Pilot Debrief

CESSNA P210N near San Diego, CA — 2023-11-16

Final reportWPR24FA037
Sign in to save
Date
2023-11-16
Location
San Diego, CA, USA
Airport
MYF
Aircraft
CESSNA P210N
Registration
N1400
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

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.

Contributing factors

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.

NTSB narrative

The instrument-rated pilot was conducting a personal night cross-county flight into an area where instrument flight rules (IFR) conditions prevailed. The pilot had flown nearly 4 hours and was conducting an instrument landing system (ILS) approach to an airport that he had diverted to due to poor weather at his intended destination and an ILS that was out of service by NOTAM at his filed alternate. There was no record of the pilot obtaining a weather briefing before the flight. During the approach, the airplane drifted from the localizer course. The pilot then reported a missed approach to air traffic control, requested another approach, and reported about 10 minutes of fuel remaining. Subsequently, the airplane made a series of erratic turns and altitude changes, and the pilot requested an emergency landing. Shortly afterward, the pilot informed the controller that he was completely out of fuel. While the controller attempted to vector the airplane toward a runway, the airplane maneuvered northwest of the airport and then communication and contact were lost. A witness reported that visibility in the area was almost zero and the ceiling was 200-300 ft above ground level (agl) with light rain and wind. However, a pilot flying behind the accident airplane on the approach was able to follow the ILS and land without issue. The airplane was not located and was the subject of a Federal Aviation Administration 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 west of the airport. A review of the pilot’s logbooks revealed that within the 6 months preceding the accident flight, he had not performed the tasks required to act as pilot-in-command under IFR. His most recent actual or simulated instrument flight occurred about 19 months before the accident flight. This lack of recent instrument experience likely contributed to the pilot’s difficulty completing the ILS approach. Postaccident examination of the airplane revealed that the fuel tanks were not damaged during the impact and were absent of fuel. In addition, there was no evidence of preimpact mechanical failures or malfunctions that would have precluded normal operation. The airplane had a specified cruise endurance of 4.2 hours with full fuel. The postaccident airplane examination, the airplane’s maximum endurance, and the pilot’s communications on his fuel status were all consistent with a total loss of engine power due to fuel exhaustion.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have diverted earlier to avoid low fuel situation.

NTSB coding

Evidence available

  • ADS-B / radar
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

Related mishaps