Causal factors of hot air ballooning incidents: identification, frequency, and potential impact.

BACKGROUND Hot air ballooning incidents are relatively rare; however, when they do occur they are likely to result in a fatality or serious injury. Human error is commonly attributed as the cause of hot air ballooning incidents; however, error in itself is not an explanation for safety failures. This research aims to identify and establish the relative importance of factors contributing toward hot air ballooning incidents. METHODS Twenty-two Australian Ballooning Federation (ABF) incident reports were thematically coded using a bottom-up approach to identify causal factors. Subsequently, 69 balloonists (mean 19.51 yr experience) participated in a survey to identify additional causal factors and rate (out of 7) the perceived frequency and potential impact to ballooning operations of each of the previously identified causal factors. Perceived associated risk was calculated by multiplying mean perceived frequency and impact ratings. RESULTS Incident report coding identified 54 causal factors within 9 higher level areas: Attributes, Crew Resource Management, Equipment, Errors, Instructors, Organizational, Physical Environment, Regulatory Body, and Violations. Overall, 'weather', 'inexperience,' and 'poor/inappropriate decisions' were rated as having greatest perceived associated risk. DISCUSSION Although errors were nominated as a prominent cause of hot air ballooning incidents, physical environment and personal attributes are also particularly important for safe hot air ballooning operations. In identifying a range of causal factors, the areas of weakness surrounding ballooning operations have been defined; it is hoped that targeted safety and training strategies can now be put into place to remove these contributing factors and reduce the chance of pilot error.