Recommendation A08-02

Reassessment of the response from Transport Canada to Aviation Safety Recommendation A08-02

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Emergency fuel shut-off

Background

On 11 August 2007 at about 0908 central daylight time, a FireFly 12B hot air balloon, C-FNVM, attempted a landing in a field adjacent to Birds Hill Provincial Park near the northern outskirts of Winnipeg, Manitoba. The balloon was operated by Sundance Balloons International under a Special Flight Operations Certificate (SFOC) issued by Transport Canada (TC). One pilot and 11 passengers were on board, for a local sightseeing flight of about one hour's duration, originating in the southeast of Winnipeg and terminating in the northeast of Winnipeg.

The flight had been extended beyond Winnipeg as the pilot searched for a suitable landing area. The winds in the landing area were much stronger than anticipated, and the balloon touched down and skipped several times. The basket was dragged on its side for about 700 feet and tipped far enough for the burners to strike the ground. When the balloon stopped, a propane fuel leak occurred and an intense fire ensued before passenger evacuation was completed. The pilot and two passengers suffered serious injuries. Four other passengers suffered minor injuries, some with burns. Two of the propane tanks and a fire extinguisher canister exploded, and the balloon basket was destroyed. The fuel system was not equipped with an emergency shut-off valve.

On 27 March 2008, the Board released interim safety recommendations as part of its investigation (A07C0151) into this occurrence.

Board Recommendation A08-02 (27 March 2008)

While some commercial balloon operators in Canada have fare-paying passenger loads in the range of those of commuter and air taxi operators, their passengers are not assured of the same level of safety and oversight by regulations and standards. The inability to quickly shut off the fuel supply during landing or in an emergency increases the risk of a fire and/or explosion, compromising balloon passenger safety. Therefore, the Board recommended that:

The Department of Transport ensure that balloons carrying fare-paying passengers have an emergency fuel shut-off.

TSB Recommendation A08-02

Transport Canada's response to A08-02 (18 June 2008)

To address the issue of the proposed emergency fuel shut-off for balloons carrying fare-paying passengers, TC is conducting a risk assessment to determine whether regulatory or non-regulatory solutions would be appropriate to address this issue. Once the review is complete, should regulatory changes be required, Notice of Proposed Amendments will be developed and submitted to the Canadian Aviation Regulation Advisory Council for consultation.

Board Assessment of the response to A08-02 (16 July 2008)

TC's response to the recommendation indicates that it intends to conduct a risk assessment and determine an appropriate means of addressing the issue of the proposed emergency fuel shut-off for balloons carrying fare-paying passengers. Once the review is complete, regulatory changes will be proposed should they be considered necessary. However, the Board believes that TC's proposed review and regulatory amendment process will not yield any specific course of action that, in the short term, would reduce or eliminate the deficiency identified in Board Recommendation A08-02. The response is assessed as Satisfactory Intent.

Next TSB action

The Board will continue to monitor the safety of passenger-carrying balloon operations, and will follow up TC's response in conducting its risk assessment process.

Transport Canada response to A08-02 (21 January 2011)

The recommendation has been discussed at the November 2009 Canadian Aviation Regulation Advisory Council (CARAC) Technical Committee meeting. TC is considering the fuel shut-off valve recommendation and will conduct, as a next step, an early stakeholder consultation via mail survey for feedback prior to further development of a regulatory policy.

Board reassessment of the response to A08-02 (09 March 2011)

TC's response indicates that it continues to progress safety action that, if fully implemented, may address the deficiencies underlying Recommendation A08-02.

The response is assessed as Satisfactory Intent.

Next TSB action

TSB staff will continue to monitor the safety of passenger-carrying balloon operations, and follow up with TC with respect to the progress of this issue through the CARAC process.

Transport Canada response to A08-02 (30 September 2011)

May 2011 input

This remains an active project and is assigned a priority within the Transport Canada standards development process.  Transport Canada is considering the fuel shut-off valve recommendations and will conduct, as a next step, an early stakeholder consultation prior to further development of a regulatory policy.

