LAX99FA177

NTSB accident investigation · Aerostar Rally RX-8 · Morgan Hill, CA · May 9, 1999

Accident · FatalField investigationFinal report
Date
May 9, 1999, 07:46 local (14:46 UTC)
Place
Morgan Hill, CA
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N70290Aerostar Rally RX-8
Weather
Visual (VMC) · Day
Status
Completed · report May 16, 2001
Report
Approved by Office Director
FAA report
19990509004829A
Case key
46330

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 selection of an inadequate takeoff site that did not allow sufficient horizontal clearance from obstacles in the takeoff path, and, his failure to ensure that all burners were connected to fuel sources, which reduced the available climb capability of the balloon. Also causal was the pilot's failure to activate the emergency vent panel and land prior to contact with the power lines, and, his use of an unapproved aluminum fuel tank, which ruptured during the power line contact and ignited a fire. A factor in the accident was the pilot's failure before takeoff to use pibals to quantify the wind speed.

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 objectTakeoff - initial climb
Fuel system,line - not connectedCause
Aircraft preflight - inadequatePilot in commandCause
Aircraft performance,climb capability - restrictedCause
All available runway - not usedPilot in commandCause
Weather condition - unfavorable wind
Weather evaluation - not usedPilot in commandFactor
Aborted takeoff - not performedPilot in commandCause
Procedures/directives - not followedPilot in commandCause
Object - wire,transmission
Fire/explosionTakeoff - initial climb
Fuel system,tank - unapproved partCause
Maintenance,installation - improperPilot in commandCause
Fuel system,tank - rupturedCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

In the takeoff initial climb, the balloon contacted power lines, caught fire, and crashed into a field. The pilot setup the balloon for takeoff from a 798-foot-long open field, 298 feet upwind from 21,000-volt power lines. The FAA approved flight manual specifies that a horizontal distance of 100 feet for each 1-knot of wind speed be allowed between the takeoff point and any obstacle in the takeoff path. During the envelope inflation process, a 7- to 10-mph surface wind developed, which started dragging the basket toward the lines. The pilot elected to continue with the planned flight. He and the two fare-paying passengers took off and drifted into the power lines, which shorted and arced. An unapproved aluminum fuel tank in the basket ruptured and ignited the basket, envelope, and occupants. The pilot jumped from the basket and sustained serious injuries. The passengers remained in the basket and succumbed to thermal injuries. The balloon had been modified by the addition of an uncertified aluminum fuel tank to the two existing factory tanks that were composed of steel. During postaccident examination of the wreckage, a fuel line to one of the two burners was found not connected; with one burner inoperative, the balloon's climb capability was significantly reduced. The envelope's emergency deflation panel was found in the closed position and subsequent testing found it functional. According to the flight manual, the pilot's preflight actions should have included providing safety helmets to the passengers, ascertaining the winds aloft by launching a pibal, and ensuring that both burners were connected to fuel tanks and operational; none of the actions were completed. In addition, the pilot did not vent activate the envelope's emergency deflation panel to land when the collision with the power lines was eminent.

Factual narrative

History of flight

On May 9, 1999, at 0746 hours Pacific daylight time, an Aerostar International, Inc., Rally RX-8, N70290, operated by Balloons by the Sea, Marina, California, drifted into power lines during the initial takeoff climb from an open field in Morgan Hill, California. Visual meteorological conditions prevailed, and no flight plan was filed for the 14 CFR Part 91 aerial sightseeing passenger flight. The balloon was destroyed. The commercial pilot was seriously injured, and the two revenue passengers were fatally injured. The planned local area flight commenced from the field about 0745.

The pilot reported to the National Transportation Safety Board investigator that he drove onto the open field and chose the location where the balloon was set up for the flight. During a previous occasion, he had used the same field to launch the balloon, and he was aware of the field's proximity to the power lines.

The pilot's sole ground crewmember reported to the Safety Board investigator that he was not a pilot. The crewmember stated that the pilot set up the balloon for takeoff. The crewmember identified the location where the balloon had been set up. This location was subsequently determined to be approximately 298 feet west of the east side of the rectangular shaped field. Power lines are located along the field's east side, where the entranceway to the field is located.

The pilot reported to the Safety Board investigator that he was unable to complete the pretakeoff check of the balloon before taking off because the wind speed increased rapidly. However, he believed that all of the balloon's systems were functional, and no mechanical malfunctions were experienced during the flight. As the balloon ascended it drifted into the power lines.

The ground crewmember stated that a fire erupted within seconds following the wire impact. Flames were visible emanating from the basket in horizontal and vertical directions. While the basket was still airborne, the partially burned pilot exited the basket and fell to the ground.

