# NTSB LAX94LA162: Head Balloons AX9-118, N45289, Sedona, AZ, March 12, 1994 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 12, 1994, 07:30 local (14:30 UTC) - Place: Sedona, AZ - Location: 34.8481° N, 111.8152° W: Placed by OpenAirDocs: center of Sedona, AZ, within about 6 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=34.8481&lon=-111.8152&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor, 3 uninjured - Status: Completed, report February 14, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 28696 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX94LA162 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28696/pdf - Page: https://openairdocs.org/ntsb/LAX94LA162 ## Probable cause the failure of the pilot lights and burners to relight in flight once extinguished due to the installation of an incorrect gas pressure regulator. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, descent - normal - balloon equipment,burner system - output low (cause) - maintenance,installation - improper, other maintenance personnel (cause) - remedial action - not possible, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis The pilot was descending to about 400 feet agl to give the passengers a better view of the surroundings and the burner pilot light went out. The pilot said he tried unsuccessfully to relight it up until ground impact. The balloon consisted of a Head AX9-118 envelope attached to a Balloon Works 5.5 basket, which included a Balloon Works Mirage F-1 burner. The installed propane gas regulator was found to be a Marshall Brass Company model 300. The envelope and basket, produced by different manufacturers, were combined together in accordance with STC SL1748. The burner tested to factory specification. The regulator was the incorrect part for the burner. Functional testing of the regulator found that it flowed at 8 psi. The correct regulator is a Marshall Brass model 301 which has a specified pressure range of 18 to 25 psi. According to Balloon Works, low regulator pressure might make reigniting the pilot lights and burners difficult once snuffed out in flight. ## Factual narrative On March 12, 1994, at 0730 mountain standard time, a Head AX9-118 balloon, N45289, collided with the ground during an unarrested descent near Sedona, Arizona. The balloon was operated by Northern Light Balloon Expeditions of Sedona, Arizona, and was engaged in for hire sightseeing operations. Visual meteorological conditions prevailed at the time and no flight plan was filed. The balloon sustained a 30-foot envelope tear in the ground collision sequence when it became entangled in trees. The certificated commercial balloon pilot and two passengers were not injured; however, one passenger sustained serious injuries consisting of fractured ankle and foot bones and one passenger incurred minor injuries. The flight originated from a field near Sedona on the day of the mishap at 0705 hours as a local area flight. In a telephone interview, the pilot reported that he intended to descend while in cruise flight to about 400 feet agl to give the passengers a better view of the surroundings. As the balloon was descending, the burner pilot light went out. The pilot said that he attempted unsuccessfully to relight the pilot light up until ground impact. Examination of the balloon determined that it consisted of a Head AX9-118 envelope attached to a Balloon Works 5.5 basket, which included a Balloon Works Mirage F-1 burner, serial number 077. The installed propane gas regulator was found to be a Marshall Brass Company model 300. The envelope and basket, produced by different manufacturers, were combined together in accordance with Federal Aviation Administration (FAA) Supplemental Type Certificate (STC) SL1748 on October 27, 1993. The burner and regulator were removed from the balloon and sent to the Balloon Works company in Statesville, North Carolina, for functional testing under the supervision of an FAA airworthiness inspector. The burner was tested to factory specification. The regulator was found to be the incorrect part for the Mirage F-1 burner. Functional testing of the regulator determined that it flowed at 8 psi, with a maximum adjustment range of 11.5 psi. According to FAA approved Balloon Works engineering drawings, the correct regulator for the Mirage burner is a Marshall Brass Company model 301, part number 301-18. The model 301 regulator has a Balloon Works Company specified pressure range of 18 to 25 psi. According to a Balloon Works company representative, low regulator pressure might make reigniting the pilot lights and burners difficult once snuffed out in flight. ## Aircraft - Registration: [N45289](https://openairdocs.org/deregistered/N45289-2015-10-05), registration cancelled 2015-10-05, S/N 217, built 1993 (OpenAirDocs) - Reported make and model: Head Balloons, Inc. AX9-118 - Registry model: [Head Balloons AX9 118](https://openairdocs.org/model/head-balloons-ax9-118) (registry code 05637CC) (OpenAirDocs) - Registry engine: [NONE](https://openairdocs.org/engine/none) (registry code 00000, none) (OpenAirDocs) - Category: Balloon - Serial number: 217 - Airframe hours: 57 - Engines: unknown - Damage: Substantial damage - Flight: Part 91 - Operator: Northern Light Balloon Expedit - Registered owner: Northern Light Balloon Expedit - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 27, 1993, 57 hours before ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; commercial, private; airplane ratings: single-engine land; medical: class 2, expired; flight hours: 2,500 total ## Weather - Conditions: Visual (VMC), Day - Visibility: 60 statute miles - Lowest ceiling: none - Temperature: 55 °F ## 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 19940312005039A](https://openairdocs.org/incident/19940312005039A), Mar 12, 1994: Thundr AX9140S2, Sedona, AZ, Substantial damage. During descent burner flamed out. Unable relight until ground impact. Incorrect low pressure regulator per burner. 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.