The investigation of the hot air balloon disaster: the pilot was inexperienced, the emergency rope was not used
11 months after the accident in which Yogev Cohen fell to his death in the Afula area, the Ministry of Transportation published the accident report at the request of Walla!
who brought up about 50 "squads" of human error.
According to the investigation, the pilot did not have the knowledge required for emergency landings, and he had already been involved in two safety incidents
Voila system!
news
09/22/2022
Thursday, September 22, 2022, 10:00 a.m
Share on Facebook
Share on WhatsApp
Share on Twitter
Share by email
Share in general
Comments
Comments
On video: Above the highway at a low altitude: new documentation from the hot air balloon disaster (Photo: Idan Rahamim)
About 50 "squadrons" of human error led to the fatal accident in which Yogev Cohen was killed about 11 months ago by falling from a hot air balloon between Afula and Moshav Balfuria.
Only now, after contacting Walla!
The investigation report of the accident is published to the Ministry of Transportation.
The report was compiled by the Office for the Investigation of Aviation Accidents and Incidents at the Ministry of Transportation.
Since that accident, 15 reports have already been published that dealt with air incidents that happened later and only in the last few days was the report of the fatal accident published.
According to the procedure, a final safety investigation report by the chief investigator in the Ministry of Transportation should now be released, and based on that, the Civil Aviation Authority will decide on its steps.
The accident happened on October 19 last year.
In the early hours of the morning, a hot air balloon of the company "Touch the Sky" took off, and together with the pilot of the balloon, there were 13 passengers in the basket.
The researcher points out that despite the change in the direction of the wind from west to east, the required actions were not taken and the pilot was determined on the direction and nature of the takeoff as he had originally planned.
In view of the various obstacles around the takeoff area, the pilot decided to take off quickly and steeply for fear that the basket with the passengers in it would hit the company's service vehicle that was standing too close, contrary to the instructions and warning of a ground crew member.
Two ground crew members tried to deflect the basket.
Cohen, who was collecting equipment from the field, noticed what was happening and joined in on his own initiative to move the basket moving in the direction of the vehicle.
However, while his two friends released their grip on the basket, Cohen did not release his grip.
His two friends on the ground shouted at him to jump and told him that they would catch him, but according to one of them he replied that he was holding on tight.
The researcher believes that Cohen was left hanging because he was not prepared for the scenario of a steep and sudden climb of the hot air balloon and because he did not know the procedure for releasing a grip when the feet are off the ground.
Explanation that he was afraid of falling on the company's service vehicle over which the balloon and the basket passed.
Cohen was hanged from the hot air balloon during the disaster, October (photo: Walla! system, without)
Yogev Cohen (photo: courtesy of the family)
The researcher writes that it is unlikely that Cohen was hung over the basket as part of a game.
This is because he only did so after seeing his two friends on the ground deflect the basket to avoid possible damage to the vehicle.
However, the researcher points out that he learned about events in various balloon companies, in which ground crew members were hung from the basket - as fun.
Such a case even happened on the day of the accident, in another company.
This event ended peacefully.
An amount of 20 nanograms per milliliter of the psychoactive component of cannabis was found in the dead man's blood.
The researcher wrote that there is no definition in the Aviation Law concerning a ground crew employee, therefore there is also no reference to the "Law on Prohibition of Preserving Alcohol and Dangerous Drugs".
Beyond that, he believes that it is not possible to determine the connection between the effect of the drug and the accident.
He also stated that according to the testimony of the staff members, the victim's behavior that morning was routine and familiar - and did not include any unusual characterization that might hint at one or another influence or a lack of functioning.
The researcher added that his behavior was based on "reasonable judgment".
The passengers reported to the pilot what was happening and he in response told Cohen to hold on tight and he intended to lower immediately for landing.
However, the ball continued to climb, and when the passengers asked for it to land immediately, he replied that Cohen was holding tight and that he must first cross the road and then he would land.
However, instead of landing immediately, the pilot took off and at a height of tens of meters, when they were above Highway 60, Cohen lost consciousness and fell onto the road.
