# NTSB LAX02FA049: Cessna T210L, N210RE, San Jacinto, CA, December 14, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 14, 2001, 15:28 local (23:28 UTC) - Place: San Jacinto, CA - Coordinates: 33.824165, -116.886947 - Nearby events: https://openairdocs.org/map.md?lat=33.8242&lon=-116.8869&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 2, 2004 - Report: Approved by Office Director - Parties: National Air Traffic Controllers Assn., Federal Aviation Administration, Cessna Aircraft Company - NTSB case key (mKey): 53923 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02FA049 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53923/pdf - Page: https://openairdocs.org/ntsb/LAX02FA049 ## Probable cause The pilot's loss of situational awareness and his failure to adhere to the prescribed instrument approach procedures, including the track and altitudes flown. The underlying reasons for the pilot's loss of situational awareness are unknown. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - iaf to faf/outer marker (ifr) - terrain condition - mountainous/hilly - weather condition - low ceiling (contributing factor) - ifr procedure - not followed, pilot in command (cause) - other psychological condition, pilot in command (cause) - altitude - not maintained, pilot in command (cause) ## Analysis During a GPS approach, the pilot did not turn onto the prescribed course toward the final approach fix, and he allowed the airplane to prematurely descend below the specified altitude for the route segment until impacting a mountainside in controlled flight. Actual instrument meteorological conditions prevailed, with a low ceiling over the mountains. About 11 minutes before the accident, the radar controller cleared the pilot to perform the GPS approach. The pilot indicated to the controller that he was aware of the initial approach fix's location and crossing altitude. At no time during the approach did the pilot indicate he was experiencing difficulty navigating or request assistance. The pilot initially navigated along the prescribed course. Seconds after passing an intermediate fix where a critical 75-degree course change was required, the controller lost radar and radio contact with the pilot. Rather than proceeding toward the final approach fix along the 153-degree prescribed course, the pilot's track averaged 107 degrees. Also, instead of maintaining the 4,100-foot msl minimum altitude until passing the final approach fix, the pilot descended to 3,550 feet msl. The airplane was equipped with a GPS receiver that had the capability of displaying a "moving" map. The airplane crashed 5.9 nm east of the prescribed course and 550 feet below the authorized altitude. The reason why the pilot lost situational awareness and his track became divergent is unknown. ## Factual narrative HISTORY OF FLIGHT On December 14, 2001, about 1528 Pacific standard time, a Cessna T210L, N210RE, collided with rising mountainous terrain during an instrument approach to the Hemet-Ryan (uncontrolled) Airport, about 4 nautical miles (nm) northeast of San Jacinto, California. The airplane was destroyed by impact forces and a postimpact ground fire. The instrument rated private pilot was fatally injured. Instrument meteorological conditions prevailed in the vicinity, and an instrument flight rules (IFR) flight plan was filed. At the time of the accident, the airplane was between the initial and final approach fixes and was approximately 5.9 nm east of the specified southerly approach course. The airplane was being operated as a personal flight under 14 CFR Part 91. Reportedly, the pilot had planned to fly to Hemet-Ryan to pickup relatives and transport them to Santa Monica, California, for a family gathering. The pilot departed from the Santa Monica Municipal Airport about 1446. At 1515, as the airplane was en route to the Hemet-Ryan Airport, a March Air Reserve Base (ARB) air traffic controller (March GCA) established radar contact with the accident airplane's pilot. The following minute the pilot advised the controller that he was descending from 7,000 to 6,000 feet mean sea level (msl). The controller informed the pilot that the altimeter was 29.68 inches of mercury. The pilot indicated that he desired to start the instrument approach to the Hemet-Ryan Airport at Seter. (Seter is the name of an initial approach fix depicted on the GPS-A initial approach procedure (IAP) chart for the airport.) At 1516:39, the controller stated to the pilot "cross Seter at ah five-thousand cleared GPS into Hemet." The pilot responded by asking "...cleared direct Seter right now?" The controller replied "affirmative, you can go direct at this time." The pilot then stated "ok, direct Seter and did you say descend to five-thousand?" The controller replied at 1516:59, and stated "stand by sir, I'm trying to see where the approach starts at, fifty-five or five, stand by." The pilot responded and said "I show it fifty-five on my ah on my chart here." The controller replied "yeah, I believe you're right, yeah you can cross Seter at five-thousand-five hundred cleared GPS into Hemet." Recorded radar data from the Los Angeles Air Route Traffic Control Center (LAX ARTCC) and the Southern California Terminal Radar Approach Control (SOCAL TRACON) indicate that between 1523:27 and 1523:49, the northeast bound accident airplane passed Seter, descended from 5,600 to 5,500 feet (as indicated by the airplane's Mode C-equipped transponder), and began tracking in an easterly direction toward the Kende intersection. For several minutes thereafter, there were no additional recorded communications to or from the accident pilot. Then, at 1525:15, the controller attempted to communicate with the pilot. The controller advised the pilot to report canceling his IFR flight on the current radio frequency, or after landing via telephone. The controller heard no response from the pilot. About this time, the accident airplane was approximately 0.6 nm south of the Kende intersection and was crossing the 153-degree prescribed direct course to the San Jacinto final approach fix. About 12 seconds later, the airplane's 077-degree track had become 092 degrees. At 1525:33, 1525:40, and 1525:47, the controller again