Lockhart Balloon Crash: Worse Than We Imagined

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High-profile aviation accidents usually get a public hearing in which the NTSB reveals what it knows and allows input from other parties on the road to establishing probable cause. Such hearings offer tantalizing factuals but they rarely reveal jaw-dropping lack of judgment. But rarely is not the same as never and this week’s hearing on the crash of a high-occupant hot air balloon in Texas last July that killed 16 people qualifies for jaw-dropping revelations. It also places both the FAA and NTSB in a can’t-win regulatory canyon.

I wrote about the Lockhart, Texas crash shortly after it occurred on July 30. A balloon carrying 15 passengers and a pilot struck power lines—possibly while attempting to land—and all of the balloon’s occupants died in the subsequent impact and fire. It was one of the most gruesome general aviation accidents ever and the highest death toll of any single GA accident I can think of for many years.

The hearing, held on Friday in Washington, revealed, for me, at least, that the accident was far more appalling than the original news reports suggested. The pilot, who had a history of medical and psychiatric conditions, plus DUIs and drug convictions, was found to have ingested seven drugs at the time of the accident, including three that the FAA considers disqualifying for flight status. None of that necessarily means he was incapacitated at the time of the crash, but it serves as a marker about his attitude toward regulatory guidance. He did not, for example, report his DUIs, nor did he report drug convictions he also had. Both of these are required under FAR 61.15, even though balloon pilots are not required to have medicals. Failing to report these things is grounds for suspension and willfully lying on medical applications is a felony.

While the drug use and obfuscation of DUI and drug history are bad enough, what’s worse is the pilot’s documented decision to fly despite adverse weather. An FSS briefer told the pilot that poor visibility and low cloud existed at his proposed time of flight, but he replied, “We find a hole and we go.” A photo recovered from one of the passenger cellphones shows the balloon floating above a layer of dense ground fog or low cloud.

Was the pilot’s judgment impaired by the cocktail of drugs he had consumed, including oxycodone, or was he just a pilot willing to operate on the edge, even with passengers aboard? From a regulatory standpoint, I’m not sure it matters because regardless of what the NTSB recommends, the FAA will have a hell of time making meaningful regulation for balloons that isn't just for appearances.

At the hearing, NTSB member Robert Sumwalt said, "Unfortunately, sometimes it takes blood to get change. And we want to make sure there are changes made before there's more bloodshed." No one can argue the sentiment. The government, in representing the public, has a compelling interest to prevent a recurrence. But entirely ignoring the onerous burden of regulation that saddles general aviation, what kind of additional regulatory filter do we imagine would have prevented this tragic accident? Willful bad judgment has always been with us and always will be because in the end, the pilot still has to make go/no-go decisions. Being under the influence of drugs or alcohol may simply be a distractor irrelevant to the outcome. Or a leading indicator of an underlying personality ill suited for flying.

Federal Air Surgeon James Fraser said this at the hearing: “I feel a medical evaluation is a part of the holistic plan to keep the national airspace safe." Yet there's little convincing data to support this view or at least to show that any safety benefits are commensurate with the cost and effort of medical examinations. Perhaps pilot certificates could be issued with the proviso that the FAA can review the driver registry and/or criminal records. You authorize that when you sign the medical form. But no medical, no waiver.

The airlines and on-demand charter industries enhance safety through detailed operating specifications that have the effect of making pilots’ decisions for them, forcing a duty of care that might not otherwise be required. A single accident does not a trend make. I think it's inarguable that regulation is a critical part of the remarkable safety record U.S. commercial aviation has achieved. But it's also true that pilot judgment is the first and last defense against accidents.   

I flew Part 135 on-demand charter for a while and flew one trip as copilot for another pilot moonlighting from an airline job. One blustery winter morning, a bunch of gamblers wanted a ride back from Atlantic City. It was clear, but the unplowed runway was covered in light snow being blown around by a gusty crosswind. Our ops specs didn’t preclude the trip; we could have launched. If we had pranged it, we’d have hung on the 91.13 hook. But we cancelled and the unhappy gamblers took the bus. But no one was advising or watching us make the decision. No dispatcher checked a box; no chief pilot office stood by to buck up the decision.

As I said in the previous blog, the NTSB wants more oversight for the balloon industry. But the accident rate is so low and there are so few fatalities that it’s impossible to imagine even the most stringent regulation moving the needle at all. With all due respect, I understand regulators must consider the political optics of such high-visibility accidents, but those of us in the industry aren’t compelled to believe that what they devise will have the vaguest effect, other than to add cost and overhead for operators. In general aviation, we've been struggling for years to rid ourselves of the Third Class medical requirement, yet the FAA clings to it with the tenacity of the universe's strongest known force: bureaucratic inertia. 

