles of the accident site, at an elevation of 2618 feet. The sounding identified a surface based temperature inversion from the surface to 1

Aircraft

Registration
N210EW
Reported as
Cameron Balloons A-210
Category
Balloon
Serial number
3134
Airframe hours
234
Engine
Damage
Substantial damage
Fire
On-Ground
Flight
Other work use · Part 91
Operator
Jeffrey Gilles, doing business as Thunderbird Adventures
Registered owner
Jeffrey and Julie Gilles
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2004 · 68 hours before
Departed
Marana, CA

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
31
Injuries
Minor
Certificate
Commercial
Last flight review
May 1, 2004
Flight hours
2,036 total · 285 in this make and model · 1,976 as pilot in command · 55 in the last 90 days · 18 in the last 30 days · 2 in the last 24 hours
Role
Co-pilot
Age
33
Injuries
Minor
Certificate
Private
Last flight review
May 1, 2004
Flight hours
43 total · 29 as pilot in command · 30 in the last 90 days · 16 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 21 °F
Altimeter
29.94 inHg
Observed at
TUS, 25 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.