ERA10LA026
ERA10LA026

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.

AIRPLANE 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 diagnosed with Alzheimer's disease. He also was not specifically aware of what medications the owner was prescribed, or was taking.

Post mortem examination of the pilot rated passenger was performed by the GBI, The GBI autopsy report indicated that the cause of death was "blunt force injuries." The CAMI toxicology report indicated that tests for carbon monoxide, cyanide, ethanol and all screened drugs were negative.

ADDITIONAL INFORMATION

Maintenance Records Information

The maintenance record entries indicated that in March 1991, at a total time (TT) in service of 6,858 hours, the "Hobbs" hour meter indicated "0.0" hours. The accident engine was installed in the Fuji in November 2003, at a TT of 7,589.3 hours, and the "Hobbs" meter registered 741.2 hours. The records indicated that at that time, the engine TT was "unknown," and it had a "TSMOH" (time since major overhaul) of "0.00" hours. The previous engine, like the accident engine, was a TCM O-470-13A. The records did not explicitly state whether the accessory components from the previous engine were transferred to the newly-installed engine, or whether new or other used accessory components were utilized.

At the time of the most recent annual inspection, the Fuji had accumulated a total time in service of 7,657 hours, and the recording hour meter (which was not cited as "Hobbs" in the records for that entry) registered 808.5 hours.

The recording hour meter that was found in the wreckage registered 812.2 hours.

Detailed Airframe Examination

Recovery personnel made cuts in the wings and fuselage in order to enable removal and transport from the accident location. The wreckage was stored outside and uncovered in a secure facility since the accident, and was examined in detail on January 26-27, 2010 by personnel from the National Transportation Safety Board (NTSB), the FAA, TCM, and the maintenance provider.

The nose, engine compartment and cockpit area were severely disrupted by impact forces. The left front seat was found fracture-separated from the airplane structure. The lap belt and shoulder harness were found to be cut through, consistent with victim rescue/recovery activities. The right front seat was found attached to the airplane structure. Its lap belt and shoulder harness were also found to be cut through, consistent with victim rescue/recovery activities. The seat was removed to facilitate the examination. The forward-facing aft bench seat was fracture-separated from the airframe structure.

Two 1-quart containers of Bell MXO-AV aviation gasoline additive were found in the cabin. One container was intact, unopened and full. The other had been opened and did not appear full. According to a product information sheet, the additive was advertised as an internal engine "detergent, lubricant, octane enhancer and moisture eliminator." A representative of the product manufacturer stated that the product was hydrocarbon-based, was last sold in the US in 2006, and that it had a shelf life of approximately 1 year under proper storage conditions.

The left instrument panel was separated from the structure, and only the turn and bank instrument and the directional gyro remained attached to the panel. The airspeed indicator was located; all airspeed designation arcs were in compliance with the speeds specified in the POH. The white arc extended from 48 to 110 knots, the green arc extended from 60 to 146 knots, and the yellow arc extended from 146 to 199 knots. The indicating needle was positioned at approximately 81 knots. The barometric setting in the altimeter was set to 30.38 inches of mercury. The indications on both the altimeter and vertical speed indicator were not readable. The left instrument sub-panel, which contained approximately 12 switches, remained attached to the structure. The generator switch was found in the "OFF" position, and the master switch was found in the "ON" position. Both switches were intact.

The center-mounted radio stack was separated from the airplane structure. Only one radio setting was discernible; the communications radio was set to a frequency of 121.8 megahertz, which was the ground control frequency at AHN.

The right instrument panel remained attached to the structure, and most instruments remained installed in the panel. The landing gear position indicator depicted that the landing gear position was not safe for landing, and all three landing gear were physically found to be in the fully retracted position. The manifold pressure gauge reading could not be determined. The right instrument sub-panel, which contained multiple switches and circuit breakers, remained attached to the structure. Several circuit breakers were absent from the sub-panel.

