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Accident Report Detail

 
Impact with Power Lines Heart of Texas Hot Air Balloon Rides Balóny Kubíček BB85Z, N2469L

Executive Summary

​On July 30, 2016, about 0742 central daylight time, a Balóny Kubíček BB85Z hot air balloon, N2469L, operated by Heart of Texas Hot Air Balloon Rides, struck power lines and crashed in a field near Lockhart, Texas. The pilot and 15 passengers died, and the balloon was destroyed by impact forces and postcrash fire. The balloon was owned and operated by the pilot, and the flight was conducted under the provisions of 14 Code of Federal Regulations Part 91 as a sightseeing passenger flight. The flight originated about 0658, just after sunrise, from Fentress Airpark, Fentress, Texas.

About 1 hour 50 minutes before launch, weather observations and forecasts that the pilot accessed indicated visual flight rules weather for airports near the planned route of flight but included observations of clouds as low as 1,100 ft above ground level and a temperature/dew point spread of 1°C (which indicated the possibility of fog formation although fog was not forecast). The pilot did not check weather again before launch; updated observations and forecasts available at that time indicated deteriorating conditions. A ground crewmember stated that fog was seen near the launch site.

The balloon launched about 0658, and the ground crew stated that they watched the balloon fly in and out of the clouds as they followed it until losing sight of it for the last time as it went above the clouds. A passenger photograph taken about 4 minutes before the accident showed the balloon flying above a dense cloud layer that appeared to extend to the horizon. The balloon impacted power lines while descending, about 44 minutes after launch.

To be able to see and avoid obstacles during landing, balloon pilots must ensure weather conditions are compatible with the limitations of balloon maneuverability. The accident pilot had the opportunity to make decisions regarding the flight based on the weather conditions at three points on the morning of the accident: before launch, en route, and near the end of the flight. At each of these points, there were indicators that the weather may not be conducive to safe flight. Updated forecast information before launch showed that conditions were deteriorating; the pilot could have decided to cancel the flight. En route photographs showed that fog and low clouds were visible along the flight route; the pilot could have decided to select a suitable landing location while still in visual contact with the ground. Lastly, once above clouds that obstructed the view of the ground, the pilot decided to land in reduced visibility conditions that diminished his ability to see and avoid obstacles.

The National Transportation Safety Board (NTSB) identified the following safety issues as a result of this accident investigation:

  • Lack of medical oversight for commercial balloon pilots. Commercial balloon pilots are not required to hold a medical certificate of any kind. The accident pilot had been diagnosed with medical conditions, including depression and attention deficit hyperactivity disorder, known to cause cognitive deficits that may affect decision-making and, ultimately, safety of flight. These conditions would likely have led an aviation medical examiner (AME) to either defer or deny a medical certificate. In addition, medications were found in the pilot’s system that are known to cause impairment and are listed on the Federal Aviation Administration’s (FAA) “Do Not Issue” and “Do Not Fly” lists. An AME would likely have deferred or denied a medical certificate to a pilot reporting use of these medications. The FAA stated the primary mitigator of risk in balloon operations is the commercial pilot certificate, yet there is no requirement for balloon pilots to hold a medical certificate to indicate that they are medically fit to fly
  • Lack of targeted FAA oversight of potentially risky commercial balloon operations. The FAA conducted 98% of its oversight of balloon operators at balloon gatherings between January 1, 2014, and December 15, 2016. Thus, those operators who do not attend the gatherings, such as the accident pilot, are likely not to receive any FAA oversight. Such focus on balloon gatherings does not support the FAA’s risk-based, data-informed approach to oversight. It also does not provide the FAA with opportunities to educate all commercial balloon operators and mitigate risk before an accident occurs.

The NTSB determines 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 FAA’s policy to not require a medical certificate for commercial balloon pilots.

As a result of this investigation, the NTSB makes two safety recommendations to the FAA.


Probable Cause

​The National Transportation Safety Board determines 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.


Accident Location: Lockhart , TX USA  
Accident Date: 7/30/2016
Accident ID: DCA16MA204

Date Adopted: 10/17/2017
NTSB Number: AAR1703
NTIS Number: PB2018-100161