A hot air balloon joy ride gone wrong, which resulted in a hard landing in the Hunter's wine region and left more than a dozen passengers injured, took place after three pilots embarked on the flight in foggy conditions, an investigation has found.
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In its final report into the 2018 incident at Pokolbin, the federal government's Australian Transport Safety Bureau recommended that the Civil Aviation Safety Authority review an exemption allowing balloon operators to take-off and land in conditions with low visibility.
The report, released on Tuesday, said three International Balloon Flight Company pilots went ahead with lift-off from Peppers Creek early on the morning of March 30 despite fog being forecast and developing in the area - but the exemption meant the pilots were allowed to do so.
They decided to abort their respective flights after they climbed 2000 feet into the sky and saw how far the fog layer extended.
With 12 knot winds in the landing zone, one of the balloons ran into trouble when it hit a tree during its descent, spinning the basket 180 degrees and resulting in a hard landing just before 7.30am.
The report said the thick layer of fog meant the pilot did not have enough time to react when obstacles became visible.
"The pilot called out to the passengers to brace for landing," the report said.
"At about 0728 [7.28am], the balloon landed heavily, beyond the trees with the basket upright.
"All of the occupants were facing forwards in the direction of travel as the balloon contacted the ground, instead of the normal rearwards-facing landing position."
It left 16 of the 24 passengers injured - three were seriously hurt - and 74 balloon panels were in need of repair.
The two other balloons landed safely.
The report was critical of the company, saying the pilot and ground crew "did not follow the operator's documented emergency procedures to not move injured passengers after the accident, increasing the risk of exacerbating their injuries".
But it noted the company had amended its operations manual since the incident to "include pilot actions in the event of extensive fog" after take-off and added fog as a local known hazard, including where it was likely to occur.
ATSB transport safety director Stuart Macleod said the investigation showed it was important for pilots to get a full appreciation of the weather for the duration of the planned flight from the Bureau of Meteorology.
"Fog is fickle and the ultimate responsibility for a pilot's decision on whether to launch or not rests with the pilot," he said.