The Analysis of Hot-Air Balloon Accidents by Human Factor Analysis and Classification System

Abstract

Although hot-air balloon accidents are infrequent with respect to the total
number of flights, the rate of hot-air balloon accidents has shown a significant
increase over the past two decades. The aim of this study is to classify the
previously identified causal factors of hot-air balloon accidents. 103 NTSB
(National Transportation Safety Board) accident reports were analyzed, and
the causal factors of hot-air balloon accidents were classified by using
HFACS (Human Factors Analyzing and Classification System) as a
framework. The relative importance of factors contributing to hot-air balloon
accidents was established. We found that environmental factors were the
most significant contributing factors, followed by skill-based errors as the
second-highest contributing factors. Our results will contribute to
countermeasures for preventing future reoccurrences of hot air balloon
accidents and incidents, and may provide an insight into high-risk factors
which are associated with the severity of balloon crashes.

Full text

JOURNAL OF AERONAUTICS AND SPACE TECHNOLOGIES
(ISSN: 1304-0448)
January 2020 Volume 13 Number 1
www.jast.hho.edu.tr
17
Research Article
The Analysis of Hot-Air Balloon Accidents by Human Factor Analysis and
Classification System
Bilal KILIÇ1
1 Ozyegin University, Faculty of Aviation and Aeronautical Sciences, 34794 Istanbul, Turkey, bilal.kilic@ozyegin.edu.tr,
https://orcid.org/0000-0002-3773-6682
Article Info
Abstract
Received: July 30, 2019
Accepted: October 30, 2019
Online: January 23, 2020
Keywords: HFACS, Accident
Investigation, General Aviation,
Hot-Air Balloon Accidents, Human
Factors
Although hot-air balloon accidents are infrequent with respect to the total
number of flights, the rate of hot-air balloon accidents has shown a significant
increase over the past two decades. The aim of this study is to classify the
previously identified causal factors of hot-air balloon accidents. 103 NTSB
(National Transportation Safety Board) accident reports were analyzed, and
the causal factors of hot-air balloon accidents were classified by using
HFACS (Human Factors Analyzing and Classification System) as a
framework. The relative importance of factors contributing to hot-air balloon
accidents was established. We found that environmental factors were the
most significant contributing factors, followed by skill-based errors as the
second-highest contributing factors. Our results will contribute to
countermeasures for preventing future reoccurrences of hot air balloon
accidents and incidents, and may provide an insight into high-risk factors
which are associated with the severity of balloon crashes.
To Cite This Article: B. Kilic “The Analysis of Hot-air Balloon Accidents by Human Factor Analysis and Classification
System” Journal of Aeronautics and Space Technologies, Vol. 13, No. 1, pp. 17- 24, Jan. 2020
Sıcak Hava Balonu Kazalarının İnsan Faktörleri Analizi ve Sınıflandırma
Yöntemi ile Analizi
Makale Bilgisi
Öz
Geliş: 30 Temmuz 2019
Kabul: 30 Ekim 2019
Yayın: 23 Ocak 2020
Anahtar Kelimeler: HFACS,
Kaza Araştırmaları, Genel
Havacılık, Sıcak Hava Balonu
Kazaları, İnsan Faktörleri
Sıcak hava balon kazalarının sayısı gerçeklesen toplam uçuş sayısına nazaran
seyrek olmasına rağmen, kaza oranları son yirmi yılda büyük ölçüde artış
göstermiştir. Bu çalışmada, sıcak hava balonu kazalarına sebep veren
faktörlerin sınıflandırılması amaçlanmıştır. İnsan faktörleri analizi ve
sınıflandırma yöntemi kullanılarak Ulusal Ulaşım Güvenlik Kurumu
tarafından hazırlanmış 103 adet sıcak hava balonu kazası raporu analizi
yapılmıştır ve bu kazalara sebep veren faktörler sınıflandırılmıştır. Bu
kazalara sebep veren faktörlerin önem dereceleri elde edilmiştir. Kazalara
sebep veren faktörler içerisinde en yüksek oranda çevresel faktörler ve ikinci
olarak yetenek hataları bulunmuştur. Bu çalışmada elde ettiğimiz sonuçlar,
sıcak hava balonu kaza ve kırımlarının gelecekte tekrar meydana gelmesini
engelleyecek önlemlere katkıda bulunacaktır ve kazaların ağır sonuçlarıyla
bağlantılı önemli etkenlerin iç yüzünün anlaşılmasını sağlayabilir.
1. INTRODUCTION
Hot-air balloon operations are attracting considerable
interest due to their enjoyable birds-eye-view of famous
tourist spots from high above [1]. The last two decades
have witnessed an enormous increase in hot-air-balloon
rides [2]. Previous research has shown that 98 accidents
occurred between 1976 and 2004 in the United Kingdom
[3]. In another study, it was demonstrated that 86 hot-air
balloon crashes occurred between 2000 and 2004 [4].
More recently, Aslaner reported that 12 hot-air balloon
tour accidents occurred between August 2013 and July
2017 [5]. Previous studies have been limited in
addressing the damage and injuries that have occurred
due to balloon crashes [4]. Likewise, very few studies
have examined the causality in hot-air balloon accidents
[6]. Moreover, to the best of the authors’ knowledge, no
report has been found so far using an HFACS framework
to examine the contributing factors of hot-air balloon
accidents. The main aim of this paper is to examine and
classify the factors that contribute to hot-air balloon
accidents.