Responding fire department personnel reported that the pilot stated he had jumped out of the basket. The passengers remained in the basket. The basket, which was engulfed in fire, came to rest in a broccoli field about 121 feet downwind (east) of the impacted power lines. Both passengers subsequently died from thermal injuries.

Other damage

Pacific Gas and Electric Company personnel reported that they examined the impacted 21,000-volt distribution electric lines, which are oriented in a north-to-south direction at the eastern edge of the field. Evidence was observed that, at 43 feet above ground level (agl), the north A phase power line had been pushed eastward until contacting the middle B phase line. This action created a fault. The associated circuit relayed and locked out, thus interrupting power to 3,558 customers. Power was restored by 1355.

Personnel information

The pilot was issued a student pilot certificate on March 5, 1992 with a limitation that it was for balloons only. He soloed on September 2, 1992.

Upon completion of the balloon school's course of instruction, the pilot was issued a commercial pilot certificate on September 8, 1992. The certificate bore the following ratings and limitations: "lighter-than-air, free balloon, limited to hot-air balloon with airborne heater." When the certificate was issued, the pilot's solo, dual, and total balloon flight time was 5.5, 14.1, and 19.6 hours, respectively.

The pilot first flew an Aerostar RX-8 model balloon when the registered owner of the accident balloon checked him out in it, on February 15, 1999. According to the pilot's logbook, by the accident date his total flying experience in the balloon was amassed during 10 flights between February 15 and April 25, 1999. By the accident date, his total flight experience in the balloon was recorded as 11.9 hours. The pilot's total balloon flying experience was approximately 122.7 hours.

Balloon information

FAA Certification and Ownership.

Aerostar manufactured the balloon in 1994. The Federal Aviation Administration (FAA) issued the balloon a standard airworthiness certificate indicating it was constructed in conformity with the requirements of Type Certificate (TC) No. A15CE.

The new balloon, with its Aerostar, HP III dual burners, having a rated power of 15,000 BTU per hour per burner, and a Model RWS-454 wicker basket (gondola) was sold to the current registered owner in November 1994.

The balloon envelope's serial number is RX8-3214. In February 1997, basket serial number RWS-442 and two fuel tanks, bearing serial numbers V853 and V843, were placed in the balloon.

The balloon was designed with a parachute style panel covering the deflation port opening in the top of the envelope. Pulling on the deflation line allows for the rapid discharge of hot air.

Maintenance & Inspection History.

The operator reported to the Safety Board investigator that he contracted out for the balloon's maintenance. On May 19, 1998, at a total time of 75:50 hours, the balloon received its last annual inspection. No subsequent evidence of any maintenance was observed in the logbook.

The last flight listed in the logbook is dated April 25, 1999. On that date, the balloon envelope's recorded total time was 89:40 hours. The basket's total time was approximately 289 hours.

Logbook Entries.

The following statement appears in the FAA Approved Flight Manual (AFM): "All time during which the balloon is inflated and buoyant/upright . . . must be recorded in the envelope log book."

An examination of the balloon's logbook indicated, that at the time of the accident flight, the balloon had been operated for 13:50 hours since its last inspection. In particular, between February 15, and April 25, 1999, the balloon had been operated for a total of 9:20 hours during 8 flights, according to its logbook record.

No record was observed in the balloon's logbook for the pilot's two, 1-hour-long flights in the balloon on March 9 and 16.

Helmets.

The AFM contains a listing of items that must be on board during flight. In pertinent part, the equipment list states that "helmets for all occupants" must be carried as required equipment.

On May 13, 1999, the Safety Board investigator interviewed the operator and inquired if helmets were available for use by the occupants in the accident balloon. The operator stated that his company had helmets, but that they were kept "in the office" and were not used.

Fuel Tanks.

Aerostar personnel and balloon records indicate that upon delivery, the balloon was equipped with two, 15-gallon vertical stainless steel propane storage fuel tanks, serial numbers V868 and V880. Aerostar reported that its tanks are especially manufactured by the company for use in its hot air balloons.

According to the TC, the accident balloon's fuel capacity was limited to two or three or four V-10 (10-gallon capacity) or V-15 (15-gallon capacity) vertical tanks. No authorization was issued for utilizing a combination of both 10- and 15-gallon tanks in the basket.

In February 1997, stainless steel fuel tank numbers V853 and V843 were installed in the basket to replace the original tanks.

The Aerostar participant reported to the Safety Board investigator that to the best of his knowledge, the manufacturer has never experienced a rupture to one of its steel fuel tanks during a wire strike occurrence.

