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WPR10FA009 · Piper PA-12

8 Oct 2009 · Burlington, WA, United States

Piper PA-12 · Accident: loss of control in flight during takeoff

From Skagit Regional Airport (KBVS) to Skagit Regional Airport (KBVS)

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Event

NTSB case
WPR10FA009
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
1 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Piper PA-12

Aircraft type
Piper PA-12
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N2087C
Operator
Bruce L. Heiner · private individual
Onboard fatalities
Unknown
Route
From Skagit Regional Airport (KBVS), Burlington, WATo Skagit Regional Airport (KBVS), Burlington, WA
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Takeoff
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Loss of control in flight
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Substantial

Cause areas

  • Aircraft › Aircraft systems
  • Personnel issues › Task performance

Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.

NTSB narrative

The pilot was nearing the completion of a rebuild/restoration of the airplane, but it had not yet been inspected and signed off by a mechanic with an Inspection Authorization. On the day of the accident the pilot was planning on doing a test run of the recently overhauled engine. Witnesses reported that the pilot ran the engine for about five minutes and then shut it down. Then, about fifteen minutes later, he started the engine again and taxied out to the active runway. Without performing a magneto or carburetor heat check, the pilot pulled onto the runway and added what sounded to witnesses like full power. The airplane then made a "very short" takeoff roll before lifting off. Although the liftoff appeared normal to the witnesses, soon thereafter the nose of the airplane pitched up to a near-vertical attitude. It then climbed to an altitude of between 150 to 200 feet above ground level. Then, with the engine still at what sounded like full power, the airplane slowed, fell off on the right wing, and descended near vertically into the grass-covered terrain near the side of the runway. A postaccident teardown inspection found that the elevator control cables had been connected to the incorrect elevator control horns, resulting in a reversal of control inputs at the elevator. A mechanic who had signed off many of the pilot's previous rebuild projects stated that he had found reversed control cables on two other airplanes the pilot had completed. The mechanic also stated that the pilot had done "high speed taxi tests" on a number of other rebuilt airplanes prior to the time they were inspected and signed off. The mechanic had warned the pilot about the dangers of doing so, but the pilot had continued the practice.

Toxicology testing of specimens from the pilot was consistent with the recent use of a medication containing diphenhydramine, an over-the-counter impairing antihistamine. Family members described a 10-year history of a skin condition consistent with chronic urticaria (hives) that resulted in severe recurrent itching and which had frequently occurred while the pilot was working on aircraft. The pilot had not indicated any conditions or medication use at the time of his last Application for Airman Medical Certificate, less than 5 months prior to the accident. Although the pilot likely would have had no opportunity to recover the aircraft once it became airborne, it is possible that impairment from the use of diphenhydramine or distraction from chronic urticaria contributed to the pilot’s failure to correctly rig the elevator cables. However, the investigation could not determine whether impairment or distraction played a role in the accident.

Probable cause

The pilot's in-flight loss of control due to his failure to correctly connect the elevator control cables during the restoration/rebuild of the airplane. Contributing to this accident was the pilot's decision to perform a high-speed taxi test prior to having the airplane inspected by a certificated mechanic, which resulted in inadvertent flight.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record WPR10FA009
Event ID
20091009X21520
Case number
WPR10FA009
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: investigation status. Values present in the bulk record are kept.
  • The date is the local date, which is the same as the UTC date the NTSB stores.
  • API snapshot SHA-256: a6885b7b6aee7e262f604a6647a3cf3993ffbff406315e9a03bca7fbf225e454; retrieved 2026-09-13T20:31:02.972Z.