# NTSB SEA05LA153: Mooney M20J, N110MP, Sunriver, OR, July 28, 2005 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 28, 2005, 12:15 local (19:15 UTC) - Place: Sunriver, OR - Coordinates: 43.876388, -121.453056 - Nearby events: https://openairdocs.org/map.md?lat=43.8764&lon=-121.4531&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report March 28, 2006 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 62080 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA05LA153 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62080/pdf - Page: https://openairdocs.org/ntsb/SEA05LA153 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, approach - vfr pattern - downwind - maintenance,lubrication - not performed, other maintenance personnel (cause) - ignition system,ignition points - not operating (cause) - Forced landing, emergency descent/landing - On ground/water encounter with terrain/water, emergency landing - terrain condition - ground - terrain condition - none suitable (contributing factor) ## 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](https://openairdocs.org/aircraft/N110MP), registered now, S/N 24-0873, built 1979 (OpenAirDocs) - Reported make and model: Mooney M20J - Registry model: [Mooney M20J](https://openairdocs.org/model/mooney-m20j) (registry code 5870219) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 24-0873 - Airframe hours: 2385 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: none; 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 (OpenAirDocs). - [Accident 20050728015399A](https://openairdocs.org/incident/20050728015399A), Jul 28, 2005: Mooney M20J, Bend, OR, Substantial damage. (-23) The aircraft departed the sac airport and flew to Sunriver, OR (S21) with two passengers. From the downwind position, 5000 feet MSL turning left base for… 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.