TSB Recommendation A08-02

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.

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.

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.

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

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.

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.

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.

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.

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.

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 FAA, 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.

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.

Transport Canada (TC) agrees in principle with the recommendation.

At the time of the publication of the recommendation in 2007, TC committed to conduct a risk assessment and determine an appropriate means of addressing the issue of the proposed emergency fuel shut-off valves (FSOV) for balloons carrying fare-paying passengers.

In 2013, TC produced an issue paper for the Civil Aviation Regulatory Committee.^{Footnote 1} The purpose of the paper was to clarify TC’s position with respect to mandating emergency fuel shut off valves in balloons carrying fare-paying passengers and to report on what other aviation authorities had concluded on this issue.

The issue paper recommended not implementing the TSB recommendation stating: “Given the overall favourable safety record of balloon operations in Canada, the need for regulatory intervention to achieve still higher levels of safety is not apparent. If the TSB recommendation to implement the emergency fuel shut-off valve were implemented, it is possible that additional failure modes may be introduced into the design that may negate the intended safety benefit.”^{Footnote 2} The issue paper also included a review of other civil aviation authorities plans and noted that none were considering implementing a requirement for fuel shut off valves.

In 2014, the work to address this recommendation resulted in a Board assessment of “Unsatisfactory” and was assigned a “Dormant” status after given that “TC now rejected the recommendation, citing certain unspecified practical and technical problems with the implementation of the recommendation.”

Since then, TC partnered with the Canadian Owners and Pilots Association and SmartPilot.ca to launch a General Aviation Safety Campaign (GASC) in 2017 to inform the general aviation community about how to fly safely. In June 2020, the GASC transitioned to the General Aviation Safety Program (GASP) and, as mentioned in our update for recommendation A08-01, safety enhancements have been accomplished by the GASP with respect to balloon operations since October 2020.

In November 2021, TC inspectors, including members of the GASP, met with the CBA to identify safety concerns in the commercial hot-air balloon sector. This resulted in drafting a preliminary list of potential projects moving forward which includes, working groups to establish industry best practices and regional coordination to encourage surveillance.

Finally, TC reviewed balloon accident statistics and found that there have been only 5 fatalities (all causes) over a 44-year period in Canada, during which an estimated 26,000 passengers were carried annually. The average balloon flight duration may be assumed to be about an hour. Therefore, the fatality rate may be calculated as 0.44 / 100,000 flight hours. Based on the above cursory review of the fatality rates associated with balloon operations in Canada, passenger carrying balloons are already achieving a safety record that outperforms general aviation (2.2 / 100,000) and commuter airline safety (1.2 / 1000,000). Further, balloon fatality rates approach the very low rate of 0.4 / 100,000 flight hours observed for many years for the transport airplane operations^{Footnote 3Footnote 4}.

TC concludes that the findings of the analysis and the overall favourable safety record of balloon operators indicated that the need for regulatory intervention to achieve higher levels of safety is not apparent and will not require that balloons carrying fare-paying passengers have an emergency FSOV, given the practical and technical problems with the implementation of the recommendation but will continue to actively engage with the balloon community to achieve the highest level of safety.

In its latest response, Transport Canada (TC) indicated that it agrees in principle with the recommendation but maintains that, given the practical and technical problems with the implementation of emergency fuel shut-off valves (FSOVs), it will not require passenger-carrying balloon operators to install emergency FSOVs. Alternatively, TC stated it will continue to engage with the balloon community and establish working groups to develop industry best practices and regional coordination to encourage surveillance.

While the Board supports ongoing engagement between TC and industry stakeholders with the intent of advancing safety, it remains concerned about the lack of any concrete interventions, action plans and timelines to reduce the risks associated with the safety deficiency identified in the recommendation. In comparison, the Australian Civil Aviation Safety Authority (CASA) issued an updated Advisory Circular (AC 131-01 v2.0)^{Footnote 5} in November 2020 on manned free balloons, providing guidance and acceptable means of compliance for operators. The AC includes a section on quick shut-off valves.

The AC was issued following an investigation by the Australian Transport Safety Bureau (ATSB) into an in-flight fire involving a hot air balloon with 15 passengers on board on 26 December 2018.^{Footnote 6} The balloon crash landed and was destroyed by the fire and one of the passengers sustained a minor injury.

The ATSB found that the in-flight fire was the result of a fuel leak at the front left burner. […] The hand-wheel valve on the liquid outlet of the fuel tank and the pilot burners were not shut off, which resulted in the pilot being unable to control the fire. Installation of a 90-degree valve on the liquid fuel outlet increases survivability in the event of fire and, may have assisted the pilot to recognize that the liquid fuel valve was not shut off. ^{Footnote 7}

The key safety message of the investigation was the following: “In the event of an in-flight balloon fire, the first priority is isolation of the fuel supply at the fuel tank. […]”^{Footnote 8}

Similarly, the European Union Aviation Safety Agency (EASA) issued a Safety Information Bulletin on 06 September 2018^{Footnote 9} on the use of valves on liquid gas cylinders in balloon operations. In this bulletin, EASA underscored that in-service experience, as well as results of investigations of severe accidents with fatal injuries due to the outbreak of fire, have shown that an easy and quick shut-off of the main liquid gas outlet increases survivability.^{Footnote 10}  

The EASA recommended “operators of hot air balloons to use already existing approved valves for propane fuel cylinders, for commercial and non-commercial balloon operations.”^{Footnote 11} The EASA further recommended “operators to include the emergency use of these valves in the pre-flight briefing of passengers.”^{Footnote 12}  

Lastly, while the number and rate of fatalities in Canada over a 44-year period provided by TC are very low, they do not provide a contextualized level of risk of the safety deficiency and do not consider the number of injuries and severity thereof. The TSB reviewed data from its Aviation Safety Information System from 01 January 1990 to 10 January 2022 and noted there were 84 occurrences in Canada involving balloons. In over 50% (43) of these occurrences, fatalities and injuries occurred. There were 4 fatalities (between 2001 and 2013), 49 serious injuries, and 37 minor injuries. 

TC’s response does not contain sufficient detail and the Board is uncertain as to how the risks associated with the safety deficiency identified in Recommendation A08-02 will be addressed.

Therefore, the response to Recommendation A08-02 is assessed as Unsatisfactory.