First Responders to Hot Air Balloon Crash in Caldwell County, Texas, Use All-Hazards Response Framework for Mass Fatality Event

What Happened

On Saturday morning, July 30, 2016, Martin Ritchey — who was then Chief of Homeland Security and Emergency Management Coordinator for Caldwell County — received a phone call from the City of Lockhart/Caldwell County Emergency Medical Services (EMS) director about a mass fatality incident in Maxwell, Texas. Maxwell is an unincorporated area of Caldwell County, located outside of Lockhart, Texas. Caldwell County EMS had arrived at the mass fatality scene of what was initially an unknown cause. While Ritchey was en route to the scene, it was determined the mass fatality incident involved a hot air balloon crash.

At 7:42 that morning, a hot air balloon descended from a cloud bank and hit the top resting wire of a high-tension power line. After the initial impact, the hot air balloon then dropped down and collided with high-voltage power lines, burning through the cables that attached the gondola to the balloon envelope. The balloon's fuel lines separated from the burner source as the basket pulled away from the envelope in the descent, and the unsupported gondola plummeted to the ground. The fall injured or killed many of the passengers upon impact. Several people survived the crash and were then killed in the subsequent fire that ignited on the excess spill of liquid propane fuel. All 16 occupants of the hot air balloon, including the captain, died in this tragic accident.

When responders arrived on scene, they encountered a contained fire, with multiple human remains inside, burning in a field. They were puzzled and shocked; what they were looking at was unclear. Responding agencies came to the scene from multiple directions. Most responded from south of the scene, and responders from the northern direction found the balloon's envelope deflating in a nearby field. The discovery of the distinctive balloon envelope in conjunction with the burning scene connected the dots for responders, who had previously wondered about the cause of the fire and casualties in the field.

Upon first glance, some first responders believed that the deceased might be mannequins. It was very difficult for many to process the tragedy of the scene, said Ritchey. None of the remains were recognizable. Since the gondola was a confined space, when it fell and landed on its side, the occupants became commingled. Due to the positioning of the bodies, first responders faced technical challenges — the primary concern was determining how many individuals were involved in the accident.

Ritchey and the response team concluded that there were 16 fatalities. However, in their first press release, they noted that they may find an additional passenger as they processed the scene further. Ultimately, their initial report was correct — a considerable feat, given that there was very little information at the scene for responders to use for victim accountability. There was no evidence other than DNA that could be used to determine who the victims were or even what sex they might have been, as all clothing and identifying features had been damaged or destroyed in the fire.

The actual fire was accelerated by multiple propane tanks that were used to lift the hot air balloon into the sky. First responders noticed the cylinders in the wreckage immediately and were able to determine that they contained some type of gas. Even after firefighters extinguished the fire, the area continued to radiate heat due to the chemically enhanced burn.

Planning

Ritchey and his team used an all-hazards approach to manage this mass fatality scene. A hot air balloon crash is not an incident that would be found in a standard operating procedure (SOP) manual, and rural emergency planners do not often have the resources to specialize in multiple areas of emergency management. According to Ritchey, the concept of all-hazards response capacity is “even more interesting and powerful” to those in his position.

Response

Responders used lessons learned from previous experiences to help manage the hot air balloon crash response. Firefighters were able to quickly put out the flames from the wreckage without it spreading to the nearby area, and responding EMS immediately identified that the incident was a mass fatality event, contacted the emergency manager, and helped set up mass fatality equipment on scene. Responders took the tools from their training and utilized the ones most appropriate for the event.

As he prepared himself to respond on scene, Ritchey contacted his assistant, who reached out to the emergency management office to coordinate with the local fire chief to hook up the Homeland Security trailer at the incident site. It was important for Ritchey and his team to establish a response process that was “very thorough and exacting” as soon as they arrived on scene. He contacted his superior, the Caldwell County Judge, who declared a state of emergency, giving Ritchey special authority to manage the incident. Immediately, responders established the chain of command under Incident Command System (ICS) principles. Ritchey served as the Incident Commander (IC), and each of the responding agencies had specific roles and responsibilities dictated by their organizational duties.