The Analysis of Hot-air Balloon Accident by Human Factor Analysis and Classification System
KILIÇ
18
HFACS is one of the most widely used analytical
frameworks to analyze accidents and incidents in various
industries such as aviation [7], railway [8], gas pipeline
[9], mining [10] and medicine [11]. It is fundamentally
based on James Reason’s Swiss cheese model and
provides an efficient analysis of an accident [12]. By
examining an occurrence within 4 levels and 19
subcategories, it aids researchers in examining an
accident in every detail and finding out both active and
latent errors. In other words, HFACS operationalizes the
Swiss cheese model of accident causation and describes
contributing factors [13], [14].
In this study, the causal factors (active and latent failures)
of hot-air balloon accidents that occurred between 2008
and 2018 in the USA are classified by using an HFACS
framework. Section 2 presents a literature review on hot-
air balloon operations and accidents. In the third section,
implementation of the method, HFACS analysis, is
demonstrated. In section 4, the results are discussed.
Conclusions are given at the end of the paper. The
contribution of this study is clear as the findings may be
capitalized as guidelines to prevent future occurrence of
accidents such as those mentioned above.
2. LITERATURE REVIEW
2.1. Hot-air Balloon
The French brothers, Joseph (1740-1810) and Etienne
Montgolfier (1745-1799) invented the first hot-air-
balloon in 1783 [15]. The first flight with a 17.37-m-high
fire balloon invented by the two French brothers was
carried out from the courtyard of the Versailles Palace
[16]. During the first public presentation of the hot-air
balloon, there were no human passengers onboard, but
living creatures such as a rooster, duck and sheep were
carried. The flight time was 8 minutes, and the hot-air
balloon reached an altitude of 2000 meters. Nearly two
months after this successful demonstration flight, the first
manned flight was performed, and it sailed over Paris for
25 minutes [17].
2.2. Hot-air Balloon Accidents
Since the first invention of the hot-air balloon and its
operation for fun and adventure, some tours have ended
with catastrophic results [18]. The first fatal hot-air
balloon accident occurred nearly two years after the
invention of the hot-air balloon. The flight was operated
by pilots Jean Francois Pilatre de Rozier and Pierre Ange
Romain. They died after the balloon caught fire and
crashed [2]. Since the first accident mentioned above,
there have been hundreds of hot-air-balloon accidents [2],
[3], [6], [18]. For instance, the Ljubljana Marshes hot-air
balloon crash was one of the deadliest hot-air ballooning
accidents in history. A hot-air balloon carrying 32 people
flew through stormy weather. A sudden weather change
and the wind shear gave rise to an immediate landing.
During the emergency landing, the balloon hit trees and
caught fire. This crash killed 6 passengers onboard. The
accident’s investigation was carried out by the Slovenian
aircraft accident investigation commission. It was found
that the main contributing factors of the accident were
“improper technique used in operating the balloon” and
“inadequate meteorological conditions and planning”
[19]. Another deadly hot-air balloon crash occurred near
the ancient city of Luxor, Egypt on February 26, 2013. It
was known as the most disastrous hot-air balloon accident
that ever occurred in history. A hot-air balloon suffering
from a fuel leakage caught fire. While attempting an
emergency landing, the pilot failed to land the balloon
and rose higher. 7 of the 19 passengers met their death
when they tried to jump out of the balloon. The remaining
12 lives were lost during the mid-air explosion of the
balloon.
Despite the restrictive regulations and lower number of
flights compared to general aviation and airline
operations, safe operation of hot-air balloons is a big
concern for the aviation industry [20]. In addition to some
major accidents mentioned above, a number of hot-air
balloon rides turned into disasters [21] (Table-1).
There has been little research on hot-air balloon accidents
and their contributing factors [2-4], [6], [15]. To the best
of our knowledge, there is no study that examined the
contributing factors of hot-air balloon accidents by using
an HFACS framework.
Table 1. The deadliest hot-air balloon accidents in
history [21].
Rank
Date
Location
Deaths
Injuries
1
26.02.2013
Luxor,
Egypt
19
2
2
30.07.2016
Maxwell,
Texas,
USA
16
0
3
13.08.1989
Australia
13
0
4
07.01.2012
Carterton
New
Zealand
11
0
5
23.08.2012
Ljubljana
Slovenia
6
26
2.3. HFACS
One of the most widely used conceptual frameworks to
examine accidents and incidents in various industries is
HFACS, which was originally developed in the U.S.
Military [14]. This conceptual approach has been proven

