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Accidents · NTSB WPR10FA009 · Final report

Piper PA-12 accident near Burlington, Washington, October 8, 2009

On October 8, 2009 at about 8:05 pm local time, a Piper PA-12, registered N2087C, was substantially damaged in an accident during takeoff near Burlington, Washington (Skagit Regional airport). It was a personal flight under general aviation rules (Part 91). 1 person was killed. The weather was visual conditions (good weather).

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The NTSB's probable cause their words, unchanged

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.

Source: NTSB aviation accident database, copy made October 4, 2026. Docket and reports at the NTSB.

What the record shows

Date
October 8, 2009 · about 8:05 pm local time
Place
Burlington, Washington · Skagit Regional · map
Type
Accident
Injuries
1 person was killed.
Weather
visual conditions (good weather)
Aircraft
Piper PA-12 · all PA-12s on the register
Registration
N2087C · registry record · serial 12-3497
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

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.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Aircraft maintenance event during prior to flight
  2. Flight control sys malf/fail during takeoff
  3. Loss of control in flight during takeoff defining event
  4. Collision with terrain or object (not controlled flight into terrain) during uncontrolled descent

The NTSB's findings

  • cause Aircraft › Aircraft systems › Flight control system › Elevator control system › Incorrect service/maintenance
  • cause Personnel issues › Task performance › Maintenance › Installation › Pilot
  • Personnel issues › Physical › Impairment/incapacitation › OTC medication › Not specified
  • Personnel issues › Physical › Health/Fitness › Predisposing condition › Not specified
  • cause Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot
  • factor Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › Pilot

Pilot

  • Certificate: private
  • Ratings: multi-engine land; single-engine land
  • Flight time: 3,500 hours in all; 20 in the last 90 days
  • Medical certificate: Class 3 (with waivers/limitations)
  • Seat: frt
  • Injury: fatal

The aircraft

  • Last inspection: inspection type not recorded
  • Maximum gross weight: 1,750 lb
  • Seats: 3
  • Landing gear: fixed
  • Engine: Lycoming O-235-C (piston); 0 hours total
  • Fire on the ground

The flight

  • Departed from: KBVS Burlington WA at 8:05 pm
  • Destination: KBVS Burlington WA
  • Flight plan: none
  • Runway 28, 5,477 ft by 100 ft

Weather at the time

  • Light: daylight
  • Wind: from 290° at 4 knots
  • Visibility: 10 statute miles
  • Sky: clear
  • Temperature: 57°F (14°C), dew point 48°F (9°C)
  • Altimeter: 30.17 inHg

Injuries

FatalSeriousMinorNone
Flig1

About this page

Everything above comes from the NTSB's public accident database: the narrative, probable cause and findings are the NTSB's own words, and the coded tables behind its report (pilot, aircraft, flight, weather, injuries, sequence of events) are written out in plain English. Pilots' ages, home towns and medical details are left out on purpose. The docket at the NTSB holds the report as a PDF and the investigation's photographs and documents. This site never names pilots, passengers or anyone else involved. A preliminary report describes what is known soon after the event and can change; the final report, with the probable cause, usually follows one to two years later and this page is refreshed when it does. Case number WPR10FA009.