The beginning stages of the response were all about setting the stage to account for the number of deceased individuals at the scene. Ritchey emphasized the importance of making sure there was some certainty of the number of fatalities before releasing this information. Information accuracy was given the highest regard to maintain public confidence in the integrity of official data sources. When the balloon's chase vehicle arrived at the scene, first responders were able to cross-reference the number of remains identified with liability waivers that had been signed by the passengers to establish an unofficial list of suspected victims.

The initial incident response required Ritchey's office to set up an operation that would enable them to provide the necessary resources to investigators who would later arrive at the site. This included taking proper care of the remains of the deceased and setting up a family assistance center for the victims' loved ones. Additionally, Ritchey had to consider how responders were going to control access to the scene, how to communicate the impact of this event to the community and public officials, and how to handle the onslaught of media interest. It was very important to the response operation that first responders maintained scene security, so they designated a place for media to gather that was located at a distance from the accident and victims' remains. Very early in the response, Ritchey's team established checkpoints through which only first responders could pass.

As part of the access mitigation strategy, Ritchey notified the Federal Aviation Administration (FAA) and asked for the airspace over the area to be shut down, to prevent the flyover of commercial aircraft and media helicopters. The FAA closed the airspace over the accident site for 5 miles, which permitted responders the flexibility of being able to properly process the scene without exposing the remains to close examination by video cameras or photographs from the air. Media helicopters still hovered 5 miles out, as permitted — however, controlling the airspace allowed first responders to maintain the sanctity of the deceased individuals' remains and provided more privacy to the families during their time of grief. All these essential activities were established within the first 30-40 minutes of the incident response.

Responders then began the steps to effectively manage the victims' remains. Fire rescue was involved in the recovery itself and assisted the justice of the peace and private medical examiner (ME) with removing the remains from the scene. The Texas Department of Public Safety (DPS) is responsible for responding to aviation accidents at the state level, while the FAA and the National Transportation Safety Board (NTSB) have jurisdiction over aviation accidents at the federal level. All of these agencies were notified of the incident and were responsible for the investigation of the crash.

Ritchey and the Public Information Officer (PIO) for DPS formed a Joint Information Center (JIC) and decided that all information must be agreed upon by both parties before it was published publicly. The Caldwell County sheriff was an elected official and known by the community, so they agreed that he would issue official statements regarding the incident.

Once the investigative agencies arrived, it was the responsibility of first responders to manage the scene. Ritchey's team was not conducting the investigation; rather, they focused on the logistics of the response. Therefore, emergency managers at the local level handled all the activities that surrounded the inquiry, including the coordination of portable restrooms, tents, food, water, and supplies. Law enforcement assisted with scene security and control, which was managed through the Incident Command Post (ICP) and ICS protocols. Law enforcement officers, responders, and investigators were assigned specific roles and were required to sign in and out of the scene.

In Texas counties, an elected official known as the justice of the peace (JP) is responsible for investigating deaths, in addition to performing other municipal roles and court functions. Within an hour of the response, the JP arrived at the scene and determined the response would need additional resources. He contacted a private autopsy firm located in the county seat, Lockhart, which is 10 minutes away from Maxwell.

The private ME arrived at the accident site and decided that she needed to examine the victims' remains in situ before the responders began the process of recovery. To preserve the scene as it was upon discovery, she made sketches, took photographs, and instructed search and rescue (SAR) volunteers who flew a drone over the site to record the scene and its surroundings. It is important to document the scene thoroughly, because whenever human remains are removed from an accident site, it can change the interpretation of what is left behind. NTSB agents traveled from San Antonio, Texas — about 1 hour south of Maxwell — and approved that the private ME's scene documentation was sufficient. They agreed that the first responders could begin the recovery process.

Recovery

Once the scene was properly documented, Ritchey gave the order to begin removing the victims' remains from the scene and out of the heat. Firefighters rendered the fuel tanks safe and removed them from the crash site before the recovery process began. Other than the tanks, there was not much left of the hot air balloon. The wicker basket gondola was completely burned away, and all that remained of the structure was a plywood base and metal support ribs. All the other equipment associated with the hot air balloon was destroyed.