I’ll admit I’m doing a bug-on-its-back here. I don’t have a response to this accident because bad judgment and irresponsibility are eternal if, fortunately, not that prolific. Perhaps require medicals for balloons carrying more than, say, four occupants or some other number that isn't 15. If there's any lemonade from lemons here, it may be this: If you’re tossing back a bunch of drugs, whether disqualifying or not, it may be worth taking a pause to consider if doing so is masking an even larger misjudgment. Or is itself a misjudgment. This is the insidious nature of subtle incapacitation due to sedating or psychotropic drugs. Personally, I feel blessed. Because I’m special, I can take as much of this stuff as I want and fly without worry. But you’re ordinary; you need to be careful.

Comments (20)

I think I have a magic solution: a new Regulation that says simply "Thou shalt not crash."

Well, at least autonomous aircraft won't violate Regs or Operating Limitations. Where's the fun in that? But is trading fun for safety a worthy goal?

Posted by: Tom Yarsley | December 11, 2016 10:40 AM    Report this comment

Your last two sentences pretty much say it all. I'm special and can take all those medications, but the rest of you guys can't be trusted. That sums up a major reason why the FAA clings to the third class medical. Their final rules for changing it will probably involve some type of drug monitoring procedure. Whether it works or not remains to be seen.

Regulatory agencies are tasked with legislating to eliminate all contingencies, but that is possible only with stifling regulation. Any time you allow individual judgement you run the risk of human error to creep in. We've all done dumb things and hopefully learned from them. But, we all know a few pilots that never seem to learn and probably have no business in the air. If you can come up with a system that can weed out human frailty and still allow the freedom to fly, I'm all ears.

Posted by: John McNamee | December 11, 2016 2:50 PM    Report this comment

A simple background check such as one required by many employers these days would probably be fairly effective in identifying pilots with the most egregiously poor judgment. In this case drug convictions and DUI's should have shown up and the FAA could intervene as necessary. Not sure why it is not already done on a regular basis (e.g. every couple years).

Posted by: Thor Thordarson | December 11, 2016 3:43 PM    Report this comment

Thor: Just as screening for gonorrhea doesn't rule out chlamydia, screening for automotive DUIs and drug convictions doesn't comprise a test that identifies most practitioners of poor judgement.

Posted by: Tom Yarsley | December 12, 2016 6:02 AM    Report this comment

"You can't fix stupid," you can't legislate bad judgement, you can't regulate irresponsibilty. Stupid does tend to gravitate to those areas where there is little or no oversight.

Posted by: Richard Montague | December 12, 2016 7:23 AM    Report this comment

Amen to that, Robert.

Posted by: John Wilson | December 12, 2016 7:53 AM    Report this comment

I don't see why the majority should have to forfeit their right to presumption of innocence because a small few decide to ignore the rules.

Background checks presume guilt. And to volunteer for one is to surrender your 5th amendment right against self-incrimination. Now you can say, "If you've done nothing wrong, you have nothing to worry about." But that is not the issue. The issue is government continual, step-by-tiny-step encroachment upon our individual liberty.

Posted by: Michael Dean | December 12, 2016 9:24 AM    Report this comment

Flying 15 passengers for hire?...why doesn't that require a 2nd class medical, which should have uncovered the health/drug issues and the DUI's? I'm not clear why the solution is complicated. It seems a small sacrifice if one is to make a living with so much responsibility.

I'm seriously asking the question...this is not a rhetorical rant.

Posted by: Jonathan Micocci | December 12, 2016 9:57 AM    Report this comment

I have 2 balloons--AX-7 Aerostars. On a cold day in Minnesota, I can take 4 passengers (if they aren't big Norwegian farm boys) without toasting the fabric. Paul says " Perhaps require medicals for balloons carrying more than, say, four occupants or some other number that isn't 15."

I'm certainly no fan of more and more regulation, but I do believe that there should be a clear division between operators of "large" commercial balloons, and those that offer the occasional ride to curious onlookers. It is analogous to the difference between giving air rides in a Cherokee and a commuter operator.

There is precedence here--Part 135 for airplanes makes a clear distinction on the size of the aircraft--type ratings for aircraft over 12,500 pounds--regular proficiency checks, ops manuals and ops specs--a requirement for a second crew member for certain operations or if the aircraft has more than 10 passenger seats--and of course, drug testing.

The question will inevitably asked is "If this is good for large balloons, why not make it applicable to ALL balloons? The answer is in two parts.

One of those parts is the pressure to make the flight. There is a lot more at stake when you are talking 15 revenue passengers vs. 4.

