Carterton balloon crash pilot Lance Hopping should not have been flying the day he and 10 passengers died, a damning report by the Civil Aviation Authority reveals.
The health and safety report shows Mr Hopping's medical certificate had expired about six weeks before the fatal flight. He should not have been piloting a commercial aircraft.
At 7.22am on January 7 last year, the balloon burst into flames after hitting a power line, then crashed into a paddock just north of Carterton, killing Mr Hopping and his 10 passengers, including two who jumped or fell from the basket.
It has not been revealed how many other flights he piloted after his medical certificate lapsed. The six weeks covered Christmas and New Year, which are usually busy times for ballooning.
The report is the first full and final account of the crash to be published, and appears to lay a large part of the blame on Mr Hopping.
The CAA initially refused to release details of his safety record under the Official Information Act, but finally did so after The Dominion Post appealed to the Office of the Ombudsman. The authority also included its July 2012 report, which so far has been seen only by the families of the dead.
Commercial pilots are responsible for ensuring their medical certificates are up to date, with the onus on them not to fly if the certificate has lapsed.
The certificates are checked when pilots undergo flight exams, which can range from every six months to every two years, and can include screening for substance abuse at the discretion of the medical examiner.
In May, an interim report by the Transport Accident Investigation Commission showed toxicology tests on Mr Hopping's body four days after the crash proved positive for cannabis.
The CAA report says Mr Hopping had time to activate the safety valve at the top of the balloon, which allows for a quick but controlled descent, but did not do so. It finds that he failed to meet his obligations under the Health and Safety in Employment Act, and those failures contributed to the accident.
"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," CAA director Graeme Harris said this week.
"Insufficient communication between the balloon and the ground crew, particularly during the landing phase of the flight, was also cited as a contributing factor."
Mr Hopping's fiancee, Nina Kelynack, would not comment on the report or whether he had any underlying health problems.
Lower Hutt man Bob Hopkirk, whose son Stephen died in the crash, said the CAA report dealt only with the "mechanics" of the tragedy, and the report that would really count was the coroner's, which is due to be published in May.
TAIC spokesman Peter Northcote confirmed that Mr Hopping's final log book, which covered the period after his licence lapsed in November 2011, had been sighted and was protected evidence in the commission's continuing inquiry.
The CAA confirmed Mr Hopping, who had 15 years experience as a balloon operator, had also been involved in two prior safety breaches and had piloted a "hard landing" in 1999 in which a passenger broke her ankle, although the incident was found "not to be extraordinary".
It had no concerns about his fitness to fly at the time of the fatal flight.
A spokesman said the CAA would review "with an open mind any recommendation" from TAIC regarding its process for checking certificates.
The CAA report clears balloon maintenance firm Hawke's Bay Aviation, although there were non-compliance issues related to test procedures. Balloon owner Early Morning Balloons has also been cleared of fault.
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