A National Transportation Safety Board report on the 2016 hot air balloon crash that killed all 16 people aboard finds that the pilot's "pattern of poor decision-making" was to blame. But the safety board also reserves some culpability for an FAA policy that exempts commercial balloon operators from needing medical certification.
"The pilot's poor decisions were his and his alone," said NTSB Chairman Robert Sumwalt during the board's meeting on Tuesday. "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."
That pilot was Alfred "Skip" Nichols, 49, the owner of Heart of Texas Balloon Rides. He launched the balloon just before 7 a.m. on July 30, 2016. The report found that Nichols had checked the weather an hour and 50 minutes before launch, but did not check again as fog developed and conditions deteriorated.
The report outlines mistakes Nichols made at every turn that morning in central Texas: the decision to launch, to not land the balloon when he had good opportunities to do so, and to then climb above the clouds. When he finally made the decision to land, his visibility was poor. On its descent, the balloon struck power lines, killing Nichols and all 15 passengers.
"The power lines have been there for years — they're like 15 stories tall," NPR's John Burnett reported last year. "And the pilot lived about 10 miles away .... he knew the route."
NTSB medical officer Dr. Nicholas Webster said Tuesday that Nichols was probably impaired by Valium, oxycodone, and enough Benadryl to mimic the blood-alcohol level of a drunken driver, the Associated Press reported.
The safety board found that Nichols' ability to make safe decisions was likely affected by depression, attention deficit hyperactivity disorder, and "the combined effects of multiple central nervous system-impairing drugs."
It also pointed to the FAA's exemption of commercial balloon pilots from medical certification requirements as problematic, and recommended the FAA remove it. That exemption "eliminated the potential opportunity" for an aviation medical examiner to identify Nichols' medical conditions and medications, or make the FAA aware of Nichols' history of drug- and alcohol-related offenses.
The FAA has been pressured by the NTSB since at least 2014 to strengthen its balloon oversight.
As NPR's Merrit Kennedy previously reported,
"In April 2014, Deborah Hersman, then the chairman of the NTSB, sent a letter to FAA Administrator Michael P. Huerta calling for greater oversight on commercial balloon operators. Citing previous incidents, the letter says that the 'potential for a high number of fatalities in a single air tour balloon accident is of particular concern if air tour balloon operators continue to conduct operations under less stringent regulations and oversight.'
"In its response, the FAA said that it rejected the recommendations, because they would 'not result in a significantly higher level of operational safety.' It added: 'Since the amount of ballooning is so low, the FAA believes the risk posed to all pilots and participants is also low given that ballooners understand the risks and general hazards associated with this activity.' Despite warnings of potential fatalities, no changes were made."
Beyond the medical loophole, the NTSB found that the FAA primarily conducts its oversight at balloon festivals, which Nichols did not attend. This "does not effectively target the operations that pose the most significant safety risks to members of the public," the safety board said.
But in its April report on the crash to the NTSB, the FAA argued that closing the medical certification loophole probably wouldn't have made a difference in the Texas crash, by far the most deadly balloon accident in U.S. history. The aviation administration's own investigation found that Nichols had falsified his FAA medical certificate application in 1996 by failing to report a conviction for drunk driving. Nichols had numerous subsequent drug and alcohol convictions that he did not report, in violation of FAA regulations.
Nichols "demonstrated a longstanding, willful non-compliance with regulations," the FAA wrote. Given that history, it said, he likely would not have complied with a medical certificate requirement had there been one.
In its report, the FAA said no new regulations were needed, and instead argued that "[v]oluntary efforts by the balloon industry will likely provide timely and effective accident prevention measures."
The safety board's full report will be released in coming days. In a statement Tuesday, the FAA said it will "carefully consider the NTSB's recommendations."