NTSB Factual Report

HISTORY OF FLIGHT

On December 23, 2003, about 1932 Pacific standard time, an Agusta A109A, N25RX, collided with mountainous terrain near Redwood Valley, California. Mediplane Inc., doing business as (d.b.a.) REACH (Redwood Empire Air Care Helicopter), was operating the helicopter under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as an emergency medical services (EMS) positioning flight. The airline transport pilot (ATP) and two flight nurses were killed, and the helicopter was destroyed by post impact fire. Night visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed for a portion of the flight.

According to REACH personnel, the flight departed Charles M. Schulz Sonoma County Airport (STS), Santa Rosa, California, about 1900 to pickup a critically injured patient at a rural hospital in Willits, California, and transport him to Santa Rosa Memorial Hospital, Santa Rosa. REACH personnel noted that, in accordance with the common procedure used when weather prevented flying direct to Willits, the accident pilot elected to file an IFR flight plan from STS to Ukiah Municipal Airport (UKI), Ukiah, California, which is an intermediate airport with an instrument approach, and meet a ground ambulance with the patient at UKI. The accident helicopter landed at UKI about 1922, ending the IFR portion of the flight.

After landing at UKI, the helicopter crewmembers were notified by California Department of Forestry (CDF) Howard's Forest dispatch (located between Ukiah and Willits) that the ground ambulance was still 40 minutes from UKI. According to the CDR dispatch log, the flight nurse radioed that the pilot was "checking the weather to see if we can attempt to get in there [Willits]." According to REACH personnel, the flight nurses are responsible for all non-emergency in-flight communications with other agencies, including REACH dispatch.

Shortly after landing at UKI, the helicopter departed about 1925 under visual flight rules (VFR) and proceeded north toward a CDF helipad just south of Willits to attempt to pickup the patient there. About 1928, the medical crewmembers on the helicopter indicated that they wanted the ground ambulance to continue to UKI and that they would advise if they were able to land at the CDF helipad. About 1930, the flight nurse told CDF dispatch that the flight was returning to UKI. No further transmissions were received from the flight nurse.

About 1933, CDF dispatch received the first 911 call from a witness who reported seeing something going down off of highway 101 and then observing a fire. About 1942, a California Highway Patrol officer on a routine patrol reported a fire and explosions on a hillside adjacent to highway 101 at milepost marker 39 and indicated that he thought that it was possibly a downed aircraft. The wreckage was located at 39 degrees 16.715 minutes north latitude by 123 degrees 16.878 minutes west longitude at an elevation of about 1,190 feet mean sea level (msl).

Residents and rescue personnel in the area of the accident stated that there were high winds and rain at the time of the accident. Emergency response personnel who arrived on scene noted that it was raining and that visibility was poor due to heavy fog. A dispatcher at CDF Howard's Forest noted that it was "pouring down rain" and was "very windy," with no fog present.

A witness located about 2 miles south of the accident along highway 101 reported that she heard the accident helicopter fly over her residence about 1920. She indicated that the helicopter was "flying real low," sounded very loud, and that the lights were on. She reported that she initially thought that the helicopter engine was having problems because it was so loud. However, when the helicopter initiated a climb and flew off, she stated that the engine sounded normal. The witness also indicated that she did not think the helicopter would clear the trees in the area because it was flying so low. The National Transportation Safety Board investigator-in-charge (IIC) estimated the treetops in the area of the witness' residence to be about 100 feet tall.

A flight nurse from CalStar, an EMS operator based out of UKI, spoke to a REACH flight nurse on board the accident flight when it was about 20 minutes from UKI. The CalStar flight nurse told the REACH crew to come inside to warm up and wait for the ground ambulance to arrive at UKI with the patient. The CalStar flight nurse reported that once the accident helicopter arrived at UKI, the pilot did not shut it down. The CalStar flight nurse stated that the REACH flight nurses got out of the helicopter, then got back in, and it took off. CalStar pilots checked weather throughout the day for the UKI area, and indicated that the weather was forecasted to be "very windy and rainy."

The charge nurse at Howard Memorial Hospital, where the patient was being transported from, reported that the emergency room doctor at Santa Rosa Memorial Hospital arranged the patient transport. She stated that she had not been outside that day but knew that the weather was bad. The charge nurse further reported that once in contact with REACH, she told them three times that the hospital had enough staff and would be able to transport the patient to UKI to meet the helicopter.

PERSONNEL INFORMATION

A review of the pilot's Federal Aviation Administration (FAA) airman certification records disclosed that the pilot held an ATP certificate with ratings for airplane multiengine land and rotorcraft helicopter, as well as commercial privileges for airplane single engine land. The pilot was type rated for the Sikorsky SK-58 (VFR only) and SK-62.

Review of the pilot's medical information revealed that the most recent first-class medical certificate was issued on October 28, 2003. The medical contained no limitations.

