On 20 January 2014, ÃÂcoala SuperioarÃÂ de AviaÃÂie CivilÃÂ Flight 111, a Britten-Norman Islander operated by Romania's Superior School of Aviation (), crashed in the Apuseni Mountains, at an altitude of approximately , near the village of Petreasa, Romania. The aircraft was transporting a five-person medical team from Bucharest to Oradea. The captain and a medical student died while the copilot and four doctors survived injured.
An investigation conducted by the Center for Investigation and Analysis for Civil Aviation Security () concluded in October 2015 that the cause of the accident was the shutdown of both engines as a result of icing affecting the carburetors.
The analysis of the search and rescue operation on the victims made late, highlighted a series of deficiencies in the Romanian emergency service that manages emergencies in the country, deficiencies that include some regulations or specific procedures, including poor communication between the responsible institutions. As a result, several executives of the structures responsible for search and rescue of victims have resigned or been fired.
The aircraft, property of the Superior School of Civil Aviation in Romania, took off at 13:35 from Aurel Vlaicu International Airport in Bucharest and was bound for Oradea International Airport, where it should have landed at 16:35. The flight was a humanitarian mission and was piloted by RÃÂzvan Petrescu. On board were Dr Radu Zamfir from Fundeni Hospital, Dr Valentin Calu from Elias Hospital, Dr CÃÂtÃÂlin Pivniceru from Saint Mary Hospital, Dr Sorin Ianceu from yjr municipal hospital in BeiuÃÂ, and Aurelia Ion, a student at the Military Medical School in Bucharest. The team were to collect organs from a donor for a transplant operation.
The accident happened in poor weather conditions and the crew was flying according to instrument flight rules.
One of the passengers, Dr Zamfir, reported the crash at 16:16 in a telephone call to the 112 emergency service. The Inspectorate for Emergency Situations Alba, part of the Romanian General Inspectorate for Emergency Situations and the team of The National Association of Mountain Rescuers of Romania (Salvamont) headquarters of Cluj was assigned to the rescue operation. Over 70 firefighters and policemen from the counties of Cluj, Bihor, and Alba and approximately 200 locals took part in the search for the wreck. The rescue team had difficulty finding the crash site: they did not know the precise location and the area was covered in snow and thick fog. Because of the fog, the SMURD helicopter from MureÃÂ could not be used.
The pilot and the student died and the copilot was in a critical state, doctors Valentin Calu, CÃÂtÃÂlin Pivniceru e Sorin Ianceu had multiple bone fractures; Dr Zamfir had no severe wounds, and was able to help other survivors. All injured were taken to the Emergency Hospital in Cluj (Spitalul Clinic JudeÃÂean de UrgenÃÂÃÂ Cluj) and were admitted to the Intensive Care Unit.
Emergency search and rescue services were delayed because they did not receive the proper coordinates of the crash site. The ELT distress beacon operated correctly, but search and rescue services could not locate the beacon on the ground, on 121.5 MHz. Moscow Mission Control Centre said that they did not receive any signal from Romania on 406 MHz during the incident.
Serviciul de Telecomunicaà £ii Speciale said that it could not precisely locate the crash site because it had not received GPS coordinates of Dr Zamfir's phone from his mobile phone service provider, who provided only the cell, which covered an area of . Using its internal GPS reference, Dr Zamfir's phone showed coordinates , at North of the actual site of the crash .
The main controversy in this accident is why all methods used to locate the crash site failed, delaying the search and rescue teams.
The aircraft involved was a Britten-Norman BN-2A-27 Islander, registration YR-BNP.
The passengers involved are:
Valentin Calu (42 years old) was a doctor in medical sciences and was working as a surgeon at Elias Hospital in Bucharest and from 2007 was the spokesperson for the health unit. He was previously the coordinator of the Emergency Department at Elias Hospital. He was part of the medical team who worked for the Romanian National program for transplants.
Pavel Constantin CÃÂtÃÂlin Pivniceru (46 years old) was a general surgery specialist at Saint Mary Hospital in Bucharest and spokesperson for that hospital.
Radu Zamfir (39 years old) graduated at Carol Davila Medical University in 1998. He was a general surgeon at Fundeni Hospital in the laboratory of surgical research. He performed transplants together with Prof Dr Irinel Popescu at the Fundeni General Surgery and Liver Transplant Center.
Sorin Ianceu (37 years old) was a surgeon at the municipal hospital in BeiuÃÂ and was part of transplant team of Oradea County Emergency Clinical Hospital. Ianceu had graduated at the Iuliu HaÃÂieganu University of Medicine and Pharmacy and specialized in transplants.