The second is the need for ground crew. Anyone who has ever crewed for even a balloon is aware of just how difficult it is to stop a balloon. You not only have a big sail up there, but you have the momentum to arrest. A 10 knot wind will be very difficult to stop for a small balloon, and almost impossible to stop without a large crew for a large balloon. Many balloon accidents involve a landing (which tends to throw passengers about the gondola) followed by the balloon being dragged toward a power line or other obstacle. Flying a large balloon single-handedly or with minimal crew is like trying to operate a large boat single-handedly--it CAN be done, but it is much safer with a trained crew.

Where to draw the line between "large" and "small" balloons? Pilot + 4 pax balloons are the most popular with private owners and small operators. They can be inflated and arrested with a crew of 3. Suggest that as a possible division--or perhaps pilot plus 6.

This would go beyond a requirement for a medical certificate--it would require the ops specs akin to a commercial aircraft operator, including the requisite number of crew members.

Posted by: jim hanson | December 12, 2016 10:06 AM    Report this comment

What regulation would have prevented the Lockhart accident? Requiring an FAA representative to be standing by at each potential flight location on days forecasting IMC, and giving each pilot a sobriety test before launching/taking off? Might as well also check each fixed-wing pilot to verify his IFR rating while they are at it.

Apparently Robert Sumwalt, NTSB agent, wants regulation changes. But typically for NTSB he would leave the changes up to the FAA. Where do the regulations stop? Keep adding regulations until there are NO accidents?

Posted by: Unknown | December 12, 2016 3:41 PM    Report this comment

Approximately 1 in 10 people in the general public use drugs illegally. The statistics for pilots are similar. In this accident a known user of drugs also known to operate a vehicle under the influence was allowed to take 15 people on a commercial balloon flight. A background check and/or a randomly administered drug test would most likely have prevented this accident. This pilot apparently showed signs of addiction or egregiously poor judgement. I would not want my loved ones to fly with a pilot with this kind of history and I certainly would expect a responsible employer to take some modest steps to ensure their safety. If employers or independent actors won't do that then the government must step in. That is precisely what will happen if pilots and the general aviation community continue to be tone deaf to public concerns regarding GA safety. There is no moral high ground in arguing for allowing pilots with these kinds of problems to fly.

Posted by: Thor Thordarson | December 12, 2016 10:38 PM    Report this comment

Thor wrote: "There is no moral high ground in arguing for allowing pilots with these kinds of problems to fly."

Perhaps I missed it, but I haven't seen anyone here making that argument. Argued issues have included "what kind of filter will identify the most common possessors of 'poor judgement'?", and "what kind of regulation would keep them out of the sky?"

Over the years, I've flown with hundreds of pilots who exhibited gold-plated, world-class poor judgement. Only two of them ever had a DUI conviction. Two.

You can screen for alcohol/drug abuse all you want to - and I won't try to stop you. But any expectation that this will ground most possessors of poor judgement is without basis. Substance abusers comprise a very tiny segment of the problem-judgement population. Most acts of aviation insanity are committed by pilots who are stone-cold sober.

Again, that's not an argument that excluding drug abusers is a bad idea. It's just a warning that doing so will not comprise a safety panacea.

Posted by: Tom Yarsley | December 13, 2016 9:27 AM    Report this comment

Well put Thor. I agree that pilots involved in commercial flight need to be subject to more scrutiny than those involved in non commercial flights. Most of my adult life, I chose to be involved in jobs that required drug pre-screening, random drug testing and even polygraph pre-screening and random polygraph tests. I did this and yes, I voluntarily abrogated some of my constitutional rights. Had I not wanted to be subjected to said testing, I could have pursued other lines of work.

As a commercial pilot flying scheduled and on demand charters (a.k.a. Part 135) I was subjected to drug screening and random drug testing. I agreed to this because I wanted to do this kind of flying. No one made me do it. So what is different from a balloon pilot flying 15 paying passengers and me flying a Caravan with 8 or 9 passengers? The passengers have the same expectation of a safe flight with a professional aviator the results of bad pilot judgement can be the same in either case. The FAA has required the aforementioned testing to ensure a reasonable expectation of customer safety. Why should a balloon pilot not be subject to such scrutiny?

The libertarian (deliberately not capital L) side of me wants less government interference in our lives and fewer regulations, however, there are some regulations that do contribute to the safety of the general public. It is not just the aviation industry that has these requirements. Much of aerospace does as do the electric utilities. Yes that is correct, when I worked for the local electric utility pushing paper and servicing customer energy conservation needs, I was subject to the same "fit for duty" requirements as were the men and women who worked with all the high voltage electricity. This was part of the company's commitment to safety.

Bottom line is that operators who hold out to the public for commercial flights, should have and enforce a "fit for duty" policy in place. Whether it is voluntary or carries the weight of FAA regulation is dependent on how well the industry self regulates.

