Athens, GA, USA
N2121J
FUJI LM1
In the 2 years prior the accident, the Japanese military airplane was flown less than 30 hours because the owner had had surrendered his Federal Aviation Administration medical certificate and had moved to another state. A pilot-rated acquaintance agreed to assist the owner by flying him to the airplane and then accompanying him back home in it. The retrieval flight was filed as an instrument flight rules flight. Visual flight rules conditions prevailed at the departure airport. After takeoff, as the airplane turned onto the crosswind leg, it was observed to cease its climb and then roll into a stall/spin until impact with the ground. Witnesses reported that the propeller was not rotating, but physical evidence was inconclusive. The airplane was not equipped with a stall warning system. Examination of the wreckage did not reveal any preimpact mechanical failures, but both the ignition switch and the fuel selector valve were found in their respective "off" positions. While it is clear that the airplane stalled and impacted the ground in uncontrolled flight, the precipitating event(s) could not be determined. Equal cases could be made that the positions of the ignition switch and the fuel selector valve were causal to the stall (through inadvertent manipulation, and resulting distraction), or that they were reactions to the stall and imminent ground impact (to reduce the fire hazard). Toxicological testing detected Donepezil and another medication in the owner's liver and kidney tissue. Donepezil (also known by the trade name "Aricept") was used almost exclusively to help treat the cognitive decline associated with Alzheimer’s disease. Neither medication would normally be expected to result in significant impairment, but the cognitive decline associated with Alzheimer’s disease would be expected to result in impairment. The investigation was unable to determine when or why the Donepezil was prescribed, or the cognitive condition of the owner. The available evidence suggested that his cognitive condition, if it was in fact diminished, was not apparent to others. The specific roles and actions of the two pilots during the accident flight could not be determined, but the evidence suggested that the owner acted as pilot in command and that he operated the controls. The investigation was unable to determine the extent of the acquaintance's knowledge of the owner's cognitive abilities and limitations or whether he was aware that the owner no longer held a valid FAA medical certificate. Evidence suggested that the acquaintance had little to no knowledge about the airplane’s operation or performance characteristics. The effect of the owner's extensive aviation experience on the acquaintance's judgment and decision-making could not be determined.
HISTORY OF FLIGHT On October 22, 2009, about 1122 eastern daylight time, an experimental Fuji LM-1, N2121J, was substantially damaged when it impacted terrain shortly after takeoff from runway 27 at Athens/Ben Epps Airport (AHN), Athens, Georgia. The airline transport pilot-rated owner and the pilot-rated acquaintance of the owner were fatally injured. The personal flight was operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at AHN, and an instrument flight rules (IFR) flight plan was filed for the flight to Leesburg International Airport (LEE), Leesburg, Florida. According to the airplane's maintenance records, a newly-overhauled engine was installed in November 2003, and in September 2007, after the engine had accumulated approximately 40 hours in service, all 6 cylinders were replaced. One month after the cylinder replacement, the engine had accumulated an additional 0.3 hours in service. According to a maintenance technician who also flew the airplane, it was operated regularly for a brief period, before it was left dormant until several weeks before the accident. He stated that this was because the owner had moved to Florida, while the airplane remained in Georgia. Maintenance records indicated that the airplane accumulated about 27 hours between September 2007 and September 2009. In September 2009, the owner informed the maintenance facility in Georgia that he wanted to move the airplane to Florida, and requested that they inspect the airplane in preparation for that flight. An annual inspection was satisfactorily completed on September 12. A technician from the maintenance facility flew the airplane on September 16, which was the last flight prior to the accident flight. In the period between the two flights, the airplane was stored in the maintenance facility's hangar. On October 21, the owner telephoned the maintenance facility to inform them that he would be picking up the airplane the following day, October 22. Maintenance