Aircraft Accident/Incident Report

Redwood Valley, California 95470
Tuesady, December 23, 2003 19:32 PST

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 12/23/2003
Event Day of the Week Tuesday
Time of Event 1932
Event Time Zone Pacific Standard Time
Event City Redwood Valley
Event State CALIFORNIA
Event Country --
Zipcode of the event site 95470
Event Date Year 2003
Event Date Month 12
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 391715N
Event Location Longitude 1231639W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1956 Pacific Standard Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID UKI
Elevation of weather observation facility 614
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation PST
Lighting Conditions Night/Dark
Lowest Ceiling Height 1500
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 11
Dew Point at event time (in degress fahrenheit) 10
Wind Direction (degrees magnetic) 130
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 9
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.79
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 3
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 3
Investigating Agency NTSB
NTSB Docket Number (internal use) 19448
NTSB Notification Source FAA
NTSB Notification Date Dec 23 2003 12:00AM
NTSB Notification Time 2000
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jan 26 2006 12:42PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Instrument Meteorological Cond
FAA District Office WP-OAK-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N25RX
NTSB Number LAX04FA076
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Agusta
Aircraft Model A109A
Aircraft Series Identifier --
Aircraft Serial Number 7220
Certified Max Gross Weight 2600
Aircraft Category Helicopter
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 5
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection AAIP
Date of Last Inspection Nov 1 2003 12:00AM
Airframe hours since last inspection 17.3
Airframe Hours 3847.5
ELT Installed Yes
ELT Activated --
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Reach Air Ambulance
Aircraft Owner Street Address 451 Aviation Blvd. Suite 201
Aircraft Owner City Santa Rosa
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 95403
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code JBZA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Positioning
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code UKI
Departure City UKIAH
Departure State CA
Departure Country USA
Departure Time 1925
Departure Time Zone PST
Destination Same as Local Flt --
Destination Airport Code --
Destination City Willits
Destination State CA
Destination Country USA
Specific Phase of Flight Maneuvering - turn to reverse direction
Report sent to ICAO? Yes
Evacuation occurred No
Date of most recent change to record Nov 3 2005 6:22PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight Yes
Medical Flight Medical Emergency