An in-depth reading of the TAIC report into the Carterton Hot Air Ballooning tragedy, in which 11 people died has shown that the CAA had received a complaint (ARC or Aviation-related concern) about the capability of deceased pilot Lance Hopping. Furthermore, the incident was dismissed as possibly being not genuine without any record of the complainant ever being contacted.
Furthermore, there were numerous irregularities in the maintenance procedures for the balloon (which had also been raised as an ARC) and Hopping had missed a mandatory medical examination.
4.4.4. However, the maintenance performed on ZK-XXF, namely the documentation, was substandard. The Commission was concerned that this could have extended to other balloons, so it published an urgent recommendation to the Director of Civil Aviation to address this safety issue. (Refer to section 7, Recommendations, and section 6, Safety actions).
4.3.2. The pilot’s medical certificate had lapsed 6 weeks before the accident. He subsequently flew 9 flights, not including the accident flight, with an expired medical certificate. CAA Rules required pilots to maintain current medical certificates as part of their licences (CAA, 2011). He had previously been made aware that his certificate was about to expire but there was no evidence found to show that the pilot was in the process of renewing it. Undertaking the flight knowing that he did not have a current Class 1 medical certificate as required by Civil Aviation Rules displayed a certain disregard for the authority of those Rules.
Furthermore, in the days leading up to the fatal flight, Hopping had been told the owner of his balloon was going to take possession of it and he was investigating buying his own. Post mortem results showed he was probably a chronic user of cannabis and witness reports suggest he may have been seen smoking a cannabis cigarette on the morning of the flight. Witnesses had initially assumed that it was a regular cigarette but no traces of tobacco were found in his system
4.3.14. The pilot was not averse to flouting rules. He had continued to operate his commercial balloon venture despite his medical certificate having expired some 6 weeks previously. There are 2 other considerations that could also have altered his normal behaviour:
- the pilot was about to lose a significant portion of his income with the return of the balloon to its owner. While he reportedly accepted this, it was the first topic he raised with the 2 ground crew and the photographer on the morning of the flight, and he was not happy about it
- the pilot was known to suffer from gout, and was seen to be limping that morning. Gout was a condition that may have affected his behaviour.
4.3.15. The 2 witnesses who saw the pilot smoking on the balcony of the shed shortly before the flight made their reports only after they became aware that the pilot had tested positive for THC. One of them was made aware of the results at a Police briefing before the public release of the Commission’s interim report on the accident. She reported what she had seen to the Police immediately after the briefing.
4.3.16. The 2 witnesses were standing about 25 m from the pilot and had a clear view of him on the balcony. Their observations were consistent. They saw the pilot taking something to his mouth and smoke then rising from it. They did not see the pilot drinking from the cup he held. Tests made of the pilot’s urine were negative for the substance of cotinine, which means that if the pilot was smoking, he was not smoking regular tobacco.
Two years previously the ACC had received a complaint about the pilot’s sobriety:
3.10.11. On 8 February 2010 a different ARC concerning the pilot had been raised. The ARC stated that a balloon passenger had been told that their planned flight was cancelled because the pilot “appeared too ‘pissed and/or high’ to perform his piloting duties for that flight”. The ARC file recorded that by the following day 3 CAA staff members had been assigned to look into the ARC.
3.10.12. The next file entry on 25 August 2011 stated that the pilot and a crew member had been spoken to and both were “adamant that the incident never occurred”, and that “considering the level of accusations within the ballooning community against certain individuals it seems likely that this incident may not be genuine. No further action required”. The status of the ARC was changed to “Assessed” but there was no record of it being closed off.
The TAIC report was also critical of the CAA’s management and its reporting and investigation system, saying
3.10.13. In view of the 2 ARCs lodged concerning the pilot and the balloon maintenance company, the Commission enquired into the CAA system for processing ARCs. The CAA advised that there had been a longstanding internal concern about its ARC management and processes. In particular the CAA was concerned about the initial recording of ARCs, the allocation of appropriate resources and the ad-hoc manner in which they were managed to logical conclusions. In 2010 a review of ARCs was initiated and a report produced titled “Aviation Related Concerns: Review of Processes and Procedures”, dated 29 June 2010. The review found there was “a systemic failure in the CAA’s internal management systems”. The treatment of ARCs varied and valuable information could be missed. A lack of resources was also identified”
You may wish to read the report and draw your own conclusions about the standards of safety regulation in New Zealand and the systematic failures in the chain of events that led up to this fatal ‘accident.’