According to REACH's written statement, the pilot had an estimated total flight time of 14,143.0 hours, with 12,858 hours of total flight time in rotorcraft. REACH indicated that the pilot had accumulated 1,382.9 hours of night total time, 484.7 total hours of actual instrument flight, and 417.8 total hours of simulated instrument flight. He had an estimated 1,670.3 hours in the accident helicopter make and model. He logged 69.8 hours in the last 90 days, with 35.3 hours of night flight and 12.5 hours of actual instrument flight. In the last 30 days, he logged 27.0 hours, of which 9.1 hours were night flight and 11.4 hours were actual instrument flight. In the last 24 hours, the pilot had accumulated 2.1 hours, with 1.6 hours of actual instrument flight and no night flights.

Review of the pilot duty records for the day of the accident showed that the pilot was scheduled from 0800 to 2000 hours. The accident flight was dispatched about 1841. He was 1 hour 20 minutes from the end of a normal 12-hour duty day, and 3 hours 20 minutes from the FAA regulation of a maximum 14-hour duty day.

The accident pilot's training records from REACH indicated that he had completed a company IFR training module on December 7, 2003. The "Instructor Comments" section of his evaluation indicated that he was ready for his Part 135 checkride. On December 15, 2003, the accident pilot completed the 14 CFR Section 135.293/.297 and Section 135.299 checkride for an airman competency/proficiency check.

AIRCRAFT INFORMATION

The helicopter was an Agusta A109A, serial number 7220. The helicopter was on an FAA approved airworthiness inspection program (AAIP), and, at the last inspection, had accumulated a total airframe time of 3,847.5 hours. The AAIP 25- and 150-hour inspections were completed on November 24-26, 2003. The helicopter had accumulated 17.3 hours since the last inspection.

The helicopter was powered by two Rolls-Royce/Allison Model 250-C20B engines. Engine No. 1 (serial number [S/N] CAE 832876) had a total of 3,599.6 hours, and engine No. 2 (S/N CAE 832148) had a total time of 6,525.5 hours at the time of the accident. At the last 150-hour inspection, completed on November 24-26, 2003, engine No. 1 had a total time of 3,582.4 hours, and engine No. 2 had a total time of 6,508.3 hours. Examination of the maintenance and flight department records revealed no unresolved maintenance discrepancies against the helicopter before departing for the accident flight.

According to REACH personnel, the helicopter was refueled at Chico Municipal Airport the day of the accident with 57 gallons of Jet A fuel. A daily preventative maintenance check was performed on the mobile refueler on the day of the accident, and no discrepancies were noted. A monthly check of the mobile refueler was completed on December 1, 2003.

METEOROLOGICAL CONDITIONS

The closest official weather observation station was at UKI, located 10 nautical miles (nm) south of the accident site. The elevation of the weather observation station is 625 feet msl. A meteorological aerodrome report (METAR) for UKI issued at 1756 reported a broken cloud layer at 1,500 feet above ground level (agl); an overcast cloud layer at 2,400 feet agl; visibility 10 statute miles (sm); winds from 130 degrees at 9 knots; temperature 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit; and an altimeter setting of 29.78 inches of mercury.

A special METAR was issued about 1826 reported a scattered cloud layer at 2,500 feet agl; an overcast cloud layer at 3,300 feet agl; visibility 10 sm; winds from 120 degrees at 9 knots; temperature 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit; and an altimeter setting of 29.77 inches of mercury. The remarks section reported that rain began about 1800 and ended about 1810.

The METAR about1856 indicated a few clouds at 2,500 feet agl; a broken cloud layer at 3,200 feet agl; and an overcast cloud layer at 4,600 feet agl; visibility 9 sm; winds from 140 degrees at 10 knots; temperature 52 degrees Fahrenheit; dew point 48 degrees Fahrenheit; and an altimeter setting of 29.78 inches of mercury. The remarks section reported rain beginning about 1800, ending about 1810, and beginning again about 1855.

The METAR issued about 1956 indicated a few clouds at 2,500 feet agl; a broken cloud layer at 3,200 feet agl; an overcast cloud layer at 4,600 feet agl; visibility 9 sm; winds from 140 degrees at 8 knots; temperature 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit; and an altimeter setting of 29.29 inches of mercury. There were no entries in the remarks section.

UKI also recorded unofficial weather observations in 5-minute intervals. About 1925, sky conditions were reported as few clouds at 2,700 feet agl; a broken cloud layer at 3,900 feet agl, and an overcast cloud layer at 6,500 feet agl; visibility 10 sm; light rain present, and winds from 130 degrees at 8 knots. The observation also recorded a pressure altitude of 760 feet and relative humidity as 96 percent, with a density altitude of 400 feet.