attempted to contact the pilot. During the latter effort, the controller stated, "If you hear me ident." At 1526:02, the controller stated, "I copy the ident." The last recorded radar hit occurred 23 seconds earlier, at 1525:39, at which time the airplane had descended to 5,100 feet. The airplane's location at 1526:02 was subsequently recalled by the controller as being southeast of Kende. The pilot's last recorded radio transmission occurred at 1526:05, when he said "ah March, do you read me, zero romeo echo." The controller replied at 1526:08, and stated "OK, I hear you now its, ah when you get behind those mountain ranges over there its ah we usually lose radar and radio back there." At 1526:16 and 1526:26, the controller again transmitted IFR cancellation instructions to the pilot, but no reply was recorded. The controller transmitted "zero romeo echo, radar contact lost" at 1526:51. No witness reported observing the accident. The pilot's route of flight between the location where radar contact was last recorded and the 6.6 nm distance to the crash site is unknown. During the last minute of radar recorded flight, the airplane's average track and ground speed were about 092 degrees and 160 knots. Based on this ground speed, and the 107-degree direct course between the last recorded radar return (hit) and the crash site, the accident occurred about 1528. PERSONNEL INFORMATION The pilot held a private pilot certificate with the following ratings: airplane single and multiengine land, instrument airplane, and rotorcraft helicopter. On February 20, 2001, when the pilot was issued a second-class aviation medical certificate, with the restriction that he must wear corrective lenses, his reported total flight time was 1,150 hours. A relative of the pilot, who completed the National Transportation Safety Board's "Pilot/Operator Aircraft Accident Report" form, indicated that the pilot's experience flying the accident model of airplane was 425 hours. Data extracted from the pilot's flight record logbook indicates that the pilot's total flight time was in excess of 1,215 hours. Also, the pilot's total actual and simulated instrument flying experience was in excess of 39 and 83 hours, respectively. On October 10, 2001, the pilot successfully completed an instrument proficiency check (IPC) in his (accident) airplane. According to the certified flight instructor (CFI) who administered the IPC, during the flight the pilot demonstrated steep turns, unusual attitudes, holding, compass turns, ILS and VOR instrument approaches. The CFI did not report that the pilot demonstrated any proficiency performing GPS approaches. AIRCRAFT INFORMATION GPS Installation and Revision Service Data. According to Able Avionics, Van Nuys, California, about April 23, 2001, its repair station personnel installed a Garmin International Inc. GPS receiver model GNS 530 into the pilot's airplane. The airplane was not equipped with a separate automatic direction finder (ADF receiver) or a secondary GPS receiver. The GNS 530 unit was certificated for instrument en route, terminal, and nonprecision instrument procedures. The GNS 530's serial number was 78401266. The software version in the unit was unchanged since Able's acquisition of the unit from the manufacturer. The pilot was advised to keep the receiver's aviation database current using Jeppesen's revision service. Personnel at Jeppesen verbally reported to the Safety Board investigator that in order to maintain a current database in the GNS 530, the pilot had subscribed to its Skybound Datawriter revision service. This service provides for revisions on a 28-day cycle via internet downloads. Jeppesen reported that the pilot had subscribed to this revision service. However, they were unable to ascertain whether, in fact, the pilot had downloaded the current data. Jeppesen's personnel also noted, however, that there had not been any changes to the Hemet GPS-A approach procedure between the receiver's April installation and the December accident date. Flight Limitation, Equipment Certification, and Maintenance. The Federal Aviation Administration (FAA) certified the airplane for flight into instrument meteorological conditions (IMC). The airplane was not certified for flight into icing conditions. The airplane was equipped with a heated pitot tube and an alternate source for obtaining static atmospheric pressure for emergency use if t ## Aircraft - Registration: [N210RE](https://openairdocs.org/deregistered/N210RE-2002-07-03), registration cancelled 2002-07-03, S/N 21060516, built 1974 (OpenAirDocs) - Reported make and model: Cessna T210L - Registry model: [Cessna T210L](https://openairdocs.org/model/cessna-t210l) (registry code 2073449) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21060516 - Airframe hours: 2432 - Engines: Continental IO-520-H 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Jay W. Meepos, Trustee - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 3, 2001 - Departed: SMO, Santa Monica, CA - Destination: HMT, Hemet, CA - Flight plan: IFR - Airport: HMT, Hemet-Ryan ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review October 10, 2001; toxicology performed; flight hours: 1,215 total, 425 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 200° at 17 knots, gusting 24 - Visibility: 5 statute miles - Lowest ceiling: 1,800 ft broken - Altimeter: 29.65 inHg - Observed at: HMT, 9 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 20011214035479A](https://openairdocs.org/incident/20011214035479A), Dec 14, 2001: Cessna T210L, Sanjacinto, CA, No damage, 1 fatal. (.19) History of flight: on December 14, 2001, about 1528 hours pacific standard time, a Cessna T210L, N210RE, collided with mountainous terrain about 4 miles… ## Other investigations on N210RE (1) 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 FTW96LA328](https://openairdocs.org/ntsb/FTW96LA328), Jul 20, 1996: Cessna T210L (N210RE), Santa Fe, NM, substantial damage. Probable cause: the pilot's improper decision to continue the flight after noting the low fuel quantity indication, which resulted in fuel starvation before reaching the airport. A factor was the lack of suitable… 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.