The Transport Accident Investigation Commission has released its findings into two hot air balloon crash landings where people were injured - one near Methven in 2022 and one near Arrowtown in 2021.
In the January 2022 incident in Methven, Canterbury, it found the pilot, who was seriously injured in a crash landing, was not wearing suitable safety gear.
The commission found the pilot was was thrown from the basket when the balloon hit the ground because they were not wearing a restraint harness.
The pilot ended up behind the basket with the rip line caught around their neck, and this resulted in serious injury from the rope and the basket passing over the top of them
The seven passengers on board remained in braced landing positions until after the balloon had deflated and were not injured.
The commission said the pilot had briefed passengers before the flight, and again before landing, which almost certainly helped prevent injuries.
But it found the pilot would almost certainly not have been thrown out of the balloon had they been wearing a harness.
Under current Civil Aviation Rules balloon pilots are not required to wear harnesses during takeoff and landing.
The commission said not wearing a harness increased the potential safety risk to passengers.
It wanted the rules updated so harnesses were mandatory for pilots during critical stages of balloon flight.
The pilot in the other crash landing which occurred near Methven, Otago in July 2021 was also thrown from their basket and suffered serious injuries.
After two attempted and aborted landings, the pilot brought the balloon down to land in a paddock, not far from Arrowtown.
The commission found they were not wearing the available restraint harness fitted to the pilot's compartment.
"The pilot was standing up and manipulating the balloon's control ropes when the basket struck the lip of the gully. The pilot ... was therefore vulnerable to being thrown from the basket. The pilot was also not wearing the available restraint harness fitted to the pilot's compartment."
The commission described the landing as fast and hard.
Two passengers were unprepared for the landing and also suffered serious injuries when thrown from the basket.
The commission found that the pair were not adequately prepared for the crash landing and they should have been crouching in a recommended position and holding onto rope handles.
Eight other passengers remained in the basket, with seven sustaining minor injuries.
The commission said that the pilot's safety briefings had not prepared passengers for a "hard and fast landing", that the pilot was ejected from the basket because they were not wearing a restraint harness and the pilot did not check all the passengers were in the correct landing position before landing.