- Date
- July 28, 2005, 12:15 local (19:15 UTC)
- Place
- Sunriver, OR
- Injuries
- 3 uninjured
- Damage
- Substantial damage
- Phase of flight
- Approach
- Aircraft
- N110MPMooney M20J
- Weather
- Visual (VMC) · Day
- Status
- Completed · report March 28, 2006
- Report
- Approved by Office Director
- Parties
- FAA FSDO
- FAA report
- 20050728015399A
- Case key
- 62080
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The loss of engine power as a result of both sets of magneto points failing to open due to excessive wear of the nylon cam followers. The excessive wear of the cam followers was due to maintenance personnel's failure to follow the magneto manufacturer's recommended maintenance procedures and inspect the cam follower felt pads for adequate lubrication at 100-hour intervals. A factor was the lack of suitable terrain available for the forced landing.
Sequence of events
NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.
Analysis
According to the pilot, while on the downwind leg for landing on runway 18, the engine "backfired, ran rough and quit." During the ensuing forced landing, the airplane collided with trees and terrain short of the runway. The left outer wing sustained structural damage. During an attempted engine run following the accident, the engine could not be started, and it was determined that both sets of magneto points were not opening. Inspection of the single-drive dual magneto found that the nylon cam followers on both sets of points were worn to the point that they could no longer open the contacts. The cam followers appeared to be burned and discolored due to a lack of lubrication. The felt pads mounted on the cam followers that are normally saturated with lubricating oil were found to be very dry. The magneto manufacturer's recommended maintenance instructions call for the cam follower felt pads to be inspected for the presence of adequate lubricating oil every 100 hours time in service. According to the airplane's maintenance records the points had accumulated 372.9 hours since installation on January 1, 2001. There were no entries found in the engine logbook indicating the points had been inspected since their installation.
Factual narrative
On July 28, 2005, approximately 1215 Pacific daylight time, a Mooney M20J airplane, N110MP, sustained substantial damage during a forced landing following a loss of engine power in the traffic pattern at Sunriver Airport, Sunriver, Oregon. The commercial pilot and his two passengers were not injured. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed and no flight plan was filed for the personal cross country flight conducted under 14 CFR Part 91. The airplane departed from Sacramento, California, at 1000 with an intended destination of Sunriver.
According to the pilot, while on the downwind leg for landing on runway 18, the engine "backfired, ran rough and quit." During the ensuing forced landing, the airplane collided with trees and terrain short of the runway. The outboard section of the left wing sustained structural damage.
During an attempted engine run following the accident, conducted at the request of the owner's insurance company, the engine could not be started, and it was determined that both sets of magneto points were not opening. The single-drive dual magneto, an Electrosystems-rebuilt TCM/Bendix D4LN-3000, P/N 10-682555-11, S/N 4082075, was removed from the engine and shipped to the NTSB investigator-in-charge (IIC) for further examination. The magneto was examined under the supervision of the IIC at Galvin Flying Service in Seattle, Washington, on October 24, 2005. The mechanic who performed the inspection found that the nylon cam followers on both sets of points were worn to the point that they could no longer open the contacts. The mechanic noted that the cam followers appeared to be burned and discolored due to a lack of lubrication. The felt pads mounted on the cam followers appeared to be very dry. According to the mechanic, these pads are normally saturated with oil to lubricate the cam followers.
The TCM Ignition Service Support Manual for the D-3000 magneto, Recommended Maintenance and Overhaul Periods section, dated July 1989, states, in part: "After the first 50 hour and 100 hour periods in service and every 100 hours thereafter, the contact assemblies should be checked as specified in paragraph 6.2.1 of Periodic Maintenance." The Periodic Maintenance section, Paragraph 6.2.1 Contact Assemblies, dated July 1989, states, in part: "Check condition of cam follower felt. Squeeze felt between thumb and forefinger. If fingers are not moistened with oil, re-oil using 2 or 3 drops of 10-86527 Lubricant."
According to the airplane's maintenance records, the magneto was delivered with a Textron Lycoming factory rebuilt engine that was installed in the airplane on October 1, 1994, at a tachometer reading of 0.0 hours. New points were installed in the magneto on January 1, 2001, at a tachometer reading of 737.4 hours. The most recent engine 100-hour inspection was performed on May 3, 2005, at a tachometer reading of 1,086.1 hours. The engine had accumulated 24.2 hours since the most recent inspection when the accident occurred. A review of the engine logbook found no entries found indicating the points had been inspected since their installation.
Aircraft
- Registration
- N110MP
- Reported as
- Mooney M20J
- Category
- Airplane
- Serial number
- 24-0873
- Airframe hours
- 2,385
- Engine
- Lycoming IO-360-A3B6D, 200 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Personal · Part 91
- Registered owner
- John P. Reeve
- Airworthiness certificate
- Standard, Normal
- Last inspection
- Annual · May 1, 2005 · 24 hours before
- Departed
- SAC · Sacramento, CA
- Destination
- S21 · Sunriver, OR
- Airport
- S21 · Sunriver, runway 18, 5,455 × 70 ft, asphalt
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 56
- Injuries
- None
- Certificates
- Flight instructor, Commercial
- Airplane ratings
- Single-engine land
- Instrument ratings
- Airplane
- Medical
- Class 3, With waivers/limitations
- Last flight review
- December 1, 2004
- Seat
- Left
- Flight hours
- 2,544 total · 1,165 in this make and model · 2,350 as pilot in command · 26 in the last 90 days · 12 in the last 30 days · 3 in the last 24 hours
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- Variable at 5 knots
- Visibility
- 10 statute miles
- Temperature
- 93 °F, dew point 30 °F
- Altimeter
- 29.97 inHg
- Observed at
- RDM, 26 nm away
FAA reports on this event · 1
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.