What happened
On 8 February 2018, a hot air balloon flight encountered a sudden shift in wind direction and speed. This change subjected the occupants to moderate turbulence and altered the balloon's flight path. After assessing the situation, the pilot determined that continuing the flight would limit future landing options and increase risks to the passengers. To mitigate this risk, the pilot chose to execute an immediate landing, which resulted in a hard landing.
The investigation
The investigation focused on why the pilot was unaware of the impending weather change and why the impact of the landing resulted in injuries. It was found that the Grid Point Wind and Temperature (GPWT) chart did not provide localized wind data below 2000 ft. Furthermore, while the Bureau of Meteorology had identified a potential wind change in the Melbourne area, an error in uploading this information to the public phone briefing system meant the pilot could not access the more accurate local forecast.
Regarding passenger safety, there were conflicting accounts of the safety briefing. While the operator and ground crew believed standard procedures were followed, the passengers reported that the briefing occurred before they boarded and that not all passengers were present. The investigation concluded that passengers likely did not receive a briefing after boarding, and the initial briefing was insufficient to ensure everyone knew the correct landing position.
Findings
- A failure to upload local weather information to the public briefing system prevented the pilot from adjusting pre-flight plans.
- The GPWT chart lacked the necessary resolution for wind data below 2000 ft.
- There was no formal check process between the pilot and ground crew to verify that all safety briefings were completed.
- Inconsistent passenger positioning during the landing likely contributed to the passenger injuries.
- The lack of a formal procedure to ensure the accuracy of weather briefing uploads created a systemic risk.