N1400

Substantial
Fatal

CESSNA P210NS/N: P210-00277

Accident Details

Date
Thursday, November 16, 2023
NTSB Number
WPR24FA037
Location
San Diego, CA
Event ID
20231116193391
Coordinates
32.868472, -117.239090
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
1
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
1

Probable Cause and Findings

A total loss of engine power due to fuel exhaustion. Contributing to the accident were the pilot’s inadequate flight and fuel planning and his decision to fly in night instrument meteorological conditions despite his lack of recent instrument flight.

Aircraft Information

Registration
Make
CESSNA
Serial Number
P210-00277
Engine Type
Reciprocating
Year Built
1979
Model / ICAO
P210NC210
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1
Seats
6
FAA Model
P210N

Registered Owner (Current)

Name
SALOUR MICHAEL M
Address
PO BOX 130878
City
CARLSBAD
State / Zip Code
CA 92013-0878
Country
United States

Analysis

HISTORY OF FLIGHTOn November 15, 2023, about 2120 Pacific standard time, a Cessna P210N airplane, N1400, was substantially damaged when it was involved in an accident near San Diego, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The airline transport pilot had filed an instrument flight rules (IFR) flight plan for the accident flight that departed from Buchanan Field Airport (CCR), Concord, California, at a cruise altitude of 9,000 ft mean sea level (msl), with a planned destination of French Valley Airport (F70), Murrieta, California. The filed alternate was Mc Clellan-Palomar Airport (CRQ), Carlsbad, California.

ADS-B data revealed that the airplane departed CCR about 1734 and climbed to an initial cruise altitude of about 9,000 ft msl. About 2030, after several cruise altitude changes, the airplane arrived near F70. According to air traffic controllers, due to poor weather conditions at F70, the pilot planned to divert to CRQ. However, there was an ILS outage at CRQ, so the pilot chose to divert to Montgomery-Gibbs Executive Airport (MYF), San Diego, California, to fly the ILS approach there. ADS-B data showed that about 2048, the airplane descended to below 3,000 ft msl and then climbed to about 5,000 ft msl.

The Southern California Terminal Radar Approach Control (TRACON) cleared the pilot for the ILS Runway 28R approach to MYF and then transferred him to the MYF common traffic advisory frequency. When the TRACON controller noticed the airplane was drifting off the localizer course, the controller attempted to contact the pilot, but there was no response.

As the airplane overflew MYF at 600 ft msl, the pilot contacted the TRACON to report he was on the missed approach. The controller issued a low-altitude alert and asked the pilot his intentions. The pilot requested another approach and advised the controller he was running low on fuel, with about 10 minutes remaining. The airplane then began a series of erratic turns with altitude changes between 1,000 and 3,000 ft msl, and the pilot said that he needed to make an emergency landing. The controller instructed the pilot to climb and turn away from higher terrain. When the pilot informed the controller that he was completely out of fuel, the controller attempted to vector the airplane toward a runway at another nearby airport, but the airplane maneuvered northwest of the airport and then communication and contact were lost (see figure).

<insert Figure 3 from Route of Flight PDF>

Figure. Last portion of flight route after missed approach at MYF.

A witness reported that visibility in the area was almost zero and the ceiling was 200300 ft agl with light rain and little wind. The pilot of an airplane flying behind the accident airplane on the approach stated that that he followed the ILS approach down without any problems, turned on the runway lights while still in IMC, broke out of the weather about 1,100 ft msl, and landed without issue.

The accident airplane was not immediately located and was the subject of an FAA Alert Notice. Subsequently, a search located the airplane early the following morning on the side of a hill in a residential area about 3 miles northwest of MYF. PERSONNEL INFORMATIONA review of the pilot’s logbooks revealed that the pilot’s most recent actual or simulated instrument flight experience occurred on April 20, 2022. In the six calendar months preceding the accident, the pilot logged one instrument approach, although this was not logged as actual or simulated instrument time. (Six instrument approaches, holding procedures and tasks, and intercepting and tracking courses through the use of navigational electronic systems are required within the six preceding calendar months to act as pilot-in-command under IFR according to 14 CFR 61.57.) The pilot had logged a total of 10 flights and 7.6 hours of flight experience during 2023. AIRCRAFT INFORMATIONThe airplane’s Pilot’s Operating Handbook (POH) indicated that the fuel tanks had a total capacity of 90 gallons, with 89 gallons usable. A fixed-base operator added 49.8 gallons of fuel to the airplane at CCR on the afternoon of November 15, 2023. The refueler said he topped off the tanks.