The pilot reported that prior to the day on which the accident occurred, he had placed the extra 10-gallon aluminum fuel tank in the basket. The pilot stated that the balloon's owner had informed him that it was permissible to use the extra tank in the balloon.

No evidence of a Major Alteration and Repair, FAA Form 337, or other logbook entry was found for the addition of a third fuel tank in the balloon's

Aircraft

Registration
N70290
Reported as
Aerostar Rally RX-8
Category
Balloon
Serial number
RX8-3214
Airframe hours
90
Engine
unknown
Damage
Destroyed
Fire
In-Flight
Flight
Part 91
Operator
Balloons By The Sea
Registered owner
Michael & Rachel Eakins
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 19, 1998 · 14 hours before

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
34
Certificate
Commercial
Medical
Class 3, Expired
Flight hours
133 total · 12 in this make and model · 12 in the last 90 days · 12 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 5 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 43 °F
Altimeter
30.00 inHg
Observed at
RHV, 13 nm away

Docket · 36

The files NTSB released with the investigation on April 25, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.9 MB in all.

Photo 1. Westerly view of truck parked in field at set up local. FAA Photo.Item 1 · .PDF · 43 KBPhoto 2. Easterly view of set up local and inflation fan. Impacted power lines appear at east end of field. FAA Photo.Item 2 · .PDF · 51 KBPhoto 3. Basket ground scar drag marks. FAA Photo.Item 3 · .PDF · 66 KBPhoto 4. Impacted power lines (near center of photo). FAA Photo.Item 4 · .PDF · 29 KBPhoto 5. Burnt envelope. FAA Photo.Item 5 · .PDF · 64 KBPhoto 6. Destroyed basket. No. 1 arrow points toward burner #1 (with no attached fuel hose). No. 2 arrow points toward burner #2 (with attached fuel hose). No. 3 arrow points toward fuel hose normally connected to burnerItem 6 · .PDF · 90 KBPhoto 7. Hose to burner #1 being held up. Respective burner #1 fuel inlet fitting appears behind hose (near center of photo). FAA Photo.Item 7 · .PDF · 61 KBPhoto 8. Overall view of 2 burners and 3 fuel tanks. FAA Photo.Item 8 · .PDF · 83 KBPhoto 9. Balloon layout.Item 9 · .PDF · 41 KBPhoto 10. Recovered parts from basket.Item 10 · .PDF · 58 KBPhoto 11. Steel fuel tank S/N V843 (hose found not connected between this tank and burner #1).Item 11 · .PDF · 45 KBPhoto 12. Steel fuel tank S/N V853 (hose found conneted between this tank and burner #2).Item 12 · .PDF · 49 KBPhoto 13. Ruptured aluminum Lennox fuel tank.Item 13 · .PDF · 49 KBPhoto 14. Ruptured Lennox fuel tank, additional view.Item 14 · .PDF · 50 KBPhoto 15. Lennox identification stamp on ruptured tank.Item 15 · .PDF · 41 KBPhoto 16. Close up view of fuel inlet fitting on burner #1. Note fitting is sooty.Item 16 · .PDF · 33 KBPhoto 17. Close up view of fuel inlet fitting on burner #2. Note fitting is clean.Item 17 · .PDF · 32 KBSupplement AItem 18 · .PDF · 265 KBSupplement BItem 19 · .PDF · 374 KBSupplement SItem 20 · .PDF · 65 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 21 · .PDF · 415 KBWitness StatementsItem 22 · .PDF · 638 KBWitness Statement, FAA PersonnelItem 23 · .PDF · 76 KBStatement of Owner, Balloons by the SeaItem 24 · .PDF · 211 KBMaps Accident Area, Wreckage DiagramItem 25 · .PDF · 216 KBWeather Reports and Weather Robot DataItem 26 · .PDF · 189 KBTranscript of Radio CommunicationsItem 27 · .PDF · 81 KBReports from Morgan Hill Police Dept.Item 28 · .PDF · 374 KBReports from Aerostar, Party to the InvestigationItem 29 · .PDF · 905 KBFuel DocumentationItem 30 · .PDF · 124 KBLennox Fuel Tank HistoryItem 31 · .PDF · 494 KBExtract from Aerostar Balloon LogbookItem 32 · .PDF · 473 KBExtract from Pilot's LogbookItem 33 · .PDF · 1.2 MBExtract from Aerostar FAA Approved Flight ManualItem 34 · .PDF · 429 KBStatement of Party Representatives to NTSB InvestigationItem 35 · .PDF · 420 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 36 · .PDF · 52 KB

FAA reports on this event · 1

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