Aviation Safety Council (ASC) releases investigation Final Report of a Taitung county government hot air balloon occurrence. On May 18, 2014, a Taitung county government CAMERON C-90 hot air balloon, registration B-00008 took off from Luye Gaotai, Taitung County with one pilot and two passengers on board, landed at rear ground of Yong’an Village elderly activity center, Luye Township. Due to barbed wire and betel palm tree surround, the pilot intended to move hot air balloon to next open ground. A ground crew held the basket handle with both hands, accidentally fell when hot air balloon was lifting, and was seriously injured.

     ASC launched investigation according to the Aviation Occurrence Investigation Act after the occurrence. Parties to the investigation included the Civil Aeronautics Administration (CAA) and Taitung county government. The Final Report was reviewed and approved by ASC’s 28th Council Meeting on November 25, 2014.

Findings related to probable causes:

1. Neither CAMERON manufacture nor Taitung county government established the Standard Operating Procedure for balloon ground movement. There were no standard callouts for hand releasing when holding and pressing the basket. The ground crew usually released their hand by instinct.
2. Two ground crew moved the balloon before whole ground team arrived. No discussion was made in advance between pilot and ground crew. The pilot lifted the balloon by increased hot air to pass the betel palm tree without notified the ground crew to release their hands. Ground crew A released his hand without notified ground crew B when the balloon was lifted. Because ground crew B’s back was facing the barbed wire fence, he did not aware that the balloon was approaching to the fence. The balloon ascended fast due to pay load suddenly reduced. Ground crew B did not followed the procedure to release his hands when his feet left the ground. He held the basket’s handle firmly when balloon lifted and then fell from 23 feet high and was injured.

Findings related to the risks

1. The first landing site was a closed farm land, barbed wire and betel palm tree surrounded. The second landing site was an opened grass land, but the obstacles such as electric pole, power line and concrete wall was at the south side. According the relevant manual, both places were not suitable landing sites. Although no direct damage was made, but the operational risk increased.
2. Due to poor radio communication, the ground crew did not arrive the landing site when the balloon landed. No direct damage was made. If the ground crew was to arrive at the landing site before the balloon landed, they can provide the obstacles information around landing site, assist safe landing and ground movement afterward. It will reduce the operational risk.

Safety Recommendations

Civil Aeronautics Administration:

1. Supervise Taitung county government to implement the safety recommendations and disseminate relevant information to other hot air balloon operators.

There are 5 safety actions taken by Taitung county government in accordance to the ASC safety recommendations proposed.

Full investigation report is available for download at http://www.asc.gov.tw

Sherry Liu, Engineer

Tel: 89127388-330

Email:sherry@asc.gov.tw