# NTSB ANC09LA102: Piper PA-12, N2594M, Lime Village, AK, September 16, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 15, 2009, 17:00 local (Sep 16, 2009, 01:00 UTC) - Place: Lime Village, AK - Coordinates: 61.5, -154.116668 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=61.5000&lon=-154.1167&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report October 21, 2010 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: Federal Aviation Administration (Airworthiness) - NTSB case key (mKey): 74761 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC09LA102 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74761/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74761 - Page: https://openairdocs.org/ntsb/ANC09LA102 ## Probable cause The passenger's inadvertent interference with, and application of the right brake pedal during takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-12, 31 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7101202), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-12, 51 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7101202), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02050000): Personnel issues › Miscellaneous · Passenger (probable cause); cases with it: [Piper PA-12, 1 case](https://openairdocs.org/ntsb-findings/02050000/cases.md?model=7101202), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/02050000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-12, 40 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7101202), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-12, 42 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7101202), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-12, 36 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7101202), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The commercial pilot and one passenger were taking off from a gravel-covered, remote off-airport site in a tailwheel-equipped airplane on a Title 14, Code of Federal Regulations Part 135 charter flight when the accident occurred. The pilot related that as the airplane accelerated, it began to turn sharply to the right, and towards a stand of trees. The airplane’s right wing struck the stand of trees, which pivoted it to the right where it nosed over, sustaining substantial damage to the wings, fuselage, and empennage. A postaccident inspection revealed that the passenger, seated in the rear of the airplane, inadvertently stepped on the right, rear-mounted dual brake pedal, as the pilot began his takeoff run. The pilot stated that there were no preaccident mechanical problems with the airplane, and that the accident could have been prevented if he had removed or covered the rear-mounted dual brake pedals. ## Factual narrative On September 15, 2009, about 1700 Alaska daylight time, a Piper PA-12 airplane, N2594M, sustained substantial damage when it collided with trees during takeoff from a gravel-covered, remote off-airport site, about 35 miles northeast of Lime Village, Alaska. The airplane was being operated as a visual flight rules (VFR) on-demand charter flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135, when the accident occurred. The airplane was owned and operated by Magnuson Airways, LLC, McGrath, Alaska. The commercial pilot and sole passenger were not injured. Visual meteorological conditions prevailed, and company flight following procedures were in effect. The accident flight was shuttling a group of hunters and gear to another off-airport site. During a telephone conversation with the National Transportation Safety Board investigator-in-charge on September 17, the pilot related that before departing from the 900 feet long gravel-covered site, he assessed the wind conditions before departing to the southwest. He determined that a slight westerly wind, ranging between 5 and 10 knots, would require a slight correction for a quartering right crosswind during his takeoff run. The pilot reported that during the takeoff run, as the airplane accelerated, it began to turn sharply to the right, and towards a stand of trees. The airplane’s right wing struck the stand of trees, which pivoted it to the right. The airplane subsequently nosed over, sustaining substantial damage to the wings, fuselage, and empennage. The pilot noted that a postaccident inspection revealed that his passenger, seated in the rear of the airplane, inadvertently stepped on the right, rear-mounted dual brake pedal, as the pilot began his takeoff run. In the pilot’s written statement to the NTSB he indicated that there were no preaccident mechanical problems with the airplane. Additionally, he recommended either removing or covering the rear-mounted dual brake pedals. ## Aircraft - Registration: [N2594M](https://openairdocs.org/aircraft/N2594M), registered now, S/N 12-1037 (OpenAirDocs) - Reported make and model: PIPER PA-12 - Registry model: [Piper PA-12](https://openairdocs.org/model/piper-pa-12) (registry code 7101202) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 12-1037 - Airframe hours: 3283 - Engines: LYCOMING O-320 160 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Magnuson Airways LLC - Registered owner: Robert L Magnuson - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, September 2, 2009, 10 hours before - Departed: Lime Village, AK - Destination: Lime Village, AK - Flight plan: Company VFR - Airport: runway 24, 900 × ft, gravel ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: front; flight hours: 2,200 total, 2,200 as pilot in command, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20090915049479A](https://openairdocs.org/incident/20090915049479A), Sep 15, 2009: Piper PA-12, Mcgrath, AK, Substantial damage. Pilot was shuttling passengers 14 miles up the swift river to a new camp site. Pilot was beginning takeoff roll with tail wheel off ground when aircraft veered… ## Docket (1 files) The files NTSB released with the investigation on August 6, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74761. 460 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 460 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40334465&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.