The control column consisted of an inverted L-shaped structure mounted in the lateral center of the left-side of the cockpit floor, with the short leg of the "L" extending horizontally to the lateral center of the right side of the cockpit. The column was separated from the fuselage structure. Two control wheels, one for each front seat position, were mounted on the short leg of the column. Both control wheels remained attached to the column. Four cables (two pitch, two roll) exited the bottom of the control column; all four had been cut several inches beyond their exit point from the column.

The control lock consisted of a tab and pin mounted to the left sub-panel; the control lock tab was slightly damaged, but the pin, and the pin mating hole in the control column, were undamaged.

The engine control quadrant remained attached to the airplane structure. The throttle cable was fracture-separated from the control knob at the quadrant, and the cable was continuous from the fracture to the engine compartment. The mixture cable was fractured at the quadrant, but remained attached to the quadrant and control knob. The cable was continuous from the fracture to the engine compartment. The propeller control cable was fracture-separated at the quadrant, but was continuous from the fracture to the propeller governor. The engine control positions at the quadrant were deemed to be unreliable, and therefore not documented.

Ignition System and Switch

The engine was equipped with two high-tension magnetos. Magneto operation was controlled by a four-position ignition switch which provided the capability to render both magnetos operative ("Both" setting), both inoperative ("Off" setting), or either magneto independently operative/inoperative ("Left" and "Right" settings) by selective electrical grounding of the magnetos. Electrically grounding a magneto rendered it inoperative.

The magneto ignition switch bore a manufacturer name/part number of Koito AN3212-1, and remained attached to the airplane by its wiring. The switch assembly included a cast-metal handle, painted red, which could be rotated to four distinct positions. The four switch position labels were arrayed in an arc across the lower face of the switch; from left to right these labels were "BOTH," "L," "R," and "OFF." The arm of the handle was fracture-separated from the handle axis, and was not recovered. The alignment of the handle was consistent with the switch set to the "OFF" position, and the lower face exhibited a dent and flakes of red paint near the "OFF" label. A metallurgist from the NTSB Materials Laboratory in Washington DC stated that "the fracture surface was difficult to interpret because of the coarse microstructure of the casting," but concluded that the fracture direction appeared to be consistent with the handle being rotated clockwise (towards the "both" position) about its axis.

The switch contained a rotating internal contactor, referred to as the "wiper" in a component drawing, to selectively ground the magnetos. Position detents for the four pilot-selected switch positions were created by four circular holes in a "click washer" plate on the handle shaft common to the wiper; the holes served as capture points for a spring-loaded ball as the handle was rotated. Tabs on each of the two ends of the wiper served as hard mechanical stops against the switch body; both tabs displayed similar wear. A braided copper cable which electrically connected the wiper to the switch body (and electrical ground) was fracture-separated at the soldered joint to the wiper.

The fractured ends of the strands in the cable were examined under a stereomicroscope at the NTSB Materials Laboratory. The ends exhibited either 45-degree or "cup and cone" fracture features, which were consistent with overstress fracture. There was no evidence of fatigue on any of the strands. There was no evidence of arcing on the fracture ends, which was consistent with the strands not being electrically energized at the time of the fracture.

Airframe Fuel System

Examination of the Japanese-language POH indicated that the Fuji was equipped with a 25-gallon (main) fuel tank in each wing, and an additional 10-gallon tank in the right wing. A fuel system schematic depicted that the 10-gallon tank was plumbed to the right wing main tank, and that the fuel selector valve was plumbed so that fuel could be provided to the engine from only one of the two main tanks at a time. The schematic indicated that the fuel selector valve had three positions. Each main tank was equipped with an electrically-driven fuel pump, and that the pumps were controlled by a switch in the cockpit. The pump switch had three positions; one position for each main tank, and one position for 'OFF'. The schematic depicted two fuel quantity gauges; one for each main tank, and both electrically-powered. A fuel pressure gauge, plumbed to the carburetor, and with a normal operating range of 9 to 15 pounds per square inch (psi), was also shown in the POH diagrams.

