What happened
A commercial hot air balloon flight, carrying 12 passengers and a pilot, was underway near Fågelsta, south of Motala, on May 17, 2024. The flight, involving a Cameron A-275 (registration SE-ZIX), had been planned following a morning weather forecast that suggested decreasing winds. After assessing local conditions at Mantorp Park and observing a decrease in wind gusts via a helium balloon test, the pilot proceeded with the flight at 20:08.
During the flight, the pilot encountered higher wind speeds than anticipated at approximately 350 feet. This led to two landing attempts. During the second attempt, atmospheric turbulence pushed the balloon downward, resulting in a hard impact where the basket tipped forward. One passenger, who was standing sideways rather than in the recommended backward-facing position, sustained a serious injury involving a forearm fracture. The pilot subsequently performed a final landing that also involved a hard impact and the basket being dragged near a road before coming to a stop in a ditch.
The investigation
The Swedish Accident Investigation Authority (SHK) examined the operational procedures, weather data, and the operator's regulatory compliance. The investigation focused on why the passengers were not positioned to minimize injury risk and why the operator's documentation was inconsistent with current EASA regulations. Investigators also reviewed the meteorological information used for flight planning and the pilot's training records.
Findings
- The primary cause of the accident was the lack of a functional safety management system within the operator's organization, which prevented effective risk assessment and mitigation.
- This systemic failure led to the passengers not being positioned in the safest manner during the landing. While the flight manual instructed passengers to face backward, the operator's operations manual lacked specific landing positioning instructions, and the passengers were instead standing sideways.
- The investigation found that the operator was not authorized to conduct commercial flights and had not updated its manuals to comply with new EASA requirements regarding safety management and training.
- A contributing factor was that updated meteorological information was not obtained closer to the time of the flight, which might have revealed the presence of wind gusts predicted in later low-level forecasts.
- No technical failures were identified in the Cameron A-275 itself, and the pilot's safety harness successfully prevented them from falling from the basket during the impact.