Investigation Summary
On the morning of August 13, 1989, five hot air balloons operated by Toddy's Safari Ballooning launched for tourist charter flights. At the time of the accident, four of these balloons were in the immediate vicinity. Two of these balloons, VH-WMS (upper) and VH-NMS (lower), were operating in close proximity. VH-WMS had taken off approximately two minutes before VH-NMS and was maintaining an altitude of roughly 2,000 feet above ground level. The pilot of VH-WMS was reportedly distracted while pointing out landmarks to passengers and failed to use the burner for an extended period, causing the balloon to descend slightly. Simultaneously, VH-NMS was climbing to follow the lead balloon. During this climb, the pilot of VH-NMS lost visual contact with the balloon above because his own envelope created a blind spot directly overhead. The basket of VH-WMS struck the envelope of VH-NMS just below the velcro rip panel. The tension of the hot air caused the initial tear to propagate rapidly through adjacent seams. As the balloons separated, the basket of VH-WMS fouled the control lines of VH-NMS, fully opening the rip panel and causing a total collapse of the envelope. VH-NMS plummeted to the ground in approximately 51 seconds.
Final Conclusions
The Bureau of Air Safety Investigation (BASI) concluded that the primary cause was a failure of both pilots to maintain adequate separation and lookout. The pilot of the upper balloon (VH-WMS) failed to give way to the lower balloon as required by the company's operations manual. Additionally, VH-WMS was not equipped with the mandatory instrument package, which hindered the pilot's ability to judge vertical movement. The pilot of the lower balloon (VH-NMS) failed to properly assess the position of the balloon above before initiating a climb into its path. The final report was released on November 28, 1989.
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Toddy's Safari Ballooning VH-NMS — Kavanagh E-260 · VH-NMS
Toddy's Safari Ballooning VH-WMS — Thunder & Colt 240 · VH-WMS
Systems & Failure Modes
Velcro Rip Panel
A safety and deflation system at the top of the balloon envelope. During the collision, the basket of the upper balloon fouled the control lines, initiating activation of the rip panel Capewell safety locks and fully opening the panel.
UHF Radio
Used for communication between balloons and ground crews. Although both aircraft were on the same channel, they failed to coordinate their vertical movements.
Interesting Facts
- 01The accident was the deadliest hot air balloon crash in history until the 2013 Luxor balloon crash.
- 02The pilot of the upper balloon (VH-WMS) refused to cooperate with investigators following legal advice.
- 03Both balloons were equipped with UHF radios on the same frequency, but no communication occurred between the pilots prior to impact.
- 04The pilot of VH-NMS turned off the gas burners before the final impact.
- 05The upper balloon was missing a mandatory instrument package, and the pilot was using a wrist altimeter instead.
Safety Actions & Advisories
Civil Aviation Authority Surveillance
The investigation recommended that the CAA improve surveillance of commercial ballooning operations.
Operational Procedures
Reinforcement of the 'upper balloon gives way' rule in formation flights to prevent basket-to-envelope contact.
Known Controversies & Unanswered Questions
Criminal Prosecution of Michael Sanby
Reference ↗The pilot of the upper balloon was initially sentenced to two years in prison for committing a 'dangerous act' in 1992, but the conviction was later overturned on appeal.