Discussions with, and examination of photographs provided by, the owner of another Fuji LM-1 revealed that the exemplar airplane and the accident airplane were similarly configured, with two 25 gallon fuel tanks, and one 10 gallon fuel tank. The fuel selector handle was mounted on a pedestal just forward of the front seats; the pedestal was situated on the lateral centerline of the airplane, about 4 inches below the top surfaces of the front left and right seat cushions. The selector handle rotated in the horizontal plane. The exemplar airplane owner confirmed that the selector valve had only three positions; left, right and off. The left tank setting (marked by a triangle, and text "25 GAL") was about 20 degrees left (counterclockwise) of alignment with the airplane longitudinal axis, the right tank setting (marked by a triangle, and text "35 GAL") was about 20 degrees right (clockwise) of alignment with the axis, and the off position was about 70 degrees right (clockwise) of the axis.

Examination of the accident airplane revealed that the fuel selector handle remained mechanically attached to the valve, but the handle placard was fracture-separated from the pedestal. The manufacturer's placard bore triangles and text in positions similar to those respectively described for the exemplar airplane left and right tank settings. The placard had witness marks which were consistent with the selector handle rotated approximately 45 degrees clockwise from the "35 Gal" triangle (right tank) position. An embossed after-market "OFF" label was located at approximately the 2 o'clock to 3 o'clock position on the pedestal, and when the placard was oriented in its as-installed position on the pedestal, the selector handle appeared to align with the "OFF" label. Slight scoring along an arc of slightly less than 90 degrees, from about the 3 o'clock to the 6 o'clock positions, was present below the handle on the placard. The pedestal, selector handle, selector valve, and short lengths of the associated fuel tubing were removed as a unit from the airplane for additional examination.

The bottom of the fuel selector valve was equipped with a quick-drain fitting to enable a fuel sample to be obtained directly from the valve. Approximately 1 fluid ounce of blue fuel was drained from valve; no contaminants were visible, and a test did not reveal the presence of alcohol. The fuel selector valve was tested by introducing pressurized air via the tubing into the various valve ports, and the results indicated that the as-found condition of the valve would not permit air (and thus fuel) to flow to the engine. The selector valve was then disassembled, which revealed that the valve was set to its "OFF" position. An internal screen was found to be clean, and a minimal amount of corrosion and some unidentified fibrous material was observed at the bottom of the valve; the amounts were minor and would not interfere with the operation of the valve or the flow of fuel.

Each of the two fuel boost pumps was properly secured in its respective fuel tank, and all pump fuel lines were properly secured. The mounting base of the right pump was fractured coincident with a crush line of the fuel tank and wing. The pump screen was clean, and crushed in the "up" direction. The pump internal chambers were clean. The left boost pump was intact, and appeared clean. No operational checks of the pumps were attempted.

The fuel boost pump switch was located in the cockpit, just aft of the fuel selector valve. It was a three-position unit with selectable positions of "Left, Off, and Right." The switch setting could not be determined due to impact damage. According to persons familiar with the Fuji, a boost pump (corresponding to the selected main tank) was used to prime the engine for starting, and also whenever a low pressure reading was observed on the cockpit fuel pressure gauge, such as would occur with a failure of the engine-driven fuel pump.

All three fuel tank inlets and caps were recessed in enclosed wells in the respective wings. The caps for the right auxiliary and left main tanks were inaccessible due to the deformation of the surrounding structure. The cap for the right main tank remained accessible, and the cap was removed and examined. The cap-to-tank-inlet seal appeared aged and exhibited multiple minor cracks; no cracks penetrated the full cross section of the seal.

Flight Controls

The trailing edge flaps were electrically driven, and were controlled by a momentary switch in the cockpit. The flaps on both wings were found in their fully-retracted positions. The left aileron remained attached to the wing, and was free to move on its hinges. Control cable continuity was established from the left aileron to the cable cuts coincident with the wing cut made by the recovery personnel. The left aileron trim tab remained attached to the left aileron, and was free to move on its hinges. The tab control link was fracture-separated from its attach point at the inboard end of the trim tab.