Ritchey stopped additional units from responding to the scene as soon as the fire was extinguished. He did not want anyone exposed to the victims' remains other than who was absolutely necessary, such as the investigators, documentarians, ME, and JP. The county kept the number of responders directly under its jurisdiction down to no more than 10-15 people at the incident site at any single time. The emergency responders “self-limited” access because they knew that this event would be a complex challenge to deal with emotionally.

DPS brought a chaplain from their headquarters to the scene, and Ritchey asked him to pray over the victims' remains. He felt that it was important to communicate to the grieving families that the minister had prayed for their loved ones before their bodies were removed from the scene. He hoped this might give the victims' loved ones some comfort in this horribly tragic time. After praying for the deceased at the accident site, the chaplain attended the family briefings to provide support. Professionals from the Ascension Seton, a hospital system operating in Austin and at a rural hospital in Luling, were stationed at the family assistance center and were later joined by trained NTSB debriefers to provide support to the grieving parties as well.

Until the victims' remains left the scene of the incident, Ritchey did not leave to go to the family meetings. Responders established a protocol in which specified briefers would communicate regularly with the families, so that they could avoid having multiple unfamiliar faces sharing updates or information. Ritchey wanted to keep the families separated from the accident site so that they would not witness the distressing scene. NTSB authorities also had trained professionals and briefers who were skilled at handling large losses of life and communicating with victims' loved ones.

Activities in the first 4-6 hours of the first day were mostly focused on recovering the victims' remains from the site and relocating them to a place where they could be properly stored. Response activities during the first day provided a platform on which investigators could begin their work. Most of the major components and investigators, however, arrived on the second day of the disaster response. Luckily, first responders did not have to operate overnight, as the human remains were removed and the accident site was secured.

Regardless of how a response is conducted, Ritchey said, no amount of effort will reverse the loss of life. Once that is evident in a response process, the main concern shifts to how responders can best handle the victims' remains in a way that is consistent with “supporting an investigation and supporting the families,” both in the moment and thereafter.

In the very early stages of the response, Ritchey's role was not associated with the families of the victims. On the second day of the response, however, he was able to attend the family briefings and was approached by an attendee who requested to visit the site of the accident. This interaction showed to Ritchey that the victims' loved ones would want to go to the scene and prompted his decision on how responders would handle opening the site to the public.

He realized that when the scene was released from investigative control that people would flock to the field, cars would drive up to the site, and the media would swarm the area. He wanted to make sure that the families were able to pay their respects in private. As a solution, Ritchey coordinated with his County Judge to allocate county funding toward buses that would take the family members to the crash site. Even though this incident response had depleted the small county's contingency budget, they agreed to pay this cost as a condolence for the victims and their families.

On the third day of response, the Caldwell County Office of Homeland Security and Emergency Management developed a strategy to bring the families of the victims to the accident site. Using buses and protocols from evacuation plans, the county drove the victims' loved ones down a private road so that they would not be exposed to the press. The buses then backed down the road near the accident site, so that the doors would open toward the scene and the vehicles would shield the bereaved from media cameras. The “wall of buses” created some privacy for the family members while visiting the accident site for the first time.

Ritchey stayed engaged with the families and the NTSB trial. He took personal time to fly to Washington, DC, to attend 2 hearings related to the accident. He used that time to speak with elected officials to advocate for changing the federal regulatory rules regarding commercial balloon operations and pilot requirements. He saw firsthand how injurious the lack of regulations was at the time, not only to the people onboard but also to their families and friends, his colleagues and partners, and the community overall. This work brought him closer to the families of the victims, as many of them also attended the NTSB hearings and wanted to hear his perspective as a responder at the scene. NTSB's official accident report outlines the causes of the crash and an analysis of the findings following the investigation.

Each year following the incident, Ritchey and other responders have joined the victims' loved ones in visiting the site on the anniversary of the crash. He no longer works for Caldwell County — in 2018 Ritchey was appointed Director of Homeland Security with the Capital Area Council of Governments (CAPCOG) for a 10-county region including the Austin Metropolitan Area — but he still maintains those relationships in Caldwell County.

