# NTSB LAX01FA194: Cessna 210A, N9462X, Escondido, CA, May 28, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 28, 2001, 11:49 local (18:49 UTC) - Place: Escondido, CA - Coordinates: 33.129768, -116.979553 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.1298&lon=-116.9796&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report February 7, 2002 - Report: Approved by Office Director - Parties: Cessna Aircraft Corporation, Continental Motors, Flight Standards District Office - NTSB case key (mKey): 52362 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01FA194 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52362/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=52362 - Page: https://openairdocs.org/ntsb/LAX01FA194 ## Probable cause the pilot's spatial disorientation and lack of instrument flight proficiency that resulted in a loss of directional control and the airplane's subsequent in-flight collision with the ground. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, climb - to cruise - weather condition - clouds (contributing factor) - spatial disorientation, pilot in command (cause) - directional control - not maintained, pilot in command (cause) - lack of recent instrument time, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - mountainous/hilly - reason for occurrence undetermined ## Analysis The airplane departed the Ramona airport approximately 1140. It was radar identified by the air traffic controller, who then instructed the pilot to climb and maintain 6,000 feet msl. The controller told the pilot to make a left turn and proceed to the Oceanside VOR. The pilot acknowledged the instructions. The airplane then made a right turn to a heading of approximately 040 degrees at 4,300 feet msl. The controller requested that the pilot fly a heading of 270 degrees and to climb to 7,000 feet msl. The pilot acknowledged the radar vector. The airplane then made a steep 320-degree turn to the left, stopping on a heading of approximately 360 degrees at an altitude of 4,800 feet msl. The controller asked the pilot to continue his right turn to a heading of 290 degrees for radar vectors to victor airway 186. Then the controller asked the pilot to say altitude. A response from another pilot onboard the airplane said, "standby, we're in a little trouble here." The controller made two subsequent calls to the accident airplane. The pilot-in-command replied, "uh, six two x-ray standby a second." The controller issued a warning that the airplane was heading for higher terrain and instructed the pilot to turn left and climb. There was no response from the pilot. The airplane began a steep left turn from an altitude of 4,700 feet msl and turned left to a heading of approximately 180 degrees, descending from 4,700 feet msl to 2,500 feet msl, and then back up to 3,100 feet msl. At 1148:39, radar contact was lost with the airplane. According to the pilot's logbook, he had logged a total of 12.6 hours in 1999, 5.6 hours in 2000, and 11.5 hours in 2001. For the 3 years indicated, he had logged a total of 0.7 hours in instrument meteorological conditions. There was no evidence of an instrument proficiency check having been completed within the 12 calendar months prior to the accident. No instrument flight experience had been logged within the 12 calendar months preceding the accident. ## Factual narrative HISTORY OF FLIGHT On May 28, 2001, at 1149 hours Pacific daylight time, a Cessna 210A, N9462X, was destroyed when it crashed in hilly terrain 5 miles east of Escondido, California. The commercial pilot and two passengers were fatally injured. Instrument meteorological conditions prevailed at the time of the accident. The flight was conducted by the owner under 14 CFR Part 91. The airplane departed Ramona, California, on an IFR flight plan and clearance to Fresno, California. The flight plan was activated upon departure at Ramona. The pilot had flown with his son, a designated pilot examiner for the Federal Aviation Administration (FAA), on May 25, 2001, for the purpose of a flight review. The son stated that he asked his father to do several maneuvers, including steep turns, a simulated engine failure, and basic air work. According to the son, the pilot performed to the standards for a commercial pilot or better for the flight review, which he subsequently endorsed in the pilot's logbook. He stated that they did not perform any instrument maneuvers during the flight, which are not required for a flight review. On May 28, 2001, at 1032, the pilot received a weather briefing from the San Diego Automated Flight Service Station. During the briefing, the pilot was informed that the tops of the overcast along his intended route of flight were between 5,500 feet mean sea level (msl) and 6,000 feet msl, and were expected to remain so for the duration of the day. The pilot then filed an IFR flight plan from Ramona to Fresno. While filing the flight plan, the pilot stated that he had approximately 5 hours of fuel on board. The pilot also positively identified himself by name. At 1134, the pilot received an IFR clearance from the Ramona to Fresno by a controller from the SOCAL radar facility. The clearance was as follows: Cleared to Fresno airport via Ramona departure, bondo, victor 208, as filed. Climb and maintain five thousand, expect one zero thousand ten minutes after departure. Squawk code one zero one six, departure frequency one two seven point three. Time now one eight three four and a half. Void if not off by forty five. If not off by forty five, call us by fifty and advise of your intentions. According to the radar data and communications transcripts obtained from the Southern California Terminal Radar Approach Control, San Diego Palomar Associate position, the following events occurred: The airplane departed the Ramona airport approximately 1140. A radar target that was displaying a discrete transponder code that was assigned to the accident aircraft was observed on radar