WPR24FA037

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.

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.

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 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. 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. 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 TRACON to 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). <insert Figure 3 from Route of Flight PDF> 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 200300 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 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 the airplane. 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. 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 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 in light 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