Aurelia Ion was a fifth-year officer student at the Military Medical Institute of the Carol Davila University of Medicine and Pharmacy in Bucharest and she was a trainee at the Fundeni Hospital. She died at the scene of the accident. Hypothermia was listed as the cause of her death. (The body temperature recorded when she was found by SMURD paramedics was 18.6ðC.)
During her years of study, Aurelia Ion had volunteered in various medical activities. She was described from those who were close to her like a "a model girl, dedicated to her profession, an exceptional child, with big dreams". The coordinator of transplant Victor Zota affirmed that she had also participated in organ harvesting, volunteered, and "was dedicated to her profession in a way that is rare to find."
Minister of National Defence, Mircea DuÃÂa, ordered posthumous promotion of Aurelia Ion from the rank of second lieutenant to lieutenant. She was buried with military honors in the military section of Ghencea Cemetery, with the presence of the Minister of Defense, Mircea DuÃÂa.
Adrian Iovan was at that time one of the most expert pilots in Romania. He graduated from the Aurel Vlaicu Aviation High School, then the Faculty of Aeronautics, from which he graduated first in his class. He flew IAR 823, An-2, BN-2, Il-18, Boeing 737 (over 10,000 hours) and Piper PA-34, with over 15,000 of total flight hours. After the retirement, flew Piper and BN-2 aircraft.
Adrian Iovan was buried with military honors at Catholic Bellu Cemetery, but according to the canons of the Orthodox Church, next to his father.
The Romanian Government announced the start of two investigations. The first would look at the accident and the second the procedures followed by the rescue teams, which reached the scene only several hours after the crash. The Attorney General of Romania, Tiberiu NiÃÂu, said he was considering investigating the authorities' handling of the plane crash.
In addiction to the investigations of aeronautical authorities, two investigations were also opened by Prosecutor's office of the Court of Appeal of Alba Iulia regarding the violations of own duties by personnel of romanian civil aviation or the failure to comply with the same and to personal injuries caused by negligence. The Prosecutor General of the Prosecutor's Office of the Court of Appeal of Alba Iulia, Augustin LazÃÂr, declared that the airplane was not equipped with a Flight recorder and that the other Flight instruments will be examined to check that are working correctly.
In a preliminary investigation report, the Center for Investigation and Analysis for Civil Aviation Security () (CIAS) said that the ELT distress beacon was type ARTEX C406-2. This beacon transmitting on frequencies 121.5 MHz, 243 MHz (now obsolete) and 406 MHz, using two different cables for antennas. The cable for 406 MHz antenna was not found at the crash scene, which explains why no signal received on 406 MHz.
The CIAS final report stated that Adrian Iovan was the crew captain, responsible for all decisions. Iovan's total flight experience at the time was 15,261 hours and 10 minutes, of which only 42 hours and 17 minutes were in Britten-Norman Islander aircraft, while Petrescu's was 886 hours and 12 minutes, of which only 21 hours and 35 minutes were on the Islander. For 11 months, from February 6, 2013, when the aircraft involved was grounded for an overhaul, both pilots (Iovan and Petrescu) did not carry out any flight activity, but this interruption was within the legal limits. Both pilots had much more experience on MEP-class aircraft, but of the Piper PA-34 Seneca type with fuel-injected engines rather than carbureted engines. The limited experience of both men favored poor decisions. Iovan entrusted the duties of pilot flying (PF) to RÃÂzvan Petrescu, assigning him the left seat, the normal flying position on an airplane. Usually, this position was to be occupied by the captain, who was actually supposed to piloting but this was not mandatory. The scheme adopted by Adrian Iovan was later considered even superior for flights in difficult conditions, precisely because it allows the commander to concentrate on analyzing the situation and decision making.
The navigation was carried out with a portable GPS system, without utilizing VOR, DME and ADF systems installed on board (not because GPS system was more advanced). With the absence of a Flight recorder, the memory of GPS system allowed the reconstruction of the flight profile. The flight plan called for an Instrumental flight at flight level 120 (12,000 feet = 3,600 meters) flight level that would never have been reached.
At the start of the day, the weather conditions at Bucharest BÃÂneasa Aurel Vlaicu International Airport did not allow the takeoff. The conditions improved at 13:00 and the captain decided to make the flight, although the weather bulletins indicated favorable conditions for ice formation. After the takeoff, it was discovered that the airplane climb rate was slow, the cause indicated on the final report was the very high weight and the poor balance. Following previous test flights, it was discovered that the airplane had too much fuel on board, but dumping some of it would have delayed takeoff, and even then very late. In reality, the effective weight was slightly low to maximum allowed, but exceeded the allowed weight according to the standard calculating method, that provides 96 kg for man and 78 kg for woman. After boarding, the passengers sat as they liked, doctors Calu, Pivniceru and Ianceu in the second and third row, and Doctor Zamfir and student Aurelia Ion in the fifth and last row. This arrangement placed the center of gravity too far forward, outside the centerline area, resulting in a nose-heavy aircraft with increased aerodynamic drag. However, the report established that a correct centerline would not have been possible by simply seating the passengers.