Success Factors

Family Assistance Center

Three years prior to the hot air balloon accident, Ritchey received funding from the Texas Department of Public Health to attend a 2-day NTSB seminar on dealing with fatal aviation incidents. The training mainly revolved around NTSB methodologies and how to interface with the organization — it also included issues that first responders may have to address, such as setting up a family assistance site. These incidents and considerations are less frequent concerns in a small, rural community, so Ritchey attributes this training to the county's success in dealing with the hot air balloon crash. By taking lessons learned in that training, Ritchey established a family assistance center within an hour of the incident. By the time that information was getting out to the public, initially through social media and then official channels via an announcement from the Sheriff's Office, there was a place to which responders could direct grieving families and friends of the victims.

The family assistance center was hosted in a local church hall, which was equipped with kitchen facilities, meeting rooms, and lots of parking. It was a fixture in the community, even though it was in a very rural area, about 2-3 miles from the accident site. Trained support personnel as well as food and other resources were available for the bereaved at the family assistance center. Ritchey said he may not have considered all the elements needed to create this resource if he had not attended the NTSB seminar prior to the incident.

Community Support

In addition to the multiple responding and investigative agencies that collaborated to manage this incident, local partners and sectors of the community came together to support first responders and the victims' families. Women in the community donated food and baked goods to the family assistance center, and the Caldwell Chamber of Commerce coordinated the delivery of portable restrooms to the rural fire station. Maxwell is a small, close-knit town and the impact of this accident was significant. Although Texas is a big state, Ritchey described it “like a little community,” and people from all over the state were trying to find out if their loved ones had been involved in the crash. The City of Lockhart Mayor and City Council received calls from concerned citizens throughout the event.

The Sunday following the crash, the Lockhart Ministerial Alliance held an ecumenical service honoring the victims at the Caldwell County Courthouse Square. The Caldwell County Office of Homeland Security and Emergency Management invited the families but let the Ministerial Alliance run the service so that no politicians or government figures would be directly involved.

While the Caldwell County community was most affected by this tragedy, first responders and family members of the victims also received an outpouring of support from the larger global community. During part of the response process, Ritchey received a note from the Pope, sending his blessing to the victims of the crash. The Chairman of the NTSB also personally reached out to Ritchey to inquire how he and the community were faring a year after the event. These examples emphasized that the impact of this event extended well beyond the scope of Texas.

Previous Experience

Ritchey had prior experience working in an emergency management and coordination position within a rural community with limited resources. Before he joined Caldwell County, he was a technology executive and entrepreneur. He also worked in emergency services as a teenager and was inspired to leave private enterprise when his community suffered a major wildfire. He used his skills in business as well as his previous training to work in the Caldwell County Office of Homeland Security and Emergency Management. For 2 years, he helped write plans and train responders. He also spent time training the volunteer fire department on ICS principles and other aspects of response.

Caldwell County responders were not equipped to perform swift water rescues, which came to light when 2 major floods occurred in the area. Ritchey spearheaded trainings to build response capacity to over 50 trained first responders and several boats. Caldwell County then experienced two of the worst floods in its history — responders were able to move over 4,000 people from along the riverway to safety. The Caldwell County community suffered from major wildfires, deadly floods, and multiple catastrophic events, including 5 presidential-declared disasters, during the time that Ritchey was the Emergency Manager for the county.

By the time of the hot air balloon crash, Caldwell County emergency managers and first responders had experienced multiple disasters and emergencies, including missing persons, highway wrecks, evacuations, and train derailments. The combination of these response experiences contributed to the success of the emergency response for the hot air balloon crash. Ritchey credits the greater community of Caldwell County, his assistant, the firefighters, and the crew of responders who went “through the crucible” to get it done for the compassionate and well-managed response to this mass fatality event.

Regional Relationships

Following the hot air balloon accident, Ritchey was elected as the Chairman of the Homeland Security Taskforce by his fellow emergency management coordinators at CAPCOG. As a taskforce member prior to his appointment, the associations with emergency planners and first responders in the region were invaluable resources during the mass fatality response. Ritchey had multiple contacts from the taskforce that he could call for additional resources or as mental support during the event. The taskforce still conducts trainings regularly, for subjects including evacuation procedure, hazardous materials clean-up response, and mental health for first responders during the COVID-19 pandemic.

