The victims of the Carterton balloon crash might have survived if the pilot had decided to immediately descend when it became clear the balloon would strike power lines, an investigation has found.
Instead, pilot Lance Hopping made the fatal decision, likely while he was under the influence of cannabis, to try to out-climb the power lines.
The country's top transport investigator has renewed calls for mandatory random drug testing after an inquiry found the Carterton balloon crash pilot had likely smoked cannabis shortly before the fatal flight.
The final report of the Transport Accident Investigation Commission (TAIC) found the January 2012 crash was caused by errors of judgment, and cannabis impairment was unable to be excluded.
Eleven people were killed when the balloon caught fire and crashed to the ground after hitting power lines near Carterton on January 7.
The report comes after an interim report, released in May last year, found Mr Hopping, 53, had cannabis in his system.
The interim report said it was not known whether that was a factor in the crash - but the final report found the crash was caused by errors of judgment, and the possibility that Mr Hopping's performance was impaired by cannabis could not be excluded.
It was "highly likely'' that Mr Hopping had smoked cannabis shortly before the fatal flight, with two witnesses saying they saw him smoking only about 25 minutes before the flight.
Toxicology results found he had 2 micrograms of cannabis per litre of blood, which was consistent with smoking cannabis 4-6 hours prior, and that he was unlikely to have been smoking tobacco.
The report pointed to errors of judgment that could have been linked to his smoking cannabis.
Among those was the decision not to rapidly descend once the balloon struck the powerlines, which was the advice given in the balloon flight manual.
"Had he done so there would have been a better chance of survival for the balloon's occupants,'' the TAIC found.
Instead, Mr Hopping tried to out-climb the power lines, which the TAIC said was an error in judgment.
The TAIC found it was highly likely that Mr Hopping knew the location of the power lines and had seen them before allowing the balloon to descend to their height.
A last-minute change in the wind carried the balloon towards the lines, two of which became stuck on the balloon's basket. The pilot applied the burners, causing the balloon to climb along the snagged power lines, while passengers tried to push the power lines off with their hands,
Electrical arcing from the power lines punctured the balloon's LPG tanks, causing an intense fuel-fed fire that consumed the basket.
Heat from the basket and, to a lesser extent, the decision of two passengers to leap from the balloon while it was still 20m off the ground, caused it to rapidly rise and break free of the power lines.
The balloon continued to rise before plummeting to the ground, killing all nine who remained on board.
The report addressed speculation the balloon's rapid rise was caused by two passengers jumping off, noting the speed of the balloon's ascent was significantly higher than expected had the load been lightened by two passengers alone.
The TAIC found Mr Hopping did not have a current medical certificate, which showed a disregard for complying with the rules.
Its said the use of drugs like cannabis by the crew of any transport vehicle was a serious safety issue that needed to be addressed as a matter of priority.
The report said the regulatory oversight of commercial ballooning in New Zealand was not sufficient to ensure a safe and sustainable industry for the public.
There were safety concerns that non-commercial balloon pilots - which was not the case here - could take non-paying passengers for a balloon flight without any prescribed training, knowledge or medical certificate.
The report comes after an urgent safety review of commercial balloon operators following the tragedy.
TAIC chief commissioner John Marshall today renewed calls for mandatory random drug testing within the aviation, marine and rail sectors.
He said there needed to be a law or rule change to set maximum limits for alcohol, and to prohibit people from operating aircraft, vessels or trains if they were impaired.
Changes were also needed to require transport operators to implement drug and alcohol detection and deterrence regimes - including random testing - and to introduce mandatory drug and alcohol testing after an incident.
Transport Minister Gerry Brownlee said the recommendations were important and he had asked the Ministry of Transport to give them careful consideration.
"There should be zero tolerance of operator impairment, where members of the public are being transported by land, sea, rail or air.''
Mr Brownlee was awaiting advice from the ministry on whether legislative change was required to address the recommendations. He expected to report to Cabinet on any proposals early next year.
Secretary for Transport Martin Matthews said the ministry was giving careful and full consideration to the recommendations, and would make its own recommendation to Mr Brownlee in December.
"Like the commission, the ministry also believes there should be zero tolerance of operator impairment, where members of the public are being transported by sea, rail and air.''