After takeoff, the airplane's climb was slow, initially unable to reach flight level 100, which suggests that the ice formation problems were present from the very beginning. During the crossing of the Southern Carpathians (in relation to which the permitted level is 105), the Romanian Regional Control Center (ACC) asks them to climb, approving level 110 (normally intended for opposite traffic, but usable if the lack of opposite traffic allowed). The answer from Iovan was that would have respected the flight level, but with a rate of climb very low. Since they were below the permitted level and were not climbing, the situation became ambiguous, because it was not clear if they are flying according to instrumental flight rules, in that case the responsibility was of the ACC, or if the flight passed to visual flight rules, in that case the responsibility came all on the captain. For every eventuality, the ACC reported that Barometric pressure (QNH) was of 1006 hPa, necessary information for set up the altimeters for a VFR flight, but the pilots did not confirm the VFR flight nor set the altimeters, so they considered flying in IFR.
After crossing the mountains, the airplane dropped to FL 85 (2,590 m) and failed to reach FL 90, which indicated ice formation problems. In the Apuseni mountains zone, permitted level is FL 80 (2,435 m), thus Iovan decide to descend to that altitude. The flight became again a IFR flight, but not according to the initial flight plane. However, the FL 80 do not offer the condition to the resolution for the problem of the icing. At 15:39:53, the flight profile indicates an increase in the descent, and the commission of inquiry considered that this was the moment in which the engines shut down due to the ice. Therefore the pilot do not have other choice to carry out a gliding flight until the forced landing, which occurred at an altitude of 1600 m in a wooded area, with consequent destruction of the airplane, the deaths of Iovan and Aurelia Ion, the serious injury of Drs Calu, Pivniceru and Ianceu and the slight injury of Dr Zamfir. With the exception of Zamfir, who had fastened his seat belt shortly before, none of the other pilots and passengers, had their seat belt fastened.
During the flight, there were periods in which the radio connection was lacking, one of the causes was that ROMITSA control centers requested to passing at higher frequencies of 136 MHz (experimental frequencies), to which the radio of the airplane (YR-BNP) could not access.
To localize the accident, the plane was equipped with an ELT type localization radio beacon. This type of radio beacon emitting signals on 121,5 MHz e 406,0xx MHz frequencies. The 406,0xx MHz frequencies can only be received by the satellites of the COSPAS - SARSAT Centre (Satellite Search and Rescue Centre), through Moscow control center, otherwise do not responded during the day of 20 January.
Since fom the preliminary report, the CIAS confirm that the ELT beacon with which it was equipped the airplane involved was an ACR Electronics ARTEX C406-2. This type of radio beacon broadcast on all three frequencies: 121,5 MHz, 243 MHz (at the time out of service) and 406,0xx MHz, using two different cables for the antennas for this. It was found that the LED of radio beacon it was flashing, that confirms the beacon was in operation, but the cable of connection of the 406 MHz antenna was broken at the base and was not found on the accident site, one situation confirmed in the final report that recognizes this aspect remains unexplained. In this circumstances, was explained the statement that the Moscow Control Center did not receive a signal from romanian territory during the accident.
Initially, STS affirmed that the localization was made from the first call to 112 emergency service, but localization was incorrect, hence was opened an investigation also on this aspect, which then determined if the fault belonged to STS or to mobile operators. The recommendations from Gabriel Oprea report revealed that at the moment of the accident, the localization procedure based on phone calls was applied only in cases required by the judicial system, not in case of an accident. On behalf of the Romanian Police, Petre TobÃÂ stated that the GSM signal tracking device was mounted on a police van and weighed 300 kg, and to carried out the localization will be moved to the vicinity of GSM terminal or the van will be found near Bucharest at the moment of the incident and could reach the Apuseni Mountains in only 6-8 hours. In the same statement, TobÃÂ as presented the excuse for not use such device because of legal reasons,that is, the lack of a magistrate's mandate, the system being intended exclusively for the handling of criminal cases. Such statements contraddicts the fact that at european level existed the obligation to localize those that called 112 emergency service in case of plane accident. Also, even in this case, like every airplane accident, was opened a criminal investigation, which would have justified the use of the system.