The Analysis of Hot-air Balloon Accident by Human Factor Analysis and Classification System
KILIÇ
19
to be an excellent tool to examine accidents and incidents
in civil aviation [22].
Level-4
Level-3
Level-2
Level-1
Figure 1. The HFACS Framework.
While examining an accident in aviation, the first step is
identification of the unsafe acts involved. As shown in
Figure 1, on the first level of the analysis (HFACS-Level-
1), errors and violations made by pilots are examined and
classified. The error category is divided into 3
subcategories as follows: decision errors, skill-based
errors and perceptual errors. Within the violation
category, the following two sub-categories are defined:
routine violation (e.g., violation of standard operating
practices/regulations) and exceptional violation (e.g.,
carrying out an unauthorized operation) [23].
On the second level of the analysis, the preconditions for
unsafe acts are examined. Namely, the factors
contributing (HFACS-Level 2) to unsafe acts (HFACS-
Level 1) are analyzed. The second level of the HFACS
framework includes the following categories:
substandard conditions of operators, environmental
factors and substandard practices of operators. The
category of substandard condition of operators comprises
adverse mental state (e.g., stress, complacency and
overconfidence), adverse physiological state (e.g.,
hypoxia, visual illusions and medical illness) and
physical/mental limitations (e.g., hearing limitation, not
current/qualified and incompatible physical capability).
The category “environmental factors” includes two sub-
categories: physical environment (e.g., weather, noise
and heat) and technological environment (e.g.,
automation reliability, manuals/checklist design and
interfaces). Another group of the second level of the
HFACS framework is substandard practices of operators.
It includes two sub-categories: crew resource (e.g., lack
of leadership and poor communication) and personal
readiness (e.g., lack of knowledge and inadequate
training) [23].
The third step of the HFACS framework (HFACS-Level-
3), “unsafe supervision”, represents latent failures
producing the failure categories on the second and first
levels of the HFACS framework. Within the category of
unsafe supervision, there are four sub-categories:
inadequate supervision (e.g., lack of professional
guidance), failed to correct a known problem (e.g., failure
to correct a safety hazard which occurs repeatedly),
planned inappropriate operations (e.g., excessive
workload for crews and failed to provide adequate time
and place for crew rest) and supervisory violations (e.g.,
planned an unqualified crew for an operation and failed
to obey the rules and regulations) [23].
The top and fourth level of the HFACS framework
(HFACS-Level-4), organizational effects, describes
failures experienced by personnel who are actively
working on the management levels of an organization that
contribute to failures on the lower levels of the HFACS
framework. The organizational effects category
Organizational
Effects
Resource
Management Organizational
Climate Organizational
Process
Unsafe
Supervision
Inadequate
Supervision
Planned
Inappropriate
Operation
Failed to
correct a
known problem
Supervisory
Violation
Precondition for
unsafe acts
Enviromental
Factors
Physical
Environment
Technological
Environment
Substandard
Conditions of
Operators
Adverse Mental
State
Adverse
Physiological
State
Physical/Mental
Limitations
Substandard
Practices of
Operators
Crew Resource
Management
Personal
Readiness
Unsafe Acts
Errors
Decision
Errors Skill-based
Errors Perceptual
Errors
Violations
Routine
Violations Exceptional
Violations