The passengers asked the pilot for a rope, hoping that he would be able to assist them in rescuing Cohen, but the pilot replied that he had no rope, even though the balloon had a rope 50 meters long, as required.
However, this rope is intended for towing the balloon by the ground crew when there is a weak wind and the surface of the ground does not allow landing.
"Under the conditions of the incident and the circumstances of the incident, it was requested that the pilot use the rope and the ground crew in order to stop the balloon's progress, lower it immediately and end the incident without getting close to obstacles," the investigation report states.
An examination conducted by the researcher revealed that the experience from accidents that have occurred in the world in the balloon industry indicates that a person hanging from the handles of a balloon basket that is at a significant height does not survive more than a few minutes, at the end of which he falls to his death.
This is also what happened in that accident.
To prevent this, the pilot should have lowered immediately, but he did not.
The researcher states that "the pilot was not experienced enough, did not fully practice operating the balloon in emergency situations in training, and in particular in an emergency situation of this type of immediate landing, in particular, and therefore did not have the knowledge, experience and confidence to make an emergency landing in the situation that arose."
According to the investigation report, an emergency landing is a rare scenario, but it must be taken into account, for example a fear of colliding with a power line or when a passenger feels unwell (fainting, fear of heights, etc.).
The researcher also notes that the pilot had two safety incidents - one year before the accident and seven months before the accident.
He stated that during the investigation, he received evidence of additional failures in which the pilot was involved.
Following the second incident, his license was suspended by the Civil Aviation Authority (RA) and after passing training and test flights, his license was returned to him four months before the accident. The
report shows that in Israel, similar to the United States and unlike Europe, the regulations for flying hot air balloons in Israel are less detailed and among other things , there is no difference in these regulations between flying large balloons that carry 20 passengers and small balloons that carry eight passengers. The hot air balloon in which the accident occurred was the type of large balloon that can carry 20 passengers. According to the investigation report, it is a type of hot air balloon whose flying is "a more complex issue and requires thinking and regulation in standards In the direction of commercial aviation." Despite the disaster, this series has not yet been performed since.
Comments
The company "Lagaat Spemis" stated in response: "There is no doubt that this is a tragic incident. The company owes all its employees to Egypt, and they grieve the incident to this day. However, the company and/or anyone on its behalf bears no responsibility for it. Unfortunately, the Office of the Chief Investigator has appointed an investigation An expert observer who is not an employee of the Ministry of Transportation, who is the owner of a competing hot air balloon company, and is in a clear conflict of interest with our company. It was a dangerous game played by the deceased, and a test after the event found a large amount of drugs in his blood, which ended in a tragic outcome. The company and the pilot had no All knowledge, control, and hand in the matter of this game. The company pilot who was on the morning of the incident, acted with composure and professionalism backed by all the professional bodies at the Aviation Authority, (a separate report by RTA will be published following the investigator's report) and by this considered and professional conduct prevented a serious disaster More for all the passengers who were at the event.
The company completely denies the conclusions of the investigation report and would like to emphasize that the report
H includes many mistakes both on the factual level and in relation to his conclusions.
The company continues to work through all the relevant channels, in order to bring the truth to light.
The company is the oldest and most professional hot air balloon airline in Israel, with a clean and flawless safety record.
The company operates and will continue to operate in accordance with all relevant legal provisions and accepted practice, and strictly observes all safety regulations."
The Ministry of Transportation stated in response: "The draft of the investigation was forwarded to those involved in mid-May 2022, however, at the request of those involved, additional time to complete the references. Apparently, the final report will be published soon, with the completion of references of all those involved in the case.
Following the accident, the Civil Aviation Authority inspected the company's activities in aspects such as: the pilot's qualifications, flight management, the pilot's response in the event of an accident, etc.
It was not found that the company or the pilot acted in violation of the Pilot Law and its regulations, or that their activities should be stopped for the sake of safety.
It should be noted that the company itself has stopped the pilot activity until the matter is investigated.
After the chief investigator at the Ministry of Transportation and Road Safety publishes the final safety investigation report, the Civil Aviation Authority will consider whether to take additional or different actions."
news
News in Israel
Events in Israel
Tags
Hot Air Balloon