at 1140:17. The target was heading approximately 310 degrees and was at an altitude of 2000 feet msl. The target was observed to continue a climb on a heading of 310 degrees. An air traffic controller made three calls for N9462X before establishing communications at 1144:03. The accident airplane was radar identified by the controller at 1144:12, who then instructed the pilot to climb and maintain 6,000 feet msl. At that time the airplane was passing through 4,100 feet msl. At 1144:57, the controller told the pilot to make a left turn and proceed to the Oceanside VOR. At 1145:02, the pilot acknowledged the instructions. The airplane was then observed making a right turn to a heading of approximately 040 degrees and was at 4,300 feet msl. At 1145;06, the controller requested that the pilot fly a heading of 270 degrees for radar vectors and to climb to 7,000 feet msl. At 1145:16, the pilot acknowledged the radar vector. The airplane then made a steep 320-degree turn to the left, stopping on a heading of approximately 360 degrees at an altitude of 4,800 feet msl. At 1145:47, the controller asked the pilot to continue his right turn to a heading of 290 degrees for radar vectors to victor airway 186. At 1146:24, the controller asked the pilot to say altitude. At 1146:26, a response from another pilot onboard the airplane, identified by family members, said, "standby, we're in a little trouble here." The controller made two subsequent calls to the accident airplane. At 1146:39, the pilot-in-command replied, "uh, six two x-ray standby a second." At 1146:56, the controller issued a warning that the airplane was heading for higher terrain and instructed the pilot to turn left to a heading of 270 degrees and climb. There was no response from the pilot. At 1147:17, the airplane began a steep left turn from an altitude of 4,700 feet msl. The airplane was observed turning left to a heading of approximately 180 degrees and descending from 4,700 feet msl to 2,500 feet msl, and then back up to 3,100 feet msl. At 1148:39, radar contact was lost with the airplane. PERSONNEL INFORMATION A review of the Federal Aviation Administration airman records revealed that the pilot held a commercial pilot certificate with airplane single engine land and instrument airplane ratings. He also held a private pilot certificate with a single engine sea rating. The pilot held a second-class medical certificate, with a limitation requiring corrective lenses be worn while acting as pilot-in-command, issued on May 15, 2001. According to the pilot's logbook, he had logged a total of 12.6 hours in 1999, 5.6 hours in 2000, and 11.5 hours in 2001. For the 3 years indicated, he had logged a total of 0.7 hours in instrument meteorological conditions. There was no evidence of an instrument proficiency check having been completed within the 12 calendar months prior to the accident. No instrument flight experience had been logged within the 12 calendar months preceding the accident. A second pilot was onboard as a passenger. He had a private pilot certificate with an airplane single engine land rating. The second pilot did not have an instrument rating. AIRCRAFT INFORMATION The aircraft was a 1961 Cessna 210A, serial number 21057762. A review of the airplane logbooks revealed that an annual inspection was completed on April 26, 2001, at a total airframe time of 5,552 hours. A 50-hour inspection was accomplished on May 25, 2001, at a total airframe time of 5,603 hours. The airplane had a Teledyne Continental IO-470-E, serial number 088742R, engine installed. The total time on the engine at the last annual was 1,460 hours since major overhaul. A 50-hour inspection was completed on May 25, 2001, at a total engine time of 1,511 hours since major overhaul. The pitot static system and transponder inspection and certification was completed on September 27, 2000. METEOROLOGICAL INFORMATION The Ramona airport is equipped with an automatic weather observation system (AWOS). The AWOS was reporting the weather conditions at 11:53 as follows: Wind was from 280 degrees at 9 knots with a visibility of 6 statute miles in mist. There was a broken cloud layer at 800 feet above ground level (agl) and an overcast layer at 1,400 feet agl. The temperature was 14 degrees Celsius with a dew point of 12 degrees Celsius. The barometric pressure was 29.93 inches of mercury. A remark noted that the ceiling was variable between 500 and 1,100 feet agl. A pilot report issued at 09:02 indicated that the cloud tops were 5,300 feet msl over the Carlsbad airport (CRQ), 15 miles from the accident site on a magnetic bearing of 240 degrees. WRECKAGE AND IMPACT INFORMATION The wreckage was located in hilly terrain at an elevation of approximately 2,400 feet msl. The area was characterized by dense brush with scattered outcroppings of granite. Immediately adjacent to the impact site was an avocado grove with trees about 25 feet in height. There was a fence separating the open field where the impact crater was located and the avocado grove. Several homes were located throughout the area. Tall bushes surrounded the west side of the impact crater. There were several disturbed branches visible immediately adjacent to the crater. The damaged branches sloped at a 30 ## Aircraft - Registration: [N9462X](https://openairdocs.org/deregistered/N9462X-2001-08-01), registration cancelled 2001-08-01, S/N 21057762 (OpenAirDocs) - Reported make and model: Cessna 210A - Registry model: [Cessna 210A](https://openairdocs.org/model/cessna-210a) (registry code 2073408) (OpenAirDocs) - Category: Airplane - Serial number: 21057762 - Airframe hours: 5603 - Engines: Continental IO-470 E 260 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, April 26, 2001, 51 hours before - Departed: RMN, Ramona, CA - Destination: FAT, Fresno, CA - Flight plan: IFR - Airport: RMN, Ramona, runway 27, 4,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 77; injuries: fatal; commercial; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review