Tuesday, July 2, 2019

Loss of Control on Ground: Balony Kubicek Spol Sro BB30Z, N717FN, fatal accident occurred June 29, 2018 in Ashland, Ohio

Pilot John Moran


The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Cleveland, Ohio

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


http://registry.faa.gov/N717FN


Location: Ashland, OH
Accident Number: CEN18LA245
Date & Time: 06/29/2018, 2000 EDT
Registration: N717FN
Aircraft: KUBICEK BB30
Aircraft Damage: Minor
Defining Event: Loss of control on ground
Injuries: 1 Fatal, 3 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

On June 29, 2018, about 2000 eastern daylight time, a Balony Kubicek SPOL SRO BB30Z hot air balloon, N717FN, tipped over after landing on a field near Ashland, Ohio. The commercial pilot on board sustained a fatal head injury. The student pilot and two passengers were not injured, and the balloon was not damaged. The balloon was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. Day visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which departed from a nearby field about 1945.

The early evening flight was a hot air balloon sponsor event for the Ashland, Ohio, Balloonfest. The commercial pilot was providing instruction to the student pilot during the flight, and after about 15 minutes, the pilot took control of the balloon and elected to land quickly and return to the Balloonfest field to participate in the evening "balloon glow" event. After landing, the student pilot exited the balloon basket to control the balloon's crown line in preparation for deflating the envelope, and the two passengers remained crouched down in the basket. As the pilot started to deflate the envelope, the wind increased, which concaved the envelope and subsequently pulled the balloon forward, tipping the basket over (see figure 1). As the basket tipped over, the pilot, who was standing in the basket, fell forward and hit his head on the dual burner assembly. The pilot became unconscious about 20 to 30 seconds later and was unresponsive when first responders arrived. He was transported to a nearby hospital, where he was later pronounced dead.

A witness photographed the balloon when it first landed in the field. Figure 1 shows a photo in which the balloon is on the ground, the balloon and basket are both tipped over about 45°, and a land owner/neighbor is standing next to the basket.


Figure 1 Accident balloon

The student pilot and the passengers stated that the pilot was not crouched down during the landing and was also not actively pulling on the vent line to deflate the envelope.

PERSONNEL INFORMATION

The pilot, age 74, held a commercial pilot certificate with a rating for lighter-than-air balloon. The pilot did not hold a medical certificate. At the time of the accident, the pilot had about 40 total flight experience in the accident balloon.

Per 14 CFR 61.233, commercial balloon pilots are allowed to provide flight instruction.

Per 14 CFR 61.23 (b), Operations not requiring a medical certificate, a person is not required to hold a medical certificate when exercising the privileges of a flight instructor certificate with a sport pilot rating in a glider or balloon.

AIRCRAFT INFORMATION

The balloon, which comprised a four-place basket and 105,000-cubic-ft envelope balloon system, serial number 1117, was manufactured in 2015, and was equipped with two standup 70-liter propane fuel tanks and an Ignis Plus dual burner capable of producing 18 million British thermal units of heat per hour.

A review of the maintenance logbook showed that an annual inspection was completed on June 10, 2018, at a recorded time in service of 37.85 hours. The last entry in the logbook was made on the day of the accident and showed a total time in service of 40.0 hours.

METEOROLOGICAL INFORMATION

At 1952, the weather conditions at Mansfield-Lahm Regional Airport (MFD), Mansfield, Ohio, 12 miles west-southwest of the accident scene, included wind from 170° at 9 knots, clear skies, 10 statute miles visibility, temperature 84°F, dew point 70°F, and altimeter setting of 30.07 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Postaccident, the balloon was located in a field 2.3 miles north of where the flight originated. The balloon envelope was found deflated and resting on the ground. The basket, with the tanks and burner system intact, came to rest on its front side on the ground. The envelope was connected to the basket support cables at the carabiners. A postaccident examination of the balloon envelope, basket, fuel tanks, fuel lines, and the dual burner system by a Federal Aviation Administration (FAA) inspector revealed no damage or anomalies.



MEDICAL AND PATHOLOGICAL INFORMATION

The Cuyahoga County Medical Examiner's Office, Cleveland, Ohio, performed an autopsy of the pilot. According to the autopsy report, the cause of death was blunt force impacts to the head and neck.

According to the coroner, the pilot had been hospitalized for blood clots a few months before the accident and was prescribed warfarin. He was diagnosed with prostate cancer in the months before the accident. He also had "high cholesterol and blood pressure issues." According to the coroner's interview with the student pilot, the pilot had recently been feeling unwell and occasionally had balance issues. The student had not seen the pilot fall previously. The pilot's postaccident medical examination demonstrated significant cardiomegaly and evidence of pulmonary edema, which supported his symptoms.

Toxicology performed by the FAA Forensic Sciences Laboratory detected terazosin and warfarin in blood (heart) and liver.

Terazosin is a prescription medication used to treat symptoms from an enlarged prostate. It also has a mild effect on lowering blood pressure. Warfarin is a prescription blood thinner. Neither is considered impairing.

Pilot Information

Certificate: Commercial
Age: 74, Male
Airplane Rating(s): None
Seat Occupied: None
Other Aircraft Rating(s): Balloon
Restraint Used: None
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: None None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 40 hours (Total, all aircraft), 40 hours (Total, this make and model)

Student Pilot Information

Certificate: Student
Age: , Male
Airplane Rating(s): None
Seat Occupied: None
Other Aircraft Rating(s): Balloon
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: None None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:

Aircraft and Owner/Operator Information

Aircraft Make: KUBICEK
Registration: N717FN
Model/Series: BB30 Z
Aircraft Category: Balloon
Year of Manufacture: 2015
Amateur Built:No 
Airworthiness Certificate: Balloon
Serial Number: 1117
Landing Gear Type: Skid
Seats: 4
Date/Type of Last Inspection: 06/10/2018, Annual
Certified Max Gross Wt.:
Time Since Last Inspection: 2 Hours
Engines:
Airframe Total Time: 40 Hours at time of accident
Engine Manufacturer:
ELT: Not installed
Engine Model/Series:
Registered Owner: On file
Rated Power:
Operator: On file
Operating Certificate(s) Held: None 


Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KMFD, 1200 ft msl
Distance from Accident Site: 12 Nautical Miles
Observation Time:1953 EDT 
Direction from Accident Site: 275°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling:None 
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 170°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.07 inches Hg
Temperature/Dew Point: 29°C / 21°C
Precipitation and Obscuration:
Departure Point: Ashland, OH
Type of Flight Plan Filed: None
Destination: Ashland, OH
Type of Clearance: None
Departure Time: 1945 EDT
Type of Airspace: Class E

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Minor
Aircraft Damage: Minor
Passenger Injuries: 2 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 3 Minor
Latitude, Longitude:  40.877222, -82.331667 (est)

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