facility personnel reported that they charged the battery, washed the airplane, and conducted an engine run, which included a magneto check. No anomalies were noted. According to several witnesses, on October 22, the owner and his acquaintance arrived at AHN in a Cessna 182 that was flown by the acquaintance's brother. After the Cessna landed, both the Cessna and the Fuji were fueled from the same fuel truck. According to the individual who fueled the Fuji, he topped off two fuel tanks by adding 7 gallons to the left fuel tank, and 14 gallons to one of the right fuel tanks. The owner seated himself in the left front seat of the Fuji while it was still being fueled. The acquaintance seated himself in the right front seat after the fueling was completed. Witness accounts differed as to whether the owner conducted a preflight inspection. A maintenance technician from the facility stated that he (the technician) took it upon himself to sample the fuel sumps after the fueling was completed, but he did not have any containers readily available, so he allowed the fuel samples to drain onto the ground. According to the pilot of the Cessna, he had filed an IFR flight plan for the two airplanes as a flight of two to LEE. Shortly after fueling was completed, both airplanes were started, and the Fuji taxied for departure behind the Cessna. Witness accounts of the estimated time from when the owner arrived at the Fuji, until the Fuji taxied out for takeoff, ranged from 20 to 40 minutes. The Cessna pilot conducted his pre-takeoff engine run-up, and he believed that an engine run-up of the Fuji was also conducted. No witnesses could definitively confirm or deny that an engine run-up of the Fuji was conducted. All air traffic control (ATC) communications were from and to the Cessna. The approach controller passed the IFR release to the AHN air traffic control tower (ATCT) local controller, and the local controller then cleared the Cessna (and therefore the Fuji) for takeoff. The airplanes took the runway about the same time, and the Cessna took off with the Fuji just behind it. The local controller turned his visual attention elsewhere, and instructed the Cessna pilot to contact Atlanta Approach control on another frequency. According to witnesses, the Fuji landing gear retracted shortly after takeoff, but the Fuji seemed to climb more slowly than the Cessna. Witnesses familiar with the Fuji stated that the initial pitch attitude appeared slightly high, and the Fuji was rocking slightly about its longitudinal axis. The pitch returned to "a normal climb attitude," the rocking stopped, and the Fuji then entered a slight left turn. Witnesses observed the Fuji cease its climb and left turn about the same time; they estimated that the Fuji's maximum altitude was between 500 and 1,000 feet above ground level (agl). The Fuji then began to descend, and soon thereafter re-entered a left turn. Some witnesses said that at this point, the left wing dropped sharply, the Fuji began a spin to the left, and disappeared from view. One witness stated that the spin began when the Fuji was approximately 150 feet above the trees. Witnesses at AHN stated that they could not hear whether the Fuji's engine was running, or whether it made any unusual sounds, due to another airplane engine running near them. One witness at AHN stated that the Fuji's "pitch up and turn reminded [him] of a hammerhead maneuver." Three witnesses on the roof of the house next to the accident site stated that noise of the Fuji striking a tree attracted their attention, and that the Fuji then overflew them. Their statement indicated that the Fuji was "basically level," and that the propeller was not rotating when they saw it. They stated that the Fuji "rolled hard right," and then impacted the ground. An airport maintenance technician saw the Fuji descend out of his field of view, and queried the local controller via radio about the situation. The local controller was not aware of any problem with the Fuji until that query. He confirmed through the approach controller that the Fuji was no longer with the Cessna, and then had the approach controller recall the Cessna to AHN. The Cessna returned uneventfully to AHN. PERSONNEL INFORMATION Left Seat Occupant (Fuji Owner) FAA records indicated that the Fuji owner held an airline transport pilot certificate with an airplane multiengine land rating, a commercial pilot certificate with multiple airplane ratings, including single engine land, a flight instructor certificate with multiple airplane ratings, and an experimental aircraft repairman certificate. In January 2007, the owner reported to the FAA that he had 23,640 total hours of civilian flight experience. The investigation was unable to locate the owner's pilot flight