Some measures have already partly addressed the TAIC's recommendations, Mr Matthews said.
Since March, adventure activity operators have been required to manage the safety risks associated with drug or alcohol impairment in their relevant safety plans.
The rule change came after a review last year.
The Civil Aviation Authority had also worked with adventure aviation operators to support the development and implementation of drug and alcohol management policies that include testing.
Large transport operators, including as Air New Zealand, Qantas, KiwiRail and Maersk Line, had also introduced have their own drug and alcohol testing regimes.
Aviation New Zealand chief executive Irene King backed calls for mandatory testing.
"It is totally unacceptable that random mandatory drug and alcohol testing has still not been introduced across the aviation industry for all those engaged in safety sensitive role.''
Ms King said all scheduled carriers in New Zealand and most general aviation companies randomly tested all employees in safety-sensitive roles.
However, there were "elements in the wider sector'' that did not recognise the serious impact of drugs and the reputational damage it did to the brand.
"We advocate testing of all involved in safety sensitive roles - this includes the many owner operators, contractors, their executives and staff, irrespective of whether they are directly involved in day to day operations,'' she said.
"Regrettably, despite our best efforts over a very long period, we have been unable to move all providers to the same standard - legislation is now the only alternative to assure substance abuse is not tolerated in the industry.''
Speaking at the release of the report, Mr Marshall made the TAIC's strongest plea yet for mandatory testing.
"Accidents such as this one, in addition to the personal tragedy and community impact, can affect New Zealand's reputation and have economic impacts that extend well beyond those immediately involved,'' he said.
"Substance impairment has again been found as an issue. We have made yet another recommendation. It is time for public debate and action.
"It is our objective that something like this never happens again.''
The TAIC had investigated six transport incidents in the last decade that involved people who had tested positive for drugs or alcohol.
Those incidents had led to 35 deaths - and there were many more incidents, including fatalities, that did not meet the TAIC's threshold for inquiry.
Mr Marshall said the use of substances such as cannabis was "a serious safety issue that needs to be addressed as a matter of priority''.
Statement of Sheryl Rule on behalf of balloon crash victims Valerie Bennett and Denise Dellabarca:
"On the 7th Jan 2011, our Aunt Valerie Bennett and Cousin Denise Dellabarca along with eight other people went on a trip of a lifetime in a balloon ride over the Wairarapa. This should have been an amazing experience they would remember for years to come, instead they were taken from us in an avoidable tragedy caused through errors of judgement, by a well respected pilot impaired by the short and long term use of cannabis.
"The Transport Accident Investigation Commissions (TAIC) report released this morning confirms to us the high level of complacency we have as a nation to drug use, especially cannabis. While what people do in their own time is not our concern, when they take other peoples lives in their hands, when they get behind the wheel of a car, the helm of a boat or pilot a balloon while drug impaired, showing complete disregard for the value of other people's lives, it should be everyone's concern.
"We as a nation need to show that we take the safety of our citizens and guests seriously and that it is not OK to be so complacent regarding the use of impairing drugs and alcohol in safety critical roles.
"We believe the only way to do this is to ensure that random drug tests are implemented across both the transport and adventure tourism sectors and that for any commercial licence holder an enforced drug test should be part of the medical exam.
"This is the third time since March 2011 that TAIC has recommended that there is a zero tolerance to drug impairment and requested the introduction of drug and alcohol detection and deterrence. The Ministry of Transport's (MoT) response each time has been that they don't believe there is enough evidence to support the economic feasibility of this.
"Economic costs are not a justification for inaction, when you take into account the police hours, the TAIC investigation, fire crew and other emergency services, voluntary helpers, Coroner, ACC, ESR and other experts and loss of tourism dollars, the cost of this one incident has been extraordinary. Most importantly how do you put a value on the loss of 11 people's lives?
"While we acknowledge that there has been some improvement in this area, MoT's response to the TAIC recommendations do not go far enough.
"MoT's course of action is to implement forced testing after an incident to gather evidence to quantify the extent of alcohol and drug use, meaning that more people will be injured or killed by impairment to ascertain the value of random drug testing, yet they state that impairment contributes to about a third of all roads deaths each year. How does this differ from any other mode of transport? There is a problem, we know there is a problem, they know there is a problem and something needs to be done about it now.
