Pilot Debrief

CESSNA P210N near Santa Monica, CA — 2012-08-11

Final reportWPR12FA349
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Date
2012-08-11
Location
Santa Monica, CA, USA
Airport
SMO
Aircraft
CESSNA P210N
Registration
N41KA
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The pilot's failure to maintain altitude during a return to the airport following an unspecified emergency; the nature of the emergency could not be determined because postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation.

NTSB narrative

About 15 minutes after departure, the pilot contacted air traffic control and requested a return to the departure airport without indicating the reason. About 10 minutes later, the pilot was instructed to enter a right base leg for the runway and was subsequently cleared to land behind traffic. One minute later, the pilot declared an emergency, but he did not identify the nature of the emergency. No further transmissions were made by the pilot. The airplane then collided with treetops on a southeasterly heading about 3 miles northeast of the airport and continued about 200 feet before striking the top of a palm tree and falling to the ground. A postcrash fire consumed the majority of the airplane. Postaccident examination of the airframe revealed no mechanical anomalies that would have precluded normal operation. The engine spark plugs were covered in heavy, dark soot indicative of an extremely rich mixture condition, which could have resulted in a loss of engine power. The engine was examined and subsequently placed on a test stand. After repairs were made to facilitate an engine run, the engine started, ran, and responded to throttle movements with no discrepancies noted. The reason for the return to the departure airport and subsequent reported emergency could not be determined. The investigation found that the pilot may have had therapeutic levels of doxylamine, a sedating antihistamine, in his blood about the time of the accident. However, based on the circumstances of the accident, it is unlikely that pilot impairment from doxylamine contributed to the accident. Further, the carbon monoxide present in the pilot's blood is consistent with postaccident exposure to combustion products.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Pilot could have declared an emergency earlier or requested assistance before losing control.

NTSB coding

Evidence available

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

Docket documents12

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