SEA05LA153

NTSB accident investigation · Mooney M20J · Sunriver, OR · July 28, 2005

Accident · No injuriesLimited investigationFinal report
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.

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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.

Loss of engine power(total) - mech failure/malfApproach - vfr pattern - downwind
Maintenance,lubrication - not performedOther maintenance personnelCause
Ignition system,ignition points - not operatingCause
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - ground
Terrain condition - none suitableFactor

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.