The Analysis of Hot-air Balloon Accident by Human Factor Analysis and Classification System
KILIÇ
20
comprises three subcategories: resource management
(e.g., cost-cutting and failed to supply enough equipment
and facilities), organizational climate (e.g., policies and
culture and hierarchical structure) and organizational
process (e.g., risk management and oversight) [23].
A considerable number of studies has been published on
HFACS analysis [7-11],[13]. These studies described the
frequency of failures within categories and sub-categories
[23], [24]. Furthermore, a recent study on this topic
demonstrated that the HFACS framework could be used
to analyze and classify the contributing factors of aviation
accidents during an undergraduate course in order to
increase the performance of student pilots [25].
3. MATERIALS and METHODS
Hot-air balloon accident data from the year 2008 to the
year 2018 were obtained from the NTSB accident and
incident database [26]. 103 accident reports were
analyzed in total. The following criteria were used to
select the accidents:
 Type of occurrence: Accident
 Operation: All General Aviation
 Aircraft Category: Balloon
 Purpose of Flight: All
 Report Status: Probable Cause
 Injury Severity: Fatal & Non-fatal
Coding was performed by using two codes: 0 for the
absence and 1 for the presence of the sub-categories.
During the coding process, only the contributing factors
that were identified and reported by NTSB were
evaluated. In other words, there have been no new
contributing factors identified. An excel spreadsheet is
implemented for data analysis after the coding process
was completed.
4. RESULTS and DISCUSSION
The discussion of the results begins with the statistical
analysis of the causal factors. In this study, 260 causal
factors were coded as underlying 103 hot-air balloon
accidents. The results of the category assignments are
demonstrated with plots and tables. Table 2 illustrates the
detailed statistical results of the HFACS analysis.
Consistent with the findings by Kilic [23], our findings
revealed that the most common causal factor contributing
to hot-air balloon accidents is physical environment
(weather conditions, terrain and object collision). The
second common causal factor is skill-based errors. The
third common contributing factor is decision-making
errors made by pilots. Our study provides further
evidence for hot air-balloon accidents [27].
Table 2. The percentages of causal factors by HFACS.
HFACS
Category
HFACS
Level
Frequency
% of all
accidents
Decision
Errors
1
47
45.63
Skill-based
Errors
1
66
64.07
Perceptual
Errors
1
16
15.53
Routine
Violations
1
4
3.88
Exceptional
Violations
1
0
0
Physical
Environment
2
80
77.66
Technological
Environment
2
7
6.79
Adverse
Mental State
2
14
13.59
Adverse
Physiological
State
2
1
0.97
Physical
2
2
1.94
Mental
Limitations
Crew Resource
Management
2
5
4.85
Personal
Readiness
2
7
6.79
Inadequate
Supervision
3
4
3.88
Planned
Inappropriate
Operation
3
0
0
Failed to
correct a
known
Problem
3
0
0
Supervisory
Violations
3
1
0.97
Resource
Management
4
0
0
Organizational
Climate
4
0
0
Organizational
Process
4
6
5.82

The Analysis of Hot-air Balloon Accident by Human Factor Analysis and Classification System
KILIÇ
21
Upon closer examination of the results, it was found that
flying into adverse weather and collusion account for the
played role in the majority of accidents (N=80). Based on
the findings of this study, it is evident that training of the
pilots of hot-air balloons is of great importance. 16
percent of the accidents were associated with perceptual
errors such as improper instrument monitoring, target
fixation on the landing site which is not suitable for
landing, and poor monitoring of the environment.
It is found that adverse mental state accounted for 14
percent of the accidents, whereas Ballard [28] reported
that distraction (adverse mental state) resulted in only 2.3
percent of hot-air balloon crashes. Differently from the
literature, we found that equipment failure and system
malfunction (technological environment) contributed to 7
accidents [28]. In contrast to earlier findings [23], we
found that hot-air balloon accident reports involved
information about latent failures (Level 3 and Level 4 of
the HFACS framework).
As seen in Figure 2, the most prevalent HFACS category
is unsafe acts of the operator (Level-1), followed by
Level-2, preconditions for unsafe acts. The most
remarkable result that emerged from the data is that 5
accidents were associated with the Level-3 of the HFACS
framework (Unsafe Supervision), and 6 accidents were
associated with the Level-4 of the HFACS framework
(Organizational Effects). Among the organizational
effects, oversight of the pilot by the civil aviation
authority was the most prevalent. For instance, one of the
deadliest hot-air balloon accidents, which occurred in
Lockhart, Texas, USA, was associated with a latent
failure (organizational effects) [24]. The policy of the
FAA (Federal Aviation Association) does not require a
medical certificate for hot-air balloon pilots.
Figure 2. The distribution of the causal factors into 4
levels of the HFACS framework.
It is also worth noting that inadequate supervision such as
oversight of meteorological services was seen in four
accidents, and one supervisory violation was found to be
a causal factor that resulted in an accident. This was in
good agreement with previous findings [24]. The results
of this study also illustrated that 83 accidents resulted in
one or more injuries, and 5 percent of the accidents gave
rise to fatal outcomes, which were very much in-line with
previous findings [28]. We found much higher values for
balloon damage with respect to those reported by Ballard
[28]. 43.7 percent of the accidents (N = 45) resulted in
substantial damage to the balloon. In 12 hot-air balloon
crashes, fires erupted, which caused 5 injuries and 2
fatalities.
As Figure 3 demonstrates, the most common phase of the
flight in which hot-air balloon accidents occurred was the
landing. This was well in-line with previous studies
[5],[28]. The majority of the crashes during landing were
hard landings. There were only 3 crashes which occurred
during the cruise phase of flight.
Figure 3. The flight phases in which accidents occurred.
These results have widened our knowledge of HFACS
analysis and the causal factors of hot-air balloon
accidents.
We need to develop preventive measures to mitigate the
risk of the aforementioned factors (active and latent
errors) contributing to hot-air balloon accidents.
5. CONCLUSIONS
This study set out to analyze the causal factors of hot-air
balloon accidents that occurred during the period between
2008 and 2018 in the USA. To the authors’ best
knowledge, no research has been carried out on the
analysis of factors contributing to hot-air balloon
accidents by using an HFACS framework. We have
133
116
56
51,15% 44,61%
1,94%
2,30%
0,00%
20,00%
40,00%
60,00%
80,00%
100,00%
0
20
40
60
80
100
120
140
Level-1 Level-2 Level-3 Level-4
Frequency %
8
84
3
9
6,79%
81,53%
2,91%
8,77%
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
80,00%
90,00%
100,00%
0
10
20
30
40
50
60
70
80
90
100
Takeoff Landing Cruise Ground
Frequency %