The San Marcos Fire Department covered the Maxwell Fire Department's territory during the emergency response, since firefighters and EMS were stretched thin from the mass fatality. This was a significant undertaking, as it added an additional 60 square miles of wildfire-susceptible land conditions to the adjacent community's territory. Maxwell's workforce and resources were limited, but local support across county lines was key to their success.

The City of Austin Fire Department (AFD) collaborated with Caldwell County and sent their Aircraft Rescue Fire Fighter (ARFF) chiefs to the scene, so that they could observe how an NTSB accident investigation and recovery operation was run. The chiefs came away from that experience with enhanced understanding of how to handle this type of mass fatality event, especially because it was so rare. AFD also sent their debriefers to the Maxwell Fire Department to assist with first responder Critical Incident Stress Debriefings (CISD).

Barriers

Unprecedented Tragedy

At the outset, Ritchey felt pressure to impress upon the rural agencies that responded to the incident that this event was a situation they had never dealt with before. At that time, the responders needed to be aware of the impact of the event and frenzy that would descend upon the scene. He warned it would be unprecedented within the small community — and it was.

Weather Conditions

The Saturday of the crash was exceptionally hot. The temperature registered between 104 and 110 degrees Fahrenheit throughout the morning and afternoon. It was extremely uncomfortable for first responders out in the sun all day. Within the first hour, Ritchey's assistant arrived with the Homeland Security trailer, which had air conditioning alongside communication equipment and other essential supplies. They also set up shade tents to help limit sun exposure and reduce the risk of heat stroke.

Responders had to work as quickly as possible to recover the remains and relocate them to an area out of the sun and heat, to preserve the remains so that MEs could perform the autopsies of the deceased. Weather conditions and a drought added to the fire at the accident site and created a significant risk of wildfire. Luckily, the fire suppression aspect of the response was not too difficult, as the area was relatively small. The incident could have turned into a much larger emergency if the firefighters had not been able to control the gas-fueled fire at the crash site.

Equipment Failure

First responders identified shortcomings with mass fatality and triage equipment during the response and recovery process. The triage tags the county was using to indicate that an individual was deceased were solid black. This is in-line with the triage tagging color system, which assigns a color code of either black, red, yellow, or green to accident victims based on the severity of their injuries. However, the fully black tags were incompatible with a mass fatality event, as responders could not write notes on them with regular pens. A white outline, suggested Ritchey, could help mitigate this issue. Caldwell County responders had exercised triage activities before. Four or five months prior to the hot air balloon crash, they hosted a full-scale decontamination exercise for the local hospital in which they used all the triage tags except the black ones, so the issue was not identified.

Budget

Caldwell County's emergency response contingency budget was drained after the hot air balloon crash. As a small county entity, the Caldwell County Office of Homeland Security and Emergency Management was already over budget before the investigation concluded. It did not even have enough money left to cover the complete costs of the DNA analyses and victim autopsies. The balloon operator, who was also a victim of this accident, did have insurance. However, it was not substantial enough to extend to all the victims' families and the county's expenses. Therefore, Ritchey's department did not submit an insurance claim, allowing the families to submit death claims instead.

Lessons Learned

Considerations for First Responders' Mental Health

Following the mass fatality response, the first responders underwent CISDs. Ritchey knew the severity of this event would impact responders in a significant way and that it was essential the county had the resources necessary to properly debrief the firefighters. He stressed the importance of this process, and the county held multiple, immediate debriefings at the local fire station that followed the prevailing guidelines at the time.

They held separate debriefings at different times of the day to accommodate both the volunteer and career firefighters. Ritchey emphasized that even though they held several debriefings and did everything that was expected, he does not believe that it was enough. First responders were already stretched thin before the mass fatality event, both emotionally and tactically, due to the stress of prior emergencies in the area, said Ritchey. Floods and wildfires created a stream of constant disasters that the community is still trying to recover from, even into 2022.

