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Accidents · NTSB MIA91FA227 · Final report

Piper PA-28-140 accident near West Palm Beach, Florida, September 28, 1991

On September 28, 1991 at about 5:14 am local time, a Piper PA-28-140, registered N5838U, was substantially damaged in an accident near West Palm Beach, Florida. It was a personal flight under general aviation rules (Part 91). 1 person was seriously injured and 3 people had minor injuries. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

THE PILOT'S IMPROPER USE OF THE MIXTURE CONTROL IN THAT HE FAILED TO PLACE IT IN FULL RICH CONDITION PRIOR TO TAKEOFF. CONTRIBUTING TO THE ACCIDENT WAS THE UNSUITABLE TERRAIN ENCOUNTERED DURING THE FORCED LANDING.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
September 28, 1991 · about 5:14 am local time
Place
West Palm Beach, Florida · map
Type
Accident
Injuries
1 person was seriously injured and 3 people had minor injuries.
Weather
visual conditions (good weather)
Aircraft
Piper PA-28-140 · all PA-28-140s on the register
Registration
N5838U · no longer on the register · serial 28-2669
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

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

THE PILOT STATED HE EXPERIENCED EXCESSIVE MAGNETO DROP ON RUN UP AND HE LEANED THE MIXTURE TO CORRECT THIS CONDITION. HE NEVER STATED HE PLACED THE MIXTURE CONTROL TO FULL RICH PRIOR TO TAKEOFF. THE ENGINE GRADUALLY LOST POWER AFTER TAKEOFF AND EVENTUALLY QUIT. THE PILOT EXECUTED A FORCED LANDING TO UNSUITABLE TERRAIN AND STRUCK A TREE AND A BUILDING DURING LANDING.

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

Pilot

  • Certificate: private
  • Ratings: single-engine land
  • Flight time: 100 hours in all; 15 in this make and model; 50 in the last 90 days; 15 in the last 30 days; 40 as pilot in command
  • Medical certificate: Class 3 (valid medical--w/ waivers/lim.)
  • Seat: left

The aircraft

  • Last inspection: inspection type not recorded; 0 hours since
  • Maximum gross weight: 2,150 lb
  • Seats: 4
  • Landing gear: fixed
  • Engine: Lycoming O-320-E2A (piston); 0 hours total

The flight

  • Destination: FXE Fort Lauderdale FL
  • Flight plan: none
  • Runway 0

Weather at the time

  • Light: night, dark
  • Wind: from 310° at 3 knots
  • Visibility: 10 statute miles
  • Sky: scat at 25,000 ft
  • Temperature: 73°F (23°C), dew point 72°F (22°C)
  • Altimeter: 29.00 inHg
  • Observation at 5:25 am from PBI, 1 miles away

Injuries

FatalSeriousMinorNone
Crew1
Passengers12

Documents from the investigation the NTSB's docket: the evidence folder behind the report

The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.