The right aileron remained attached to the wing, and was free to move on its hinges. Control cable continuity was established from the right aileron to the cable cuts coincident with the wing cut made by the recovery personnel. The right aileron trim tab remained attached to the right aileron, and was positioned approximately 20 degrees tab trailing edge up, which corresponded to a left wing down trim input.

The rudder remained attached to the vertical stabilizer, and was free to move on its hinges. Control cable continuity was established from the rudder to the fuselage cut made by the recovery personnel. The right rudder cable was fractured in a pattern consistent with overload; the left rudder cable was cut. The rudder trim tab remained attached to the rudder, and was positioned approximately 10 degrees tab trailing edge right, which corresponded to an airplane nose left trim input.

The left horizontal stabilizer remained attached to the aft fuselage, and the right horizontal stabilizer was cut from the fuselage by the recovery personnel. Each elevator remained attached to its respective horizontal stabilizer. Control cable continuity was established from the elevator horn to the fuselage cut made by the recovery personnel. The up-elevator cable was fractured in a pattern consistent with overload; the down-elevator cable was cut. Each elevator trim tab remained attached to its respective elevator, and both were free to pivot on their hinges. The elevator trim cables were continuous from the trim tab horn to their cuts by recovery personnel at the fuselage cut.

The maintenance facility owner stated that he had flown the accident Fuji on several occasions. He stated that normal takeoff configuration was with the wing flaps retracted. He stated that the airplane was not equipped with a stall warning system. He also stated that he "could not emphasize this point enough;" the Fuji was "extremely light in pitch," and that "you could run the elevator trim from end to end" with no appreciable change in control stick force.

Engine Examination

According to the TCM representative, the engine data plate indicated that the engine was produced under contract for the United States Air Force Beech T34 program. The engine and its components exhibited significant impact and crush damage. Both crankcase halves were fractured at the dome at the front of the engine. The induction and exhaust tubing exhibited severe crush and fracture damage. The accessory case on the aft end of the engine was damaged, and the left magneto was fracture separated from the case. All ignition cables were cut or fragmented into multiple segments. The external oil tank that was mounted on the firewall was crushed.

The starter, top spark plugs, and spinner were removed, the spinner backing plate was reformed to prevent it from interfering with crankshaft rotation, and the crankshaft was then rotated manually. Thumb compression was obtained on all six cylinders, and crankshaft/gearing continuity to the accessory drives at the aft end of the engine was confirmed. The propeller governor rotated freely with the rotation of the crankshaft, but its control links were impact-damaged.

The bottom spark plugs were removed, and all spark plugs were examined. The electrodes of the top spark plug from cylinder No. 3 were observed to be heavily sooted. The electrodes of the top spark plug from cylinder No. 6 were also sooted. The electrodes of the bottom spark plugs from cylinder Nos. 3 and 5 were coated with oil. All cylinders were visually examined with a borescope, and all were unremarkable, with normal wear characteristics.

The timing of the magnetos was not determined. The left magneto was fracture-separated from the engine. The magneto could not be rotated, but the case was opened; the internal components were examined, and appeared intact. The coil was red in color, which indicated that the coil had been replaced in accordance with TCM Mandatory Service Bulletin (MSB) 644.

The right magneto was removed from the engine, and was observed to produce sparks at all towers when the drive was rotated. The magneto case was opened; the internal components were examined, and appeared intact. The coil was red, which indicated compliance with TCM MSB644.

The starter and generator were removed from engine, and both were able to be freely hand rotated.

The engine-driven fuel pump was intact, and remained affixed to the engine. The fuel line from the pump to the carburetor was intact, and when it was detached from the pump, no fuel was observed in the line. The pump was removed from the engine; initial hand rotation of the pump drive presented light to moderate resistance, but diminished with additional rotation, and no unusual sounds or tactile sensations were observed. The witness drain line was fracture-separated from the pump at the pump fitting.

