DCA16MA204

NTSB accident investigation · Kubicek BB85 · Lockhart, TX · July 30, 2016

Accident · FatalClass 1 · MajorFinal report
Date
July 30, 2016
Place
Lockhart, TX
Injuries
16 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N2469LKubicek BB85
Weather
Instrument (IMC) · Day
Status
Completed · report November 29, 2017
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20160730012659A
Case key
93715

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Ceiling/visibility/precip: fogEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionBalony Kubicek Spol Sro BB85Z: 1 caseAll aircraft: 78 casesProbable cause
Oversight: oversight of personnelOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBalony Kubicek Spol Sro BB85Z: 1 caseAll aircraft: 26 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-17/03. On July 30, 2016, about 0742 central daylight time, a Balóny Kubícek 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.

Factual narrative

The NTSB's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-17/03. On July 30, 2016, about 0742 central daylight time, a Balóny Kubícek 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.

Aircraft

Registration
N2469L
Reported as
Kubicek BB85 (Z)
Category
Balloon
Serial number
unknown
Damage
Destroyed
Fire
In-Flight
Flight
Business · Part 91
Operator
Heart of Texas Hot Air Balloon Rides
Registered owner
Nichols Alfred G
Airworthiness certificate
Standard, Balloon
Departed
XS90 · Fentress, TX
Destination
XS90 · Fentress, TX

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Weather

Conditions
Instrument (IMC) · Day

Docket · 83

The files NTSB released with the investigation on December 9, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 158 MB in all.

1A Order of HearingItem 1 · .PDF · 46 KB1B Notice of Designation of Chairman of Board of InquiryItem 2 · .PDF · 55 KB1C Designation of Hearing OfficerItem 3 · .PDF · 54 KB1D Designation of Parties to HearingItem 4 · .PDF · 42 KB1E Notice of HearingItem 5 · .PDF · 47 KB1F Statement of Purpose of a HearingItem 6 · .PDF · 68 KB1H Witness BiosItem 7 · .PDF · 270 KBExhibit 1J Safety Recommendations A-14-11 and -12 and responsesItem 8 · .PDF · 1.9 MBExhibit 1K FAA Balloon Flying HandbookItem 9 · .PDF · 33.8 MBExhibit 1L Balloon Tour LOA White PaperItem 10 · .PDF · 1.1 MBExhibit 1M BFA Industry Best Practices GuidelinesItem 11 · .PDF · 1.4 MBExhibit 1N BFA Best Practices - post-accidentItem 12 · .PDF · 634 KB1P BFA Action Plan - post-accidentItem 13 · .PDF · 92 KBExhibit 1Q FAA Safety Briefing MagazineItem 14 · .PDF · 3.8 MBExhibit 1R - FAA Data Report-Rev1 - Balloon OperationsItem 15 · .PDF · 324 KBExhibit 1S FAA Order 8000.373Item 16 · .PDF · 93 KBExhibit 1T FAA Presentation MalechaItem 17 · .PDF · 262 KBExhibit 1U - BFA Response to NTSB RecommendationsItem 18 · .PDF · 5.5 MBExhibit 1V - FAA Back-up Slides - Data - LOAItem 19 · .PDF · 271 KBExhibit 2A Ops Group Chairman's Factual ReportItem 20 · .PDF · 4 photos · 1.6 MBExhibit 2B Attachment 1 - Interview SummariesItem 21 · .PDF · 230 KBExhibit 2C Attachment 2 - Witness StatementsItem 22 · .PDF · 1.8 MBExhibit 2D Attachment 3 - LCRA DataItem 23 · .PDF · 237 KBExhibit 2E Attachment 4 - Pilot InformationItem 24 · .PDF · 2.3 MBExhibit 2F Attachment 5 - FAA MemorandumItem 25 · .PDF · 404 KBExhibit 2G Attachment 6 - Balloon InformationItem 26 · .PDF · 3.0 MBExhibit 2H Attachment 7 - N2469L Inspection RecordItem 27 · .PDF · 17.2 MBExhibit 2I Attachment 8 - N2469L LogbookItem 28 · .PDF · 17.1 MBExhibit 2J - Attachment 9 - Flight ManifestItem 29 · .PDF · 1.6 MBExhibit 2K Attachment 10 - Kubicek Performance InformationItem 30 · .PDF · 175 KBExhibit 2L Attachment 11 - Kubicek Weather LimitationsItem 31 · .PDF · 153 KBExhibit 2M Attachment 12 - Kubicek ChecklistsItem 32 · .PDF · 600 KBExhibit 2N Attachment 13 - Kubicek Emergency ProceduresItem 33 · .PDF · 422 KBExhibit 2O Attachment 14 - Kubicek Passenger BriefingItem 34 · .PDF · 180 KBExhibit 2P Attachment 15 - Powerlines and ThunderstormsItem 35 · .PDF · 362 KBExhibit 2Q Addendum 1 - FAA StatisticsItem 36 · .PDF · 238 KBExhibit 2R Advisory Circular 91071Item 37 · .PDF · 1.7 MBExhibit 2S Addendum 2 - FAA Memo DetailsItem 38 · .PDF · 3.0 MBExhibit 2T Addendum 3 - Kubicek Balloon PerformanceItem 39 · .PDF · 249 KBOperations Addendum 4 - N2469L Inspection Records DetailsItem 40 · .PDF · 5.1 MBExhibit 5A Weather FactualItem 41 · .PDF · 8.9 MBWeather Attachment 1Item 42 · .PDF · 92 KBExhibit 5B Weather Attachment 2Item 43 · .PDF · 102 KBWeather Attachment 3Item 44 · .PDF · 92 KBExhibit 5C Weather Attachment 4Item 45 · .PDF · 183 KBExhibit 5D Weather Attachment 5Item 46 · .PDF · 967 KBExhibit 5E Weather Attachment 6Item 47 · .PDF · 87 KBExhibit 5F Weather Attachment 7Item 48 · .PDF · 120 KBExhibit 5G Weather Attachment 8Item 49 · .PDF · 121 KBExhibit 5H Weather Attachment 9Item 50 · .PDF · 87 KBExhibit 5I Weather Attachment 10Item 51 · .PDF · 98 KBExhibit 5J Weather Attachment 11Item 52 · .PDF · 542 KBExhibit 5K Balloon Safety Tips - False Lift, Shear, and RotorsItem 53 · .PDF · 359 KBWeather Attachment 12Item 54 · .PDF · 405 KBWeather Attachment 13Item 55 · .PDF · 383 KBExhibit 5L SkewT-Log P from HYIItem 56 · .PDF · 3.8 MBExhibit 17A Airworthiness Group Chairman's Factual ReportItem 57 · .PDF · 19 photos · 3.3 MBExhibit 17B Airworthiness Group On-Scene Balloon Cable ExaminationItem 58 · .PDF · 1.2 MBExhibit 17C Airworthiness Examination of Envelope and Basket Load CablesItem 59 · .PDF · 2.7 MBAirworthiness Group Chairman's Factual Report - Addendum 1Item 60 · .PDF · 2 photos · 478 KB
All 83 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.