The Analysis of Hot-air Balloon Accident by Human Factor Analysis and Classification System
KILIÇ
22
shown that the majority of hot-air balloon accidents
occurred due to an unsafe act of the operators (i.e., pilots)
and a precondition for unsafe acts (i.e., physical
environment). The clearest finding to emerge from this
study was that almost 5 percent of accidents that we
examined in this study were associated with latent errors
(Level-3 and Level-4 of the HFACS framework).
Our findings may aid pilots or balloon companies that
strive to increase the safety of hot-air balloon tourism and
decrease the number of hot-air balloon accidents.
Furthermore, these findings add to a growing body of
literature on HFACS analysis in aviation and hot-air
balloon accidents.
It is plausible that a number of limitations might have
influenced the results that we obtained. The first is that
hot-air balloon accidents are underreported. Any injuries
after an accident have to be reported within 10 days, and
a fatality must be reported within 30 days according to the
FAA’s regulations. However, passenger injuries and
fatalities might not have been sufficiently reported since
tourists who have hot-air balloon rides return to their
homes. Therefore, organizations should encourage pilots
to report any occurrences (e.g., accident, incident, serious
errors, mishaps and near misses) to inform other parties
in the aviation industry.
The second limitation is the lack of information about
hot-air balloon pilots’ drug and alcohol abuse since there
are no regulations that require checking the medical status
of these pilots and their medical certificates. This
limitation may have given rise to the relatively low
frequency of physiological state and physical/mental
limitations among the contributing factors of hot-air
balloon accidents that were examined in this study.
To further our research, we are planning to investigate the
relationship between hot-air balloon operations and
organizations in terms of hot-air balloon rides. Further
research should be undertaken regarding the role of
organizations (e.g., flight training organizations, hot-air
balloon operators and civil aviation authorities in hot-air
balloon accidents).
In conclusion, each accident investigation is an
opportunity to identify causal factors that can be averted
in the future to improve the overall safety of aviation.
However, these opportunities may come at a terrible
price, as in the case of the Tenerife Disaster. Therefore,
we need to make every effort to benefit from accident
investigation and learn from failures.
6. ACKNOWLEDGEMENT
We would like to thank the National Transportation
Safety Board for providing accident reports upon which
the HFACS analysis was performed.
No financial disclosure was declared by the author.
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The Analysis of Hot-air Balloon Accident by Human Factor Analysis and Classification System
KILIÇ
24
8. VITAE
Bilal KILIÇ earned an M.S. in Organic Chemistry from
Bilkent University and got his Ph.D. in Material Science
and Nanotechnology at the same university. While at
Bilkent University, he was accepted into a flight training
program which took place at the Turkish Airlines Flight
Academy, and he was employed as a first officer at the
Boeing 737 Fleet. Currently, he is flying as a senior first
officer at the Boeing 777 Fleet. Dr. Kilic is a part-time
faculty member of the Aeronautical Science and Aviation
Faculty of Ozyegin University. His research interests
include aircraft accident and incident investigation,
human factors and ab-initio pilot training.