Accident at Lockhart, Texas, 30 Jul 2016 (N2469L)
On July 30, 2016, an aircraft (registration N2469L) was involved in an aviation accident near Lockhart, Texas. Investigators recorded the probable cause as: The Board concluded that the pilot exhibited poor decision-making when he did not land the balloon despite having had suitable opportunities to land safely in visual conditions, and when he decided to climb above the clouds. This summary draws on records from the U.S. National Transportation Safety Board (NTSB) Aircraft Accident Reports.
Probable cause
The Board concluded that the pilot exhibited poor decision-making when he did not land the balloon despite having had suitable opportunities to land safely in visual conditions, and when he decided to climb above the clouds. The Board further concluded that his decision to land in reduced visibility conditions diminished his ability to see and avoid obstacles, resulting in the balloon impacting power lines. The National Transportation Safety Board determined that the probable cause of this accident was "the pilot’s pattern of poor decision-making that led to the initial launch, continued flight in fog and above clouds, and descent near or through clouds that decreased the pilot’s ability to see and avoid obstacles. Contributing to the accident were (1) the pilot’s impairing medical conditions and medications and (2) the Federal Aviation Administration’s policy to not require a medical certificate for commercial balloon pilots."
— NTSB Determination
Accident narrative
On July 30, 2016, about 0742 central daylight time, a Balóny Kubíček BB85Z hot air balloon, registration N2469L, struck power lines and crashed in a field near Lockhart, Texas. The balloon was operated by Heart of Texas Hot Air Balloon Rides as a sightseeing passenger flight under 14 Code of Federal Regulations Part 91. The pilot and 15 passengers died, and the balloon was destroyed by impact forces and a postcrash fire.
### Preflight and Weather
The pilot, a ground crew of three, and 15 passengers met in a commercial parking lot in San Marcos, Texas, about 0545. The pilot released a pibal—a small helium balloon used to determine wind direction—and selected Fentress Airpark as the launch site.
At 0506, the pilot called a flight service station for a weather briefing. The briefing included an automated observation from San Marcos Regional Airport at 0455, which recorded 10 statute miles visibility, scattered clouds at 1,100 feet above ground level, a temperature of 23°C, and a dew point of 22°C. The 1°C temperature/dew point spread indicated the possibility of fog formation. The flight service station briefer told the pilot, "clouds may be a problem for you, I don't know how low you want to stay." The pilot replied, "well we just fly in between them" and "we find a hole and we go."
The pilot did not check the weather again before launch. Updated observations at 0635 and 0646 showed deteriorating conditions, including a temperature/dew point spread of 0°C, two statute miles visibility, mist, and a broken ceiling at 700 feet.
The ground crew and other witnesses reported seeing patchy fog along the route to and near the launch site. A ground crewmember stated that the pilot determined visibility was acceptable by observing nearby white utility poles. After releasing another pibal, the pilot made the final decision to launch.
### The Flight
The balloon launched about 0658 on a northerly course. The ground crew watched the flight from the launch site for about 10 minutes before following in vehicles. Photographs taken by passengers showed fog and low clouds along the flight route within two minutes of launch. The ground crew chief stated he saw the balloon enter fog, which became thicker until he could only see the basket beneath low clouds just above the treetops. The ground crew watched the balloon fly in and out of the clouds until losing sight of it when it climbed into the clouds.
Passenger photographs showed the ground remained visible through thin clouds 24, 26, and 27 minutes after launch. About 0726, 28 minutes after launch, the pilot sent a position signal to the ground crew chief's cell phone using a navigation application. The crew chief stated they tried to send messages back but were unsuccessful.
A passenger photograph taken about 0738, 40 minutes after launch, showed the balloon flying above an overcast cloud layer that appeared to extend to the horizon. Another photograph taken about 0740 showed the balloon's shadow near a hole in the clouds that revealed a power line tower.
### Impact and Wreckage
Data from the pilot's navigation application indicated the balloon's flightpath intersected power lines about 0742, and the power line operator reported a power trip on the line at that same time. The crash site was located about 8 miles north of the launch site in an open field crossed by power lines carrying 340,000 volts.
The balloon's basket was located beneath the power lines. The envelope and burner assembly were found about 0.5 miles downwind. The National Transportation Safety Board found electrical arcing damage on the envelope support cables, the red burner assembly, the basket support cables, and the basket frame. The basket was almost entirely consumed by fire, and the fuel hoses had separated at the burners.
The Board concluded that the balloon's support cables struck the power lines, causing separation of the basket from the envelope and burner assembly, the release of fuel, and the subsequent fire and ground impact. Postaccident examination found no evidence of preimpact structural or system failures. The balloon's logbook indicated an annual inspection date of May 23, 2015, and the NTSB was unable to locate any records documenting an annual inspection current at the time of the accident.
### Pilot Information and Medical Findings
The pilot held a commercial pilot certificate with a lighter-than-air balloon rating. No records could be found to indicate that he had a current flight review.
The pilot had been diagnosed with major depressive disorder, attention deficit hyperactivity disorder (ADHD), fibromyalgia, and diabetes. Postaccident toxicology detected multiple prescription medications in the pilot's blood, including bupropion, cyclobenzaprine, diazepam, methylphenidate, oxycodone, and fluoxetine, as well as the over-the-counter antihistamine diphenhydramine. Several of these medications are listed on the Federal Aviation Administration's "Do Not Issue" and "Do Not Fly" lists.
The Board concluded that the pilot was not under the influence of alcohol or illicit drugs, and that his high blood pressure, high cholesterol, diabetes, chronic back pain, and fibromyalgia did not affect his performance. However, the Board concluded that depression, ADHD, and the combined effects of multiple central nervous system-impairing drugs likely affected the pilot's ability to make safe decisions.
Records indicated the pilot had multiple arrests and convictions for driving while intoxicated and drug possession, and did not hold a valid driver's license at the time of the accident. When he applied for a third-class medical certificate in 1996, he answered "no" to a question regarding his history of nontraffic convictions.
### FAA Oversight
Title 14 CFR 61.23(b) exempts balloon pilots from all medical certificate requirements. The Board concluded that this exemption eliminated the potential opportunity for an aviation medical examiner to identify the pilot's potentially impairing medical conditions and medications, or for the FAA to become aware of his history of drug- and alcohol-related offenses.
The FAA conducted surveillance of commercial balloon operations randomly. Between January 1, 2014, and December 16, 2016, the FAA conducted 2,300 balloon inspections, with more than 98 percent occurring at locations where multiple balloons were inspected on the same date, such as balloon gatherings. The pilot was not known to have operated at any balloon gatherings, and a review of FAA data found no records identifying the pilot or operator as a subject of inspection. The Board concluded that the FAA's primary method of oversight—sampling balloon operators at festivals—does not effectively target the operations that pose the most significant safety risks to members of the public.
### Probable Cause
The Board concluded that the pilot exhibited poor decision-making when he did not land the balloon despite having had suitable opportunities to land safely in visual conditions, and when he decided to climb above the clouds. The Board further concluded that his decision to land in reduced visibility conditions diminished his ability to see and avoid obstacles, resulting in the balloon impacting power lines.
The National Transportation Safety Board determined that the probable cause of this accident was "the pilot’s pattern of poor decision-making that led to the initial launch, continued flight in fog and above clouds, and descent near or through clouds that decreased the pilot’s ability to see and avoid obstacles. Contributing to the accident were (1) the pilot’s impairing medical conditions and medications and (2) the Federal Aviation Administration’s policy to not require a medical certificate for commercial balloon pilots."