"In response to the Fox Glacier report, MoT is encouraging the CAA to step up in its educational campaign within the aviation community but is not providing the CAA with the means to regulate and enforce the zero tolerance message. Would you still jump out of a plane if you knew the person you were strapped to may have their decision making ability impaired by drugs or alcohol?
"As a family we want to see the commission's recommendations taken seriously this time and implemented immediately so that no other families have to experience the horrific loss of loved ones from a completely avoidable event.''
Statement from Alexis Still's family. Parents: Allan and Vivienne.
"Upon reading the TAIC report the cause of the tragedy is very clear. The fault very firmly sits with the pilot.
"The immediate cause of the incident was consequential to three errors of judgement made by him.
"However one of the root causes upsets our family the most. The pilot's drug-taking habits and that he very probably used drugs immediately prior to taking 10 people on the flight, indicate that this was a man who did not consider or care what the impact of his illegal behaviour would have on those who paid him for an experience of a lifetime.
"The fact that he couldn't be bothered renewing his medical certificate reinforces the view that this pilot was unfit to accept the responsibility of protecting the lives of those under his care. On the evening prior to her flight Alexis commented that the pilot was the 'safest around'. That was a fatal assumption and we can tell you that Alexis would not have boarded that flight if she was aware that the pilot was a chronic cannabis user as revealed in the Commission's inquiry.
"We cannot change the past. So as a family what would we like to see as an outcome or learning from this experience?
"There have been 34 fatalities over the past 10 years involving incidents where drugs were implicated in air, marine, or rail operations.
"How long will our society tolerate this? We do in fact have the means to end it now. It is imperative that random drug testing and post incident drug testing is introduced immediately for all commercial balloon operators. It should be standard operating procedure that all balloon operators are drug tested prior to attaining their licence and also at each medical review.
"We need the will of the law makers (politicians and officials) to make a stand for not only the victims and loved ones of the Carterton Balloon Tragedy but for all New Zealanders and foreign tourists who might use commercial adventure tourism operators.
"This is a crucial issue looking all of us in the eye. It is important not only to our tourism industry but to future generations who deserve the right to engage in these activities knowing that suitable systems are in place to protect them.
"One thing is certain if nothing is done then history will repeat itself. We want action now!"
Image 1 of 16: Chrisjan Jordaan and Alexis Still. Photo / Geoff Walker
- Pilot Lance Hopping, 53 - Valerie Bennett, 70 - Husband and wife Desmond and Ann Dean, aged 70 and 65.
Wellington
- Ms Bennett's cousin Denise Dellabarca, 58 - Husband and wife Howard and Diana Cox, aged 71 and 63 - Lower Hutt couple Stephen Hopkirk, 50, and Belinda Harter, 49 - Couple Chrisjan Jordann, 21, and Alexis Still, 19
The aviation industry says it is frustrated that mandatory drug and alcohol testing in safety sensitive aviation workplaces has not yet been introduced.
"We accept that education is an integral part of enhancing safety but we can only do so much. Without the ability to test all working in safety sensitive roles, it can be difficult to detect the presence of these substances - for this reason alone regulation is essential," said Irene King, chief executive of Aviation New Zealand.
"We advocate testing of all involved in safety sensitive roles - this includes the many owner operators, contractors, their executives and staff, irrespective of whether they are directly involved in day to day operations".
Mandatory random alcohol and drug testing provided transparent assurance to the public that all sectors of aviation operated at the same zero tolerance level.
The travelling public, including New Zealand's valuable tourism industry, had the right to expect that exemplary safety standards would be delivered and there would be accountability, Ms King said.
"Regrettably, despite our best efforts over a very long period, we have been unable to move all providers to the same standard - legislation is now the only alternative to assure substance abuse is not tolerated in the industry."
Prime Minister John Key, also the Minister of Tourism, raised the possibility of mandatory random drug and alcohol testing in the adventure tourism sector following the Carterton ballooning tragedy and a skydiving plane crash at Fox Glacier in 2010 which killed nine people.
Two skydive masters on the plane were found to have cannabis in their systems, although this did not contribute to the crash, according to the coroner.
Masterton couple Ann and Desmond Dean, shortly before they died in the January 7 hot air balloon crash.
Photo / supplied.
