NTSB: Poor Pilot Decisions Led To Fatal Balloon Crash

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A commercial balloon pilot’s “pattern of poor decision-making” led to his balloon striking power lines and then crashing to the ground in Texas in July 2016, killing all 16 on board, the NTSB concluded in its final report, issued on Tuesday. It was the deadliest balloon crash in U.S. history. Contributing to the accident were the pilot’s medical conditions and medications that likely affected his decision-making, the board said. Alfred “Skip” Nichols, 49, the owner of Heart of Texas Balloons and the pilot on the day of the accident, had Valium, oxycodone and the antihistamine Benadryl in his system on the day of the crash, the board said. The combined effect was enough to mimic "the impairing effect of a blood-alcohol level" of a drunk driver, said Dr. Nicholas Webster, a medical officer with the NTSB.

“The pilot’s poor decisions were his and his alone,’’ said Robert Sumwalt, NTSB chairman. “But other decisions within government, dating back decades, enabled his poor decision to fly with impairing medical conditions, while using medications that should have grounded him.” The board said the FAA should require commercial balloon operators to carry an aviation medical certificate. Had a medical certificate been required, the board said, the FAA also would have had an opportunity to identify Nichols’ history of drug- and alcohol-related traffic offenses. Nichols was being treated by a psychiatrist for depression and attention deficit hyperactivity disorder, and had been prescribed 13 medications.

The NTSB also concluded Nichols should have cancelled the sightseeing flight because of deteriorating weather conditions and, once in the air, should not have climbed above the clouds. His decision to then attempt to land in reduced visibility conditions diminished his ability to see and avoid obstacles. The board also called on the FAA to find better ways to provide oversight of balloon operators. “Today’s recommendations, if acted on, will help to bring the safety standards closer to those that apply to powered flight,’’ Sumwalt said. “Balloon pilots, their passengers, and their passengers’ loved ones deserve no less.’’ The abstract of the NTSB’s final report (PDF) is posted online. The complete text of the final report will be released publicly later this week. The webcast of the board meeting will be available online for 90 days.

Comments (3)

An inescapable fact is that the causation of almost every harmful event involves impaired human performance. These impaired behaviors and/or inactions are influenced by phenomena such as distraction, fatigue, cognitive work load, multitasking, hours of service, sleep deprivation, sleep interruption, task interruption, circadian rhythm issues, exposure to neurotoxins, use of alcohol, use of drugs, use of medicines, nutrition, transient emotions, mental stress, mental health issues, physical stress, ergonomics, ambient conditions, noise, vibration, lighting, clothing, equipment, family crises, marital challenges, pre-event activities, chilling effects, culture, leadership, schedules, budgets, and the like.

Reported causation of harm is incomplete without the inclusion of human performance impairments and their causations. Impaired human performance subsumes human error. All human error involves impairment. Impairment is never a root cause.

Observation: Confidence in the quality of corrective and preventive actions for specific harmful conditions, behaviors, actions, and/or inactions due to human performance impairment depends on confidence in the causation of the impairment even when the impairment cannot be confidently eliminated.

Quotation: "Then said Jesus, Father, forgive them; for they know not what they do." -Luke 23:34 (KJV)

Posted by: Bill Corcoran | October 18, 2017 2:59 AM    Report this comment

Noticed a typo in the article: The accident did not happen "Last July" - it happened July 2016. Not a huge deal - but I was initially amazed at the speed of the NTSB's final report - until I realized the typo.

Posted by: Dave B | October 18, 2017 9:23 AM    Report this comment

Noticed a typo in the article: The accident did not happen "Last July" - it happened July 2016. Not a huge deal - but I was initially amazed at the speed of the NTSB's final report - until I realized the typo.

Maybe the typo can be corrected.

Posted by: Dave B | October 18, 2017 9:24 AM    Report this comment

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