# NTSB WPR24FA037: Cessna P210N, N1400, San Diego, CA, November 16, 2023 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: November 15, 2023, 21:20 local (Nov 16, 2023, 05:20 UTC) - Place: San Diego, CA · Side of hill. - Coordinates: 32.868472, -117.23909 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.8685&lon=-117.2391&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR missed approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 10, 2025 - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA, Textron Aviation - NTSB case key (mKey): 193391 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR24FA037 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193391/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193391 - Page: https://openairdocs.org/ntsb/WPR24FA037 ## 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. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna P210N, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073454), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna P210N, 5 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=2073454), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna P210N, 11 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2073454), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Experience/qualifications: recent instrument experience](https://openairdocs.org/ntsb-findings/02031050): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/02031050/cases.md?model=2073454), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/02031050/cases.md) - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate; cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=2073454), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed approach: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Cessna P210N, 3 cases](https://openairdocs.org/ntsb-events/192/sequence.md?model=2073454), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Emergency descent: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Cessna P210N, 4 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2073454), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis 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. ## Factual narrative According 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. The 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. MYF had an operational control tower that was attended from 0700 to 1800 and was closed during the pilot’s instrument approach to MYF. The MYF airport had a NOTAM for runway 28R runway alignment indicator lights unserviceable (out of service), issued on August 18, 2023, and cancelled on December 5, 2023. The pilot’s filed alternate airport of CRQ had an ILS runway 24 unserviceable (out of service) NOTAM issued on November 9, 2023, and cancelled on December 21, 2023. On 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 TRACONto 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). 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 200 300 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. The 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. The 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 inlight 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. A 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. The 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 theairplane. ## Aircraft - Registration: [N1400](https://openairdocs.org/aircraft/N1400), registered now, S/N P210-00277, built 1979 (OpenAirDocs) - Reported make and model: CESSNA P210N - Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P210-00277 - Year built: 1979 - Airframe hours: 2845.9 - Engines: CONT MOTOR TSIO-520 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 1, 2023 - Departed: CCR, Concord, CA - Destination: F70, Murietta, CA - Flight plan: IFR - Airport: MYF, Montgomery-Gibbs Exec, runway 28R, 4,598 × 150 ft, asphalt - Equipment: Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: fatal; flight engineer, flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 17,372 total ## Weather - Conditions: Instrument (IMC), Night - Wind: 80° at 4 knots - Visibility: 4 statute miles - Lowest ceiling: 1,100 ft overcast - Temperature: 57 °F, dew point 57 °F - Altimeter: 30.01 inHg - Observed at: KNKX, 5 nm away - METAR: KNKX 160538Z 08004KT 4SM -RA BR OVC011 14/14 A3001 RMK AO2 DZE32RAB32 P0001 T01440144 $ ## 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 20231115019319A](https://openairdocs.org/incident/20231115019319A), Nov 15, 2023: Cessna P210N, San Diego, CA, Substantial damage, 1 fatal. The accident aircraft was cleared for the ILS approach at myf airport after failing to land at its planned destination airport F70 and the planned alternate… ## Docket (19 files) The files NTSB released with the investigation on December 10, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193391. 40.1 MB in all. - IFR flight plan (item 1, PDF, 2 pages, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553436&FileExtension=pdf&FileName=N1400%20Flight%20Plan%20Information_Redacted-Rel.pdf - Route of flight illustrations (item 2, PDF, 3 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19565219&FileExtension=pdf&FileName=Route%20of%20Flight-Rel.pdf - Accident site summary report (item 3, PDF, 5 pages, 847 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553949&FileExtension=pdf&FileName=WPR24FA037%20Accident%20Site%20Factual%20Report%20Final%201-Rel.pdf - Weather report (item 4, PDF, 11 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19556511&FileExtension=pdf&FileName=WPR24FA037%20Weather%20Final-Rel.pdf - Memorandums for record (item 5, PDF, 5 pages, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19565389&FileExtension=pdf&FileName=WPR24FA037%20Memorandums%20of%20Record-Rel.pdf - Avionics examination summary report (item 6, PDF, 4 pages, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19554215&FileExtension=pdf&FileName=WPR23FA037%20Avoinics%20Exam%20-Rel.pdf - Airplane examination summary report (item 7, PDF, 6 pages, 701 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19554887&FileExtension=pdf&FileName=WPR23FA037%20Airframe%20Examination-Rel.pdf - Airplane logbook excerpts (item 8, PDF, 1 page, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553386&FileExtension=pdf&FileName=Airplane%20Logbook%20Excerpts_Redacted-Rel.pdf - Pilot logbook excerpts (item 9, PDF, 6 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19555731&FileExtension=pdf&FileName=WPR24FA037%20Pilot%20Logbook%20Excerpts_Redacted-Rel.pdf - POH excerpts (item 10, PDF, 7 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19554759&FileExtension=pdf&FileName=POH%20Excerpts-Rel.pdf - ADS-B flight data (item 11, XLSX, 28.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553788&FileExtension=xlsx&FileName=20231116_A0A508_533339297_ADSB-Rel.xlsx - Fuel receipt (item 12, PDF, 1 page, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553246&FileExtension=pdf&FileName=N1400%201115%20Fuel-Rel.pdf - Myf ILS 28R approach (item 13, PDF, 1 page, 354 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553798&FileExtension=pdf&FileName=MYFIILS28R-Rel.pdf - NOTAMS (item 14, PDF, 2 pages, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553236&FileExtension=pdf&FileName=NOTAMs_Redacted-Rel.pdf - FAA info 08004 comparison of minimum fuel, emergency fuel and reserve fuel (item 15, PDF, 3 pages, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553416&FileExtension=pdf&FileName=INFO_08004-Rel.pdf - FAA info 15012 logging instrument approach procedures (iap) (item 16, PDF, 3 pages, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553426&FileExtension=pdf&FileName=InFO15012-Rel.pdf - Toxicological report (item 17, PDF, 1 page, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19552577&FileExtension=pdf&FileName=Tox%20Test%20Final_Redacted-Rel.pdf - Party form (item 18, PDF, 1 page, 838 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553205&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 19, PDF, 1 page, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=19553396&FileExtension=pdf&FileName=2024%20Retention-Release-of-Wreckage-Form%20Final_Redacted-Rel.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.