The pilot of the hot-air balloon that crashed killing himself and 10 passengers in rural Carterton just over three years ago had two chances to take action which could have saved all on board but did not take them, a just released coroner's report reveals.
Coroner JP Ryan said Lance Hopping had two opportunities to "rip out", a process which involves a balloon pilot pulling on a rip line that opens a vent at the top of the envelope causing a rush of hot air to escape and the balloon to descend rapidly.
In his findings the coroner said Hopping could have activated a rip out as the balloon approached the power lines as some time prior to contact it would have been obvious to him there was a real danger he could not out-climb the lines.
"At this point Mr Hopping should have applied the balloon pilots' adage 'when in doubt, rip out'," Mr Ryan said.
The second opportunity arose after contact with the power lines when the basket was trapped under a line.
Hopping had about 30 seconds between the initial contact and when arcing occurred.
During that half minute a witness had seen two people trying to push the line off the rim of the basket, one of them was probably the pilot.
Therefore it was likely Hopping had not been "incapacitated" by the initial contact.
Mr Ryan found that had Hopping activated a rip-out at either time, even if contact had been made with power lines, there would have been a "significant chance" everyone would have been saved.
The balloon basket would probably have dropped below the power lines and contact would have been made with the ropes or envelope and not with the basket.
Passengers would have a fall of around 10-12 metres but "logic" suggested residual air in the envelope that had not yet escaped would have given some resistance to an uncontrolled fall.
The coroner said Hopping's decisions on the fatal day, January 7, 2012, seemed inexplicable for an experienced and competent balloon pilot.
In answer to the issue as to how did the balloon become caught under the power lines, Mr Ryan found " the simple answer" was that Hopping failed in his duty to fly the balloon in such a way to prevent it coming into contact with power lines.
He had been flying across a silage paddock below the level of the lines probably intending to land in a paddock on the other side of Somerset Road.
Hopping had been well aware of the existence and location of the power lines.
The low flying was likely to either be in preparation for landing or because Hopping wanted to give his passengers "a thrill or experience of low flying".
Evidence had been given at the inquest that Hopping often flew the balloon at low altitudes, particularly over a river south of Carterton, and would sometimes dip the basket into the river.
Mr Ryan found the balloon had not even come close to clearing the power lines and that it was possible Hopping's decision-making ability was impaired due to the carry-over effects of cannabis which had been found in his blood during a post-mortem.
During the inquest into the deaths of the five men and six women on the balloon flight evidence was given that Hopping was a chronic cannabis user who had smoked cannabis on a "weekly basis" for 10 to 15 years.
But toxicologists agreed from the level of tetrahydrocannabinol (THC) found in Hopping's blood it was not proved he had smoked cannabis in the hours immediately before the fatal flight.
It was also unlikely Hopping had smoked cannabis on a balcony overlooking the launch site despite evidence given by a woman to the inquest which stated she saw Hopping smoking on the balcony prior to the flight.
The coroner found the deaths were "clearly preventable" and that on the simplest level if Hopping had complied with the rules he would not have flown that day as his medical certificate had expired. "He also should not have flown that day because he had ingested an illicit substance, cannabis."
Mr Ryan said on a more complex level if Hopping had shown the judgment and skill expected of an experienced and competent pilot free of impairment from illicit substances, he would not have exposed the balloon to the risk of coming into into contact with power lines.
The coroner listed a series of recommendations to authorities and aviators as a result of the inquest including that consideration be given to amending the Civil Aviation Act 1990 to provide tougher sanctions if an adventure aviation pilot tests positive for drug or alcohol use. This could include a suspension of licences.
The Civil Aviation Authority should give consideration to requiring balloon baskets to be fitted with some means which would prevent power lines from becoming trapped over the rim should contact be made with power lines.