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NTSB investigation record

ERA10LA026

Completed

Fuji Lm1· N2121J

Date
October 22, 2009
Location
Athens, GA
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

An aerodynamic stall shortly after takeoff for undetermined reasons.

Investigator assessment

Analysis narrative

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.

Source record

Factual narrative

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 C

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