The POH specified a cruise time of 4.2 hours at 80% power and an altitude of 10,000 ft, with the usable fuel of 89 gallons and the recommended lean mixture setting. This time included a fuel allowance for engine start, taxi, climb, and 45 minutes reserve at 45% power. METEOROLOGICAL INFORMATIONThe National Weather Service Surface Analysis Chart depicted a cold front extending along the California coast with two high pressure centers over the southern California coast, with visibility restricted in light rain and mist, and overcast clouds.

The closest weather reporting location to the accident site was Marine Corps Air Station Miramar (NZY), San Diego, California. At 2136, a special weather observation at NZY reported 3 miles visibility in light rain and mist, and the ceiling broken at 300 ft agl.

At 2053, the visibility at MYF, where the pilot performed an instrument approach, was 3 miles in light rain and mist, and the ceiling was broken at 500 ft agl.

A numerical sounding model indicated that at 2100 at the accident site, the freezing level was about 12,700 ft msl. The model predicted nimbostratus clouds with bases near 400 ft agl and tops near 10,000 ft msl . The sounding wind profile indicated a surface wind from 110° at 4 kts and a maximum low-level wind near 2,000 ft agl at 165° at 21 kts. Additionally, the model predicted several layers of light to moderate turbulence at altitudes the accident airplane flew during the final portion of the flight.

No SIGMETs or convective SIGMETs were active for the accident area. AIRMETs were active for IFR conditions, mountain obscuration, and occasional moderate turbulence below 16,000 ft msl. The Los Angeles Center Weather Service Unit did not issue any Center Weather Advisories applicable to the area and time of the accident.

At the time of the accident, night conditions prevailed, and both the sun and moon were more than 15° below the horizon and provided no illumination over the area.

Neither the FAA’s Automated Flight Service Station operator nor the ForeFlight flight planning software provider had a record of the pilot obtaining a formal weather briefing. Although the pilot had a ForeFlight account, he did not create a "flight" in the application for the trip from CCR to F70, so no weather briefing was generated through ForeFlight. AIRPORT INFORMATIONThe airplane’s Pilot’s Operating Handbook (POH) indicated that the fuel tanks had a total capacity of 90 gallons, with 89 gallons usable. A fixed-base operator added 49.8 gallons of fuel to the airplane at CCR on the afternoon of November 15, 2023. The refueler said he topped off the tanks.

The POH specified a cruise time of 4.2 hours at 80% power and an altitude of 10,000 ft, with the usable fuel of 89 gallons and the recommended lean mixture setting. This time included a fuel allowance for engine start, taxi, climb, and 45 minutes reserve at 45% power. WRECKAGE AND IMPACT INFORMATIONThe terrain was populated with trees and vegetation. The airplane came to rest a few feet from the initial point of impact on a magnetic heading of about 273°. All major structural components of the airplane were located within the main wreckage site.

The accident site was located in a residential area and was situated near the top of a hillside with a slope of about 70°. The initial point of impact was about 40 ft below the hilltop. The main wreckage was located at an elevation of about 370 ft msl.

Postaccident examination of the airplane revealed that the fuel tanks were intact and empty, consistent with fuel exhaustion. In addition, an aircraft navigation test set device was used to check the navigation and ILS of the airplane. No anomalies were noted during the check. Overall, there was no evidence of preimpact mechanical failures or malfunctions that would have precluded normal operation of the airplane. ADDITIONAL INFORMATIONAccording to 14 CFR 91.167, IFR fuel requirements are to have enough fuel to fly to the first airport of intended landing and then enough fuel for 45 minutes of flight at normal cruising speed after reaching the alternate airport. MEDICAL AND PATHOLOGICAL INFORMATIONThe San Diego County Medical Examiner Department, San Diego, California, performed an autopsy of the pilot. According to the autopsy report, the cause of death was multiple blunt force injuries, and the manner of death was accident.

Toxicology testing performed by the FAA Forensic Sciences Laboratory was negative for drugs of abuse and ethanol. The following medications were detected in blood and urine: rosuvastatin (Crestor), a prescription cholesterol medication that the FAA states is acceptable for pilots; metformin, an oral medication used alone or with other medications, including insulin, to treat type 2 diabetes mellitus, and which the FAA states may be acceptable for pilots under certain conditions and may require FAA review; and diltiazem (Cardizem), an alpha-blocker used to treat high blood pressure that the FAA states is acceptable for pilots.

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR24FA037