September 2011 update

No change.

On 28 March 2012, TC submitted an update stating the following:

This remains an active project. By fall 2012 discussions will be held to review the project to decide on what the next steps will be.

Board reassessment of the response to A08-02 (31 March 2012)

In its 18 June 2008 response, TC had indicated that it was conducting a risk assessment to determine whether regulatory or non-regulatory solutions would be appropriate to address the deficiency identified in Recommendation A08-02. To date, TC has not provided the TSB with any information regarding the results of this risk assessment project or any decisions on how they plan to address the deficiency identified in Recommendation A08-02.

In its 21 January 2011 response, TC indicated that Recommendation A08-02 had been discussed at the November 2009 CARAC Technical Committee meeting. It then indicated that it would conduct, as a next step, an early stakeholder consultation via mail survey for feedback prior to further development of a regulatory policy. To date, TC has not provided the TSB with any information to indicate whether or not the planned survey has been conducted, or any survey results.

In its latest response, TC is vague as it simply indicates that addressing Recommendation A08-02 remains an active project. It then reiterates comments from last year's response, that as a next step, it will conduct an early stakeholder consultation. It does not indicate a timeframe as to when this stakeholder consultation will be taking place, nor does it provide any information regarding the other planned actions.

In an email dated 06 February 2012, TC stated the following:

The CARAC Working Group for Balloons with Fare-Paying Passengers will be submitting a final report containing the WG's recommendations at the fall 2012 CARAC Technical Committee meeting.

On 28 March 2012, TC submitted an update stating the following:

A Working Group meeting will be held in April/May 2012. The final report containing the Working Group recommendations are expected to be presented at the 2012 fall CARAC Technical Committee meeting.

The response is assessed as Satisfactory Intent.

Next TSB action

The TSB will continue to monitor the safety of passenger-carrying balloon operations, and follow up with TC with respect to the progress of this issue through the CARAC process.

The deficiency file is assigned an Active status.

Transport Canada’s response to A08-02 (04 December 2012)

TC will review the recommendations associated with balloon operations in early 2013 along with our past responses to determine what other steps can be taken.

Board assessment of the response to A08-02 (06 March 2013)

TC did not provide details regarding the progress of the CARAC Working Group for Balloons with Fare-Paying Passengers and its recommendations expected to be presented at the fall 2012 CARAC Technical Committee meeting; nor has TC provided any indication of what recommendations it states it is continuing to consider. The Board is very concerned about the lack of concrete plans to address the underlying safety deficiency which supports this recommendation.

The response is considered as Unable to Assess.

Next TSB action

The TSB will continue to monitor the safety of passenger-carrying balloon operations, and follow up with TC with respect to the progress of this issue through the CARAC process.

The deficiency file is assigned an Active status.

Transport Canada’s response to A08-02 (26 November 2013)

Balloon accident statistics have been reviewed and analyzed. The findings of the analysis and the overall favourable safety record of balloon operators indicate that the need for regulatory intervention to achieve higher levels of safety is not apparent. TC will not require that balloons carrying fare-paying passengers have an emergency fuel shut-off, given the practical and technical problems with the implementation of the recommendation. TC will continue to work cooperatively with the Federal Aviation Administration (FAA), the European Aviation Safety Agency (EASA), and other authorities, as appropriate, in the ongoing development of design standards for aeronautical products. No additional regulatory or advisory material is planned at this time, and no further updates will be provided.

Board assessment of the response to A08-02 (02 April 2014)

TC has now rejected the recommendation, citing certain unspecified practical and technical problems with the implementation of the recommendation.

Therefore, TC’s response is considered as Unsatisfactory.

Next TSB action

The TSB will continue to monitor the safety of passenger-carrying balloon operations.

As a result of TC’s response the deficiency file is assigned a Dormant status.