Ritchey shared how initial efforts to support responders' mental health after this event were strong. However, in August 2017, Hurricane Harvey decimated much of Texas and halted Caldwell County's focus on the aftermath of the hot air balloon incident. Still, Ritchey kept focus on the county's first responders. When the fire department suffered the loss of two first responders during a fire response, he personally visited the department and spent a week providing resources and support to the firefighters. However, he said he has regrets and feels that he probably could have done more in support of the mental health of responders following the hot air balloon tragedy. Just because “you feel like you're breaking ground” during a CISD does not mean that trauma will be resolved, he said.

Ritchey has dedicated significant focus of his career following the hot air balloon accident to raising awareness for the mental health considerations that must be addressed for responders to mass fatality events. He has given presentations on the hot air balloon crash and the long-lasting effects of the tragedy at nationwide events, including the Texas Emergency Management Conference, the Atlanta Urban Area Security Initiative (UASI), and the National Homeland Security Conference. He affirmed the importance of continuing to provide support after the official conclusion of an incident and emphasized that the ways in which the brain processes trauma are often underestimated. The COVID-19 pandemic has revealed this even more in the Caldwell County region. While there will always be lingering effects of traumatic incidents such as mass fatalities, first responders should not suffer as they continue to provide life-saving services.

Importance of Training

When Ritchey was offered the opportunity to travel to Dallas for the NTSB seminar, he did not hesitate to accept. He said he never expected a large commercial passenger jet to crash in Caldwell County, for example, but he knew there were multiple practices covered in the lectures that would be easily applied elsewhere. Using an all-hazards approach, these lessons learned could be useful in events like a mass shooting, where a family assistance center would need to be established.

Ritchey worked hard to ensure training was always a central piece of the county's emergency preparedness efforts. He later brought the NTSB to Austin to present the same lecture that he attended before the hot air balloon crash. None of his current jurisdictions are funded by Emergency Management Performance Grants (EMPGs); however, he insists that they run annual regional exercises all the same. In his current role as the Director of Homeland Security for a 10-county area, he manages 89 cities and hundreds of agencies, jurisdictions, and stakeholders. Training can be as simple as conducting a tabletop exercise or signing into the emergency management software Web Emergency Operations Center (WebEOC). Training must then be reinforced with situational planning and exercises.

Soft Skills

Ritchey spent a lot of time contemplating what he could do to help others be prepared and successful in emergency planning. He identified that while agencies may have the necessary training and operational skills to conduct a response, they must also have soft skills to connect with people and the community. Ritchey described how education, training, running drills and exercises, and life lessons all work together to build soft skills. He emphasized the importance of mentoring as a means of sharing and teaching soft skills to individuals working in emergency management, especially as experienced emergency management professionals begin to retire.

Advice

For rural communities and emergency managers responding to a mass fatality event, Ritchey provided the following advice:

Establish Relationships

It is not advisable to exchange business cards with response partners for the first time at the scene of an incident, said Ritchey. Having regular meetings ahead of a disaster can create trusted relationships to benefit the capacity of multijurisdictional responses in the future. Ritchey stressed the importance of making sure you have the contact information of the emergency response stakeholders in the community and establishing a partnership that you feel comfortable calling upon.

Assess Capacity

Understand the capabilities and capacities that each agency involved in an emergency response possesses. A successful response always comes down to the “simplest elements of boots on the ground” and interagency capabilities at any given time.

Be Methodical

When you arrive at an incident, your adrenaline will be running and you can have tunnel vision, said Ritchey — however, you must combat those physical manifestations of your response. Responders can “slow down time” by slowing down their thought processes, especially when an incident appears to have the luxury of time, since there is no additional risk of imminent injury or death. Ritchey stressed the importance of talking the response processes over with other responders, being methodical with your thinking, and leaning on people whom you know and trust.

Limit Exposure

Do not underestimate the need, depth, and duration of providing mental health support to responders. Minimize the number of people who have access to a scene, and do not bring more people into the response than are needed, warned Ritchey. There is no amount of preparation that can ready a first responder or make them truly understand the personal impact of a mass fatality scene — however, there is also “no amount of unlearning that you can do when you've been exposed to it directly.”

Person(s) Interviewed

Martin Ritchey, Director of Homeland Security
Capital Area Council of Governments