logbooks. He previously served as a pilot in the United States Air Force, and as a captain for Pan American World Airways. The owner's most recent FAA second-class medical certificate was issued in January 2007. In February 2007, due to an abnormal EKG and the use of an certain medication, the Aerospace Medical Certification Division of the FAA Civil Aerospace Medical Institute (CAMI) initiated correspondence with the owner, requesting clarification and substantiation of his medical history. In July 2007, the owner informed CAMI that he had experienced a "slight stroke" several days before, and in September 2007, he surrendered his medical certificate in response to CAMI's request. In October 2007, CAMI informed the owner that his eligibility to hold a medical certificate would be reconsidered in June 2009, pending his provision of certain substantiating documentation. The CAMI-specified documentation subjects included sleep apnea, hypertension, prostatic hypertrophy, and current medications and symptoms. No records of any subsequent medical certificate applications by the owner, or communications between CAMI and the owner, were discovered. Right Seat Occupant FAA records indicated that the right seat occupant (who was an acquaintance of the owner, and the brother of the Cessna pilot) held a private pilot certificate with airplane single- and multi-engine land ratings. He did not hold an instrument rating. An examination of his pilot logbook revealed a high-performance endorsement dated December 2006. The logbook documented approximately 223 total hours of flight experience, including 17 hours in multi-engine airplanes. No flight time was logged from late March to late August 2009. On August 22, 2009, he logged 1.5 hours, and on October 2, 2009 he logged an additional 0.5 hours, all in a Cessna 182. The logbook indicated that a total of five landings were conducted during those two flights. His most recent FAA third-class medical certificate was issued in January 2009. AIRCRAFT INFORMATION The Fuji LM-1 was a modified version of the Beech T-34 Mentor, that was re-designed and manufactured by the Japanese company Fuji Heavy Industries. The airplane was a four-place, low-wing monoplane of all-metal construction. It was equipped with a Teledyne Continental Motors (TCM) O-470-13A piston engine, retractable tricycle-style landing gear, and dual flight controls at the side-by-side front seats. According to FAA records, the airplane was manufactured about 1956, and initially operated by the Japanese government. In 1982 it was transferred from the United States (US) government to a private flying organization in the US, and was first registered to the accident owner in 1990. All placards, instrument panel, and control markings were in Japanese, but some were supplemented by manually-fabricated English labels. A pilot's operating handbook (POH) for the Fuji with Japanese text was retrieved from the wreckage, but no English-language manuals were located. Diagrams in the POH depicted a relatively standard layout of the instruments and flight controls. The engine controls quadrant was depicted at the lower center of the main instrument panel, the ignition switch was depicted on a sub-panel to the right of the engine controls quadrant, and the fuel selector valve was shown to be located between the two front seats. Pages from the POH that contained takeoff procedures and stall speed charts were examined. The takeoff procedure appeared to be to rotate, or lift off, at a speed of 70 to 75 knots, and then climb at a speed of 100 knots once any obstacles were cleared. The stall speed charts could not be completely deciphered, but the zero-bank, wings-level speeds ranged from 44 to 55 knots, depending on the weight and configuration. Weight and balance calculations using full fuel, the occupant's weights, and POH weight and arm values yielded an approximate takeoff weight of 2,945 pounds, and a center of gravity (CG) location of 83.2 inches aft of the datum. The published maximum takeoff weight was 3,530 pounds, and the CG range was 80.88 to 92.43 inches. METEOROLOGICAL INFORMATION The AHN 1131 recorded weather observation included winds from 100 degrees at 6 knots, 8 miles visibility, scattered clouds at 1,900 feet, temperature 18 degrees C, dew point 13 degrees C, and an altimeter setting of 30.15 inches of mercury. COMMUNICATIONS The AHN ATCT was a non-federal facility operated by Robinson Aviation (RVA). RVA provided a transcript of the ATC communications regarding the flight. The transcripts indicated that the air traffic controllers were aware that this was a flight of two aircraft, and that all radio communications were between ATC and the Cessna. At 1518:55 the approach controller passed the IFR release to the AHN