LAX04FA076

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.

Following an encounter with night instrument meteorological conditions, the emergency medical services (EMS) helicopter collided with rising hilly terrain while attempting to reverse course in a narrow mountain valley near Redwood Valley, California. The purpose of the flight was to pickup a patient at a rural hospital in a mountainous area for transport to a larger medical facility. When weather conditions would not permit reaching the rural hospital, common practice for the operator's flight crews was to fly to an intermediate airport with an instrument approach where the helicopter could meet ground transport of the patient and continue the evacuation. Prior to departure from home base, the pilot received a weather briefing from DUATS, which indicated that areas along the route of flight would experience light rain showers, as well as cloud layers that ranged from 1,500 feet above ground level (agl) to 6,000 feet agl ,and visibilities between 3 to 5 statute miles (sm). The pilot filed an instrument flight rules flight plan from his home base to the intermediate airport. An employee of another EMS operator based at the intermediate airport said that there was rain and reduced visibilities at the airport, and that she told the accident medical crew by radio that they should come inside and wait for the ambulance to get to the airport because of the weather. Once the accident helicopter arrived at the intermediate airport, the helicopter was not shut down, the flight nurses got out and got back in, and helicopter departed the airport. Communications between a fire department dispatcher and the accident medical crew indicated that the accident flight was attempting to fly to the fire department's helipad located between the intermediate airport and the hospital. Recorded company communications indicated that a few minutes after the conversation with the fire department dispatcher, the accident flight was diverting back to the intermediate airport. There were no further communications with the accident crew. Witnesses in the area of the accident site all reported heavy rain and wind and poor visibilities due to a heavy fog in the area. Another witness about 2 miles south of the accident site reported hearing the helicopter flying very low over her house, just above the 100-foot tall treetops, about 12 minutes before the accident. The charge nurse at the rural hospital indicated that the weather was poor, and she had indicated to the operator's dispatch that the rural hospital would transport the patient to the intermediate airport. The accident area was located in a narrow valley with mountain peak elevations ranging up to 2,000 feet on either side of a major highway that ran in a north/south direction. The airframe and engines were inspected with no preimpact mechanical anomalies noted.

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