May 25, 2001; seat: left; flight hours: 3,900 total, 10 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 280° at 9 knots - Visibility: 6 statute miles - Lowest ceiling: 800 ft broken - Temperature: 57 °F, dew point 54 °F - Altimeter: 29.93 inHg - Observed at: RMN, 8 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20010528019329A](https://openairdocs.org/incident/20010528019329A), May 28, 2001: Cessna 210A, Ramona, CA, Destroyed, 3 fatal. (.19) On may 28, 2001, at 1149 hours pacific daylight time, a Cessna 210A, N9462X, was destroyed when it crashed in hilly terrain 5 miles east of escondido,… ## Other investigations on N9462X (2) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB OAK75FVA64](https://openairdocs.org/ntsb/OAK75FVA64), May 22, 1975: Cessna 210A (N9462X), Porterville, CA, substantial damage - [NTSB LAX70D0042](https://openairdocs.org/ntsb/LAX70D0042), Jul 1, 1969: Cessna 210 (N9462X), Phoenix, AZ, substantial damage ## Docket (29 files) The files NTSB released with the investigation on January 15, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=52362. 4.9 MB in all. - Supplement A (item 1, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155697&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 399 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155703&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement E (item 3, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155698&FileExtension=.PDF&FileName=Supplement%20E-Master.PDF - Supplement K (item 4, .PDF, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155699&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Witness Statements (item 5, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398404&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Wreckage Diagram (item 6, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155701&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Weather Reports and Records (item 7, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155702&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Maps or Charts of Accident Area. (item 8, .PDF, 845 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155704&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area.-Master.PDF - Other Pertinent Forms and Reports, Pilot logbook pages. (item 9, .PDF, 951 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155705&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports,%20Pilot%20logbook%20pages.-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398405&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398406&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. Impact crater, looking east toward wreckage. (item 12, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155708&FileExtension=.PDF&FileName=Photo%201.%20%20Impact%20crater,%20looking%20east%20toward%20wreckage.-Master.PDF - Photo 2. Impact crater, looking west. (item 13, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155709&FileExtension=.PDF&FileName=Photo%202.%20%20Impact%20crater,%20looking%20west.-Master.PDF - Photo 3. Right wing. (item 14, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155710&FileExtension=.PDF&FileName=Photo%203.%20%20Right%20wing.-Master.PDF - Photo 4. Vertical stabilizer, cabin, and engine. (item 15, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155711&FileExtension=.PDF&FileName=Photo%204.%20%20Vertical%20stabilizer,%20cabin,%20and%20engine.-Master.PDF - Photo 5. Left horizontal stabilizer and engine. (item 16, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155712&FileExtension=.PDF&FileName=Photo%205.%20%20Left%20horizontal%20stabilizer%20and%20engine.-Master.PDF - Photo 6. Vertical stabilizer. (item 17, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155713&FileExtension=.PDF&FileName=Photo%206.%20%20Vertical%20stabilizer.-Master.PDF - Photo 7. Propeller blade. (item 18, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155714&FileExtension=.PDF&FileName=Photo%207.%20%20Propeller%20blade.-Master.PDF - Photo 8. Propeller blade and hub. (item 19, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155715&FileExtension=.PDF&FileName=Photo%208.%20%20Propeller%20blade%20and%20hub.-Master.PDF - Photo 9. Engine. (item 20, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155716&FileExtension=.PDF&FileName=Photo%209.%20%20Engine.-Master.PDF - Photo 10. Spark plugs. (item 21, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155717&FileExtension=.PDF&FileName=Photo%2010.%20%20Spark%20plugs.-Master.PDF - Photo 11. Mag switch. (item 22, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155718&FileExtension=.PDF&FileName=Photo%2011.%20%20Mag%20switch.-Master.PDF - Photo 12. Engine. (item 23, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155719&FileExtension=.PDF&FileName=Photo%2012.%20%20Engine.-Master.PDF - Photo 13. Vacuum pump. (item 24, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155720&FileExtension=.PDF&FileName=Photo%2013.%20%20Vacuum%20pump.-Master.PDF - Photo 14. Vacuum pump. (item 25, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155721&FileExtension=.PDF&FileName=Photo%2014.%20%20Vacuum%20pump.-Master.PDF - Photo 15. Rotational scoring in baffling behind alternator. (item 26, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155722&FileExtension=.PDF&FileName=Photo%2015.%20%20Rotational%20scoring%20in%20baffling%20behind%20alternator.-Master.PDF - Photo 16. Gyro rotor exhibiting rotational scoring. (item 27, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155723&FileExtension=.PDF&FileName=Photo%2016.%20%20Gyro%20rotor%20exhibiting%20rotational%20scoring.-Master.PDF - Photo 17. Gyro. (item 28, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155724&FileExtension=.PDF&FileName=Photo%2017.%20%20Gyro.-Master.PDF - Transcript of Radio Communications (item 29, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40155725&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.