Posted by: Leo LeBoeuf | December 13, 2016 10:00 AM    Report this comment

As others have said, the delineation should be on the type of operation i.e. commercial and pax capability. As a commercial operation there should be some requirement for the 'professional' pilot to have demonstrated medical fitness.I also believe that as the pax capacity increases so should the regulatory oversight. Although I don't like extra layers upon layers of govt. regulation, I do believe citizen joe smith should be afforded some extra layer of protection if they are paying for the experience.

Posted by: TIM HOWARD | December 13, 2016 10:49 AM    Report this comment

Some good comments and positions. But no one has opined on passenger culpability in this incident. Why didn't one or more of those passengers look at the sky and determine things "don't look right" and balk at a flight? I have actually cancelled commercial airline trips during storms. If one in 10 of 'em was a drug user, surely 1 or two had some common sense? Maybe not?

There are LOTs of days when I'd love to go flying but I look out the window and determine it isn't a good thing to do. Coupled with the forecast and some good experience based judgment, a go or no-go decision is made. A small part of the blame has to fall on the passengers who were seeking a thrill. Still, the PIC's decision making and likely hunger for revenue was the primary cause factor. As usual, there were multiple factors in the equation which allowed this terrible incident to occur.

In this case, it appears to me that there was no "QC" backup to the pilot. Airline operations have 1st officers, dispatchers, weather people and etc. When I do an annual inspection on my airplanes, I don't have a second person so I do it by going away for a day and coming back with fresh eyes to review critical elements of that work if the IA I work with isn't involved. The predominant reason this happened was poor judgment and decision making on the part of the PIC ... period. If he had to answer to a second person, THAT would have at least thrown some rocks into his gear train.

Finally ... be careful what you wish for vis-a-vis drug testing. Both my IA and the CFI I do my FR's with have gotten themselves into trouble with the FAA over ADMINISTRATIVE oversights involving their drug testing which they had nothing to do with (they hired outside entities to handle that for them). Both had to hire aviation attorneys and spend money AND pay fines for doing nothing wrong themselves. And -- in the end -- the FAA is more interested in dotting the I's and crossing the T's than in the actual end result. Above all else ... don't let the camel get his nose under the tent at all costs!

Posted by: Larry Stencel | December 13, 2016 1:30 PM    Report this comment

Larry wrote "...and coming back with fresh eyes to review critical elements of that work if the IA I work with isn't involved."

This is Absolutely good advice! As much as I respect the IAs I have worked with, they can make mistakes too. I see people hop in and take off after an annual without giving a thought.

I learned this lesson when I had the wing struts on a high-wing Piper replaced with modern sealed struts. Turns out the AP/IA didn't (or maybe just plain forgot) to set the wing washout (you set this by shortening or lengthening the struts with a screw adjustment). I paid the bill and subsequently took off only to find the ship in a 30 deg left crab and requiring about half the aileron throw just to keep it level. Fortunately I got back down OK even though I was flying heavily cross-controlled just to keep it going straight! A simple glance from 50 feet away on the ramp before takeoff would have revealed the twisted wings.

Posted by: A Richie | December 13, 2016 3:07 PM    Report this comment

I nominate Richie for the best "There I Was" story of the day. Suggested title: "Twist of Fate."

Posted by: Tom Yarsley | December 13, 2016 3:40 PM    Report this comment

Tom: I think you misunderstand what I am saying. I am not stating that drug tests and background checks would catch most pilots with bad judgment. Only those with the most egregiously poor judgment. That is admittedly a small portion of the problem but it would at least allow us to do something and about this. Any progress is better than not doing anything. What you permit you promote.

Posted by: Thor Thordarson | December 13, 2016 9:52 PM    Report this comment

The only reason FAA requires drug testing is because Congress passed a law requiring them to do so. The original rule very nearly put pt 61 CFI's out of business due to the cost. It also ended most sightseeing rides again due to the cost, a "solution" looking for a non existent problem. As far as making ballooning rides pt 135, the FAA does not has the resources to enforce it and the cost to operators would put most if not all balloon operators out of business. I think a limit on amount of passenger capacity for commercially operated balloons might be a reasonable rule. Putting a medical requirement or adding other regs could have unintended consequences that will benefit no one.

Posted by: matthew wagner | December 13, 2016 11:52 PM    Report this comment

"Why didn't one or more of those passengers look at the sky and determine things "don't look right" and balk at a flight?"

At least in my experience, the average person (and this includes my friends and family) often is not qualified enough to determine if weather conditions are suitable for flight except for the most extreme/obvious cases. But even then, just read some accident reports and it's clear that even if they *do* think it's not a good day to fly but the pilot thinks so, they usually defer to the pilot's decision.

Posted by: Gary Baluha | December 14, 2016 9:19 AM    Report this comment

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