local controller, and the Cessna was cleared for takeoff at 1119:16. At 1120:34, the local controller issued the instructions for the Cessna pilot to contact Atlanta Approach. At 1122:22, after he was notified by the airport maintenance technician that the Fuji might have crashed, the local controller unsuccessfully attempted to contact the pilot of the Cessna. At 1126:10, the local controller asked the approach controller to determine whether the Cessna still had "his wingman with him," and added that he thought the Fuji might not be airborne any more. At 1126:53, the approach controller informed the local controller that the Cessna pilot did not know where the Fuji was, and shortly thereafter, the local controller asked the approach controller to recall the Cessna to AHN. At 1133:28 a police helicopter confirmed that the Fuji was down, and about 1135 the Cessna landed at AHN. About 1140, the police helicopter reported to the ATCT controller that the situation with the Fuji did not "look good," but that there was "no fire whatsoever." WRECKAGE AND IMPACT INFORMATION According to information provided by the FAA inspector who responded to the accident scene, the Fuji struck trees and terrain on a private residence approximately 4,700 feet west-southwest of the threshold of runway 9. The inspector noted that some trees across the street from the accident location were also struck by the Fuji, and he estimated that those trees were about 70 feet high. The Fuji came to rest in a heavily wooded area, in a nose-down attitude, with the longitudinal axis approximately perpendicular to the ground. The nose, engine, forward cabin, and wings exhibited significant crush damage in the aft direction. One propeller blade was bent aft, and the other was fracture-separated from the hub. The aft cabin, aft fuselage and the empennage incurred minor damage. All flight control surfaces were accounted for, and all remained attached to their respective primary airfoils. Elevator control cable continuity, from approximately the aft cabin to the elevator, was established. Review of FAA-provided on-site photographs revealed the following instrument readings: Tachometer 800 rpm; Fuel pressure 1 psi; Suction 0 psi; Cylinder head temperature 50 degrees C; Exhaust gas temperature off scale low; Manifold pressure needle missing. The Fuji was recovered to a secure facility for additional examination. In a written statement to the NTSB, the owner of the Fuji's maintenance facility at AHN reported that he was telephoned by a law enforcement officer who was still on scene at the time of his call; the officer inquired about the identities of the persons on board the Fuji. The facility owner stated that the officer told him that the "fuel selector was off." MEDICAL AND PATHOLOGICAL INFORMATION Post mortem examination of the pilot/airplane owner was performed by the Georgia Bureau of Investigation (GBI), The autopsy report included findings of "Heart, coronary atherosclerotic disease, left anterior descending artery, 70 percent luminal narrowing." The autopsy indicated that the cause of death was "blunt force injuries." The Civil Aeromedical Institute (CAMI) toxicology report indicated that ethanol was detected in muscle tissue but not in the brain tissue, and that the "ethanol found in this case is from sources other than ingestion." Tests for carbon monoxide and cyanide were not performed. Donepezil and Metoclopramide were detected in the liver and kidney tissue. Tests for all other screened drugs were negative. According to the NTSB medical officer, Donepezil is also known by the trade name "Aricept," and is used almost exclusively to help treat the cognitive decline associated with Alzheimer’s disease. Metoclopramide, also known by the trade name Reglan, is an older medication used to treat certain types of heartburn and other digestive problems. An August 2010 email from the owner's adult son to the NTSB also stated that the owner had a stroke in 2007, and that although the owner "was not having any more symptoms from [the stroke] he was still under the "no fly" order which he obviously took very seriously since he asked [the acquaintance] to fly the plane [from Georgia to Florida with] him." He stated that the owner had been living on his own since July 2009, that he held a valid driver's license, and that he had conducted several recent long-distance driving trips. Neither the owner's son nor adult daughter had "any reservations about [the owner's] mental or physical health." The son did not have any information regarding whether his father (the owner) had ever been diagnos
An aerodynamic stall shortly after takeoff for undetermined reasons.
Source: NTSB Aviation Accident Database
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