Skagit Regional Airport
Aircraft Accident/Incident Report

Burlington, Washington 98273
Thursday, October 8, 2009 13:05 PDT

NTSB Narrative Summary Released at Completion of Accident

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.

NTSB Probable Cause Narrative

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.

Event Information

Type of Event Accident
Event Date 10/8/2009
Event Day of the Week Thursday
Time of Event 1305
Event Time Zone Pacific Daylight Time
Event City Burlington
Event State WASHINGTON
Event Country --
Zipcode of the event site 98273
Event Date Year 2009
Event Date Month 10
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 482815N
Event Location Longitude 1222515W
Event Location Airport Skagit Regional
Event Location Nearest Airport ID KBVS
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Witness
Time of the weather observation
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID --
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation --
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 14
Dew Point at event time (in degress fahrenheit) 9
Wind Direction (degrees magnetic) 290
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 4
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.17
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 26766
NTSB Notification Source FAA Operations Center
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Apr 2 2010 5:53PM
User who most recently changed record stam
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N2087C
NTSB Number WPR10FA009
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name PIPER
Aircraft Model PA-12
Aircraft Series Identifier --
Aircraft Serial Number 12-3497
Certified Max Gross Weight 1750
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 1
Cabin Crew Seats --
Passenger Seats 2
Total number of seats on the aircraft 3
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Unknown
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site No
ELT Type C91
Aircraft Owner Name Bruce L. Heiner
Aircraft Owner Street Address --
Aircraft Owner City Bow
Aircraft Owner State WA
Aircraft Owner Country USA
Aircraft Owner Zipcode 98232
Operator is an individual? No
Operator Name Bruce L. Heiner
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City Bow
Operator State WA
Operator Country USA
Operator Zip code 98232
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code KBVS
Departure City Burlington
Departure State WA
Departure Country USA
Departure Time 1305
Departure Time Zone PDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code KBVS
Destination City Burlington
Destination State WA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Apr 2 2010 5:17PM
User who most recently changed record stam
Since inspection or accident --
Event Location Runway Number and Location 28
Runway Length 5477
Runway Width 100
Sight Seeing flight No
Air Medical Flight No
Medical Flight --