The Bendix model PS-5L pressure carburetor remained attached to the engine, and exhibited impact damage on its lower side, and a segment of the body was fracture-separated, exposing the internal chambers. The throttle link remained attached to the unit, and the throttle valve moved freely through its full travel range. The carburetor was removed from the engine and partially disassembled. All internal diaphragms were clean and intact. A few droplets of water and the odor of fuel were observed in some of the carburetor chambers, but no liquid fuel was observed in the carburetor.

The oil screen was removed, and a small amount of carbon deposits were observed on the screen; the screen was not obstructed. The oil pump was removed from the engine; oil was present in the pump body, the pump gears rotated freely by hand, and no internal scoring or other damage was observed in the pump chambers.

Propeller Examination

The Fuji was equipped with a 2-blade, constant-speed, all-metal propeller. One blade remained attached to the propeller hub. It was bent aft about 70 degrees about 12 inches from the hub, and exhibited some trailing edge damage, but did not exhibit chordwise scoring. The other blade was fracture-separated from the hub. It exhibited S-bending, and was also bent aft and twisted, with damage to the leading edge. It did not exhibit any chordwise scoring.

GPS

A handheld global positioning system unit, a Garmin GPSMap 195, was recovered from the wreckage. The unit's non-volatile memory was downloaded and examined for possible accident flight path information, but the recovered data did not include the accident flight.

IFR Flight Capability and Requirements

The Cessna pilot filed a single IFR flight plan for the flight of two airplanes. FAA regulations required that each airplane, and one pilot in each airplane, was to be in compliance with the requirements for IFR operations. Neither the Fuji occupants nor the airplane met all applicable FAA requirements for IFR operations. The owner did not hold a valid FAA medical certificate, and the acquaintance in the right seat did not hold an instrument rating.

No records were located that indicated that the Fuji was properly equipped for IFR operations. No maintenance record entries were located that indicated that any IFR-required components were either inspected or certified for IFR operations within the applicable calendar time limits. Federal Aviation Regulations required that in order to operate in controlled airspace under IFR, each static pressure system, altimeter instrument, and automatic pressure altitude reporting system was tested, inspected, and found to comply with the specified standards within 24 calendar months preceding the flight. The most recent entries in the Fuji's maintenance records regarding those systems were dated May 15, 1991.


Flight Planning and Preparations

According to the Cessna pilot, his brother (the right seat occupant) made the acquaintance of the owner through social events over the course of several years. In the spring of 2009, the owner asked the two if they could fly him to AHN in the Cessna, so that he could bring the Fuji to LEE, and they agreed to do so. In May 2009, the owner informed the acquaintance that he had scheduled the Fuji to be "serviced," so that it could be flown to LEE. They then arranged for all three plus a certificated flight instructor (CFI) to fly to AHN in the Cessna, and for the CFI to conduct the return flight with the owner. That and several subsequent flight attempts were cancelled, "because the plane was not ready – for several different reasons." On the "third or fourth attempt to schedule" an opportunity to retrieve the Fuji, the CFI was not available, and since the acquaintance did not want to burden another pilot with the request, it was decided that he would "accompany" the owner in the Fuji for the flight to LEE.

The investigation was unable to definitively determine why the owner had originally planned to have a CFI accompany him on the trip from AHN to LEE. The investigation was also unable to definitively determine the specifics of the flight preparations between the owner and the acquaintance, particularly the expected role and responsibilities of the acquaintance. In response to NTSB inquiries regarding that subject, the Cessna pilot (the brother of the acquaintance) stated that there "was just a verbal agreement that [the acquaintance] would fly back to Leesburg in" the Fuji.

According to the Cessna pilot, the acquaintance "was very well acquainted with [the owner's] flying history, including his military… and his professional airline pilot experience," and knew that the owner had "extensive" airshow experience in the Fuji. However, the acquaintance had limited or no knowledge of the owner’s recent flying experience, and he was not aware that the owner did not possess a valid FAA medical certificate. The Cessna pilot stated that the acquaintance had no prior experience in the Fuji, had never seen it prior to the day of the accident, and likely had little or no knowledge of its flight or performance characteristics.

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