Carterton balloon deaths 'entirely preventable' - coroner
Thursday, 23 April 2015
The deaths of 11 people in the Carterton balloon crash were entirely preventable, a coroner has ruled.
He has recommended law changes to ensure it never happens again.
The inquest in Wellington into the crash on January 7, 2012, which killed pilot Lance Hopping and his 10 passengers, wrapped up in July 2014.
After consulting affected authorities and parties, coroner Peter Ryan released his findings at 5pm on Thursday.
He found that the balloon crashed because of a significant error of judgment by Hopping when he tried to out-climb a power line he was drifting towards, causing the balloon to become stuck, catch fire, soar into the air, then plummet to the ground.
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Noting the mistake seemed inexplicable for Hopping's experience, the coroner said the pilot's weekly cannabis use - established through post-mortem forensic tests and uncontested statements from people who knew him -could have had a 'carry-over effect' on his perception and thinking, explaining such a 'gross error'.
He said Hopping's failure to pull an emergency 'rip-out' line, which would have immediately deflated the balloon and probably prevented some, if not all, the deaths, could have also been due to his long-term cannabis use.
However, he found no proof Hopping, 53, had smoked cannabis immediately before the flight.
But he also made criticisms around the wider issue of industry safety. While it had since improved, the aviation safety regulatory system in January 2012 relied too much on pilots being honest in their self-monitoring and failed to prevent Hopping continuing to fly commercially without a medical certificate, which lapsed in 2011, and as a weekly cannabis user.
And there was still a lack of clarity and enforcement around mandatory random drug and alcohol testing of balloon pilots. He called for a law-change to improve this.
He criticised legislators for taking seven years to implement changes around monitoring of balloon pilots' fitness to fly which came into force a few months after the crash, but would have prevented Hopping flying that day if the implementation had happened quicker. Ryan said a lack of resources was to blame for the delay.
He also found passengers on the fatal flight were 'robbed' of the opportunity to save their lives by pulling the rip-out line, because they were not told of its existence.
While the CAA's 2012 regulatory changes meant pilots using drugs would now likely be discovered, he noted that random drug testing was still not mandatory and said there was no reason why it couldn't be, especially given the commercial adventure aviation industry's small size.
Recommendations to the CAA and/or the Ministry of Transport included:
Implement mandatory random drug and alcohol testing of adventure aviation pilots by CAA or Police
Look at tougher sanctions for pilots testing positive for drugs or alcohol, including licence suspension
Take further measures to educate and remind pilot licence holders about their obligation to have a current medical certificate
Encourage and help people to report concerns about pilots' medical certification
Implement a system for monitoring the currency of medical certificates
Look at publishing pilots' and operators' medical certification and licensing status
Changing the flight test standard guide to include training on avoiding power lines and what to do if they were contacted
Look at recommending changes to balloon design to prevent them catching on power lines
Look at requiring balloon pilots to carry a second crew member, trained in using the emergency 'rip-out' deflation device
Recommendations to adventure aviation companies included:
Publish on their websites whether pilots had up-to-date licences and medical certificates
Pilots to carry GPS systems showing power lines
Better pre-flight briefings, especially to tell passengers how they can complain to CAA about safety concerns post-flight
Ryan noted it was the country's third-worst air disaster, after the 1979 Mt Erebus crash and a 1963 crash in the Kaimai Ranges.
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