About 1930, about 2 minutes before the accident, the sky condition was reported as few clouds at 2,700 feet, a broken cloud layer at 4,700 feet, and an overcast cloud layer at 6,500 feet.

About 1935, the sky condition was reported as few clouds at 2,800 feet, a broken cloud layer at 4,900 feet, and an overcast cloud layer at 6,500 feet. The pressure altitude increased to 750 feet.

Pilot reports (PIREPS) obtained for the Northern California and Oregon coastal areas ranged from 75 nm to more than 190 nm from the accident site in different geographical locations and were not pertinent to the accident area.

An aviation area forecast (FA) issued by the Aviation Weather Center, Kansas City, Missouri, for the northern California Pacific Coast (FA6) about 1245, indicated that the cloud layers along the coastal sections were scattered to broken from 2,500 to 3,500 feet, overcast conditions at 7,000 feet, with tops at 25,000 feet. Visibilities were occasionally 3 to 5 sm with light rain and mist. After 1800, the forecast called for a broken ceiling at 3,000 feet and southerly winds gusting to 25 knots. The FA6 forecast for the Sacramento Valley indicated cloud layers that were scattered to broken from 1,000 feet, broken at 3,000 feet, and layered to 25,000 feet. Visibilities were occasionally from 3 to 5 sm with light rain showers and mist. After 1600, the forecast called for an overcast ceiling at 3,000 feet with occasional light rain.

The FA6 issued at 1945 for northern California indicated cloud layers along the coastal sections that were broken to overcast to 6,000 feet, overcast at 12,000 feet, and layered to 20,000 feet. Visibilities were occasionally from 3 to 5 sm with rain.

The Terminal Aerodrome Forecasts (TAFs) valid for December 23, 2003, at UKI from about 1600 through the accident time indicated visibilities greater than 6 sm, light rain showers, a scattered cloud layer at 1,500 feet, and an overcast cloud layer at 2,500 feet. The wind was forecast from 120 degrees at 10 knots.

The amended TAF issued for December 23 about 1917 for UKI indicated visibilities greater than 6 sm, light rain showers and a scattered cloud layer at 2,500 feet, and an overcast cloud layer at 3,000 feet. The wind was forecast from 140 degrees at 10 knots.

AIRMET SIERRA Update 5 was issued on December 23 and valid from 1245 until 1900 for IFR conditions and mountain obscuration for Northern California. Airmet TANGO (turbulence) for occasional moderate turbulence issued for the same time period encompassed California and coastal waters.

AIRMET SIERRA was issued on December 23 about 1845 and valid until 0100 on December 24 for IFR conditions and mountain obscuration for northern California. AIRMET TANGO for occasional moderate turbulence below 18,000 feet issued for the same time period encompassed California and coastal waters.

According to the National Transportation Safety Board senior meteorologist, a strong frontal system off the Pacific Northwest coastline was prevalent during the accident time. In advance of the frontal system along the Northern California area, moderate to strong southerly low-level winds existed, along with high relative humidity, rainfall, and an upslope flow in the accident area. All of these conditions combined to form patchy mountain obscuration and IFR conditions throughout Northern California.

The accident pilot received and reviewed a Direct User Access Terminal Service (DUATS) weather report, which contained the same information provided by the Safety Board senior meteorologist.

WRECKAGE AND IMPACT INFORMATION

The accident site is located 0.25-mile west of highway 101 near Reeves Canyon Road. Highway 101 is a north/south interstate highway situated in a corridor between the cities of Ukiah and Willits. The terrain has sharp contrasts between the valley floors and mountain peaks with elevations ranging up to 2,000 feet. The helicopter came to rest on the side of a 1,190-foot mountain in a ravine on a 60-degree upslope with uneven, stepped terrain. The helicopter came to rest about 150 feet below the mountain's ridgeline. The debris path was along a magnetic bearing of 165 degrees.

The east-facing slope of the ravine contained part of a rock outcropping. Near the bottom of the rock outcropping were two distinct witness marks. A 20-foot-tall tree on the west side of the ravine had broken branches near the top facing toward the east.

An Agusta representative identified the witness marks (pieces of main rotor blades, and indentations) on the rock outcropping as main rotor blades strikes. He estimated that the helicopter airspeed was about 89 knots at the time of the accident based on the distance between the main rotor blade strikes.

The forward portion of the right side of the helicopter collided with a lower steppe of the mountain face. The upper portion of the cockpit area was sheared off and came to rest about 5 feet south of the main wreckage area. All four of the main rotor blades remained connected to the main rotor hub and exhibited chordwise buckling along the entire span of the blades. Both engines remained attached to their mounting points, which remained connected to the engine transmission deck. The transmission also remained connected to the tr

NTSB Probable Cause

The pilot's improper in-flight planning and decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in an inadvertent in-flight encounter with instrument meteorological conditions and a collision with rising terrain while attempting to reverse course.