The Civil Aviation Authority has attributed blame for the Carterton balloon tragedy partly to failures by the pilot Lance Hopping.
One year after the balloon crash that claimed the lives of Mr Hopping and 10 passengers, the CAA has released its final report which says Mr Hopping's medical certificate to fly was not current at the time of the crash and his "failures contributed to the accident".
Under the Health and Safety in Employment Act, Mr Hopping was "expected to take 'all practicable steps' to ensure the safety of his passengers", the CAA's director of civil aviation Graeme Harris said.
"The balloon had on-board safety features, including a rapid deflation system and a parachute valve, but there was no evidence that the passengers were ever briefed on their use, and in the event, they were never deployed," Mr Harris said in a statement.
"Insufficient communication between the balloon and the ground crew, particularly during the landing phase of the flight, was also cited as contributing factor."
The CAA investigation also found:
- There were "some non-compliance issues" for the test procedures used by Hawkes Bay Aviation, the maintenance provider;
- No other duty holders, including operator and maintenance providers, were found in breach of the Act;
- The pilot's medical certificate had expired six weeks prior to the accident;
- The pilot had recorded an incident involving a hard landing in 1999 in which a passenger fell sideways and broke her ankle. "It was not considered to be extraordinary," the CAA said.
The report recommends simulations of emergency features during biennial reviews of safety.
It also recommends reviewing basket design, passenger safety briefings and effective communication between pilots and ground crew.
Mr Harris said since the accident there had been "major changes" to the safety of adventure and aviation tourism.
He said the CAA would not comment further on the Carterton tragedy while "more wide-ranging investigations are ongoing".