STS affirmed that, despite all efforts, GPS tracking of the phones at the accident site was not possible. For this motive, in 2008 European commission has started a procedure of infringement against Romania, but this procedure was closed through diplomatic efforts only after the promise that the problem was resolved. Only in 2009 the implementation of the infrastructure as begun, only for Bucharest, spending over 10 million romanian lei. As the accident revealed, the sistem was not working in all the country at the moment of the accident. In response to an open letter, Gary Machado, Executive Director of European Emergency Number Association assigned blame for the situation on Neelie Kroes, who at the time of the incident had not enacted European-level regulation requiring provision of GPS co-ordinates in emergencies. The lack of provision of this critical information from the mobile company of the 112 caller to the emergency services was recognised as a major factor in the lethal delay in the rescue. The CIAS final report indicated the coordinates of the impact site as data provided by the GPS navigation system.
The Gabriel Oprea report affirms that the 121,5 MHz frequency will be received by ROMATSA, but not will be utilized for locating the ground. The equipment required for field location was a lightweight radio receiver, similar to that used for orienteering (see ELT). Annex 1 from the final report observed that in Romania the Search and Rescue service it was not specific to different situations, but was incorporated into the IGSU, which was designed for mass relief operations, which required the mobilization of large logistical resources, but in a slow manner. The SAR Command Center (CC-SAR) inside ROMATSA did not have its own logistic resources, could only appeal to IGSU, that, however, had no resources like helicopters equipped with 121.5 MHz receiving stations, with a reaction time of minutes. Regarding of the alarm, the report highlighted that ROMATSA was responsible only if the alarm had arrived from Air traffic controllers, but it was done at 112, therefore the responsibility of ROMATSA has been limited to making the information in its possession available upon request.
On October 19, 2015, the Center for Investigation and Analysis for Civil Aviation Security () (CIAS) published, as the authority responsible for investigating civil aviation incidents, the final accident report, and made public during a press conference on October 19, 2015. During the press conference, Eugen Stanciu, member of the inquiry committee of CIAS, affirmed that the plane was piloted by RÃÂzvan Petrescu, but the captain was Adrian Iovan, who had the decisional power. He also underlined that the purpose of CIAS investigations wasn't to consider those who had made mistakes accountable, but to establish the causes of the accidents and to recommend the necessary measures to avoid it in future.
According to the report, the principal cause of the incident was the engine shutdown due to severe icing of the carburetor. The contributing causes were the incorrect evaluation of the specific risk factors of this flight due to the long flight interruption and the inexperience of the crew on the Britten-Norman Islander, included in the Multi-engine piston (MEP) class, as well as several bad decisions by the commander of the airplane continue the flight mission in weather conditions that favored severe icing of the carburetor, flying for an extended period of time in icing conditions, continue the mission in AMA, in IMC flight conditions according to visual flight rules (VFR), and take off with the mass exceeding the maximum permitted limit and with the position of the center of gravity outside the limits calculated and imposed by the manufacturer.
In accordance with its purpose, the final report made a number of recommendations:
In the ROMATSA Report:
On January 22, 2014, Gabriel Oprea presented to the Government of Romania a report, the part of which was made public was a summary.
That summary gave the following results:
The report concludes that ROMATSA doesn't take the necessary proceedings to stabilize a search area for the airplane, doesn't started the search operations and doesn't requested the support from Air Operations Center of the Ministry of National Defense of Romania.
Octavian Thor Pleter, Associate professor at Faculty of Aerospace Engineering of Bucharest, has evaluated that the accident was caused by Adrian Iovan. In case of icing the pilot would have had three options: climb above the atmospheric front with humidity (but the low power of the engines did not allow this maneuver), descending below the atmospheric front or return to Sibiu. The pilot would have opted for the second option, which he failed to do. According to mister Pleter, the pilot would have opted for the third option. At the same time, affirms that the wrong decision of the pilot would be exonerated ROMATSA from every responsibility.
On February 2, 2014, it was held an analysis Supreme Council of National Defence for discussing of incident and ask for resignation of general Marcel OpriÃÂ, head of the STS. In his statement after the meeting, Traian BÃÂsescu affirmed the impression that the Romanian state was not able to act in situations of emergency was wrong. He also stated that the STS could not have done more in that moment, because could locate only landlines and, in the case of mobile phones, the only informations were that received for telephone operator, the cell, which in the area had a surface area of about 200 km. He also believed that the information spread in the press was lies.
However, recognized that the rescue operation was a failure, attributing to the fact that wasn't coordinated occording to the current regulations and that no commands have been established by either the Ministry of the Interior or the Ministry of Transport. From the other part, Ion Burlui, head of IGSU at the moment of the accident, declared in is onorary resignations that the ministers doesn't have operational powers. They are responsible only of the organization of the ministry they lead, but they interference in operational actions is not advantageous.
The report presented by Ministry of Transport claimed that the first localization was carried out through "apps on the phone of one of the survivors", while the ISU Cluj received the coordinates from STS. , that were transmitted from ISU Alba. This coordinates indicated a place located at almost 5,5 km north of effective place of the impact, which has the coordinates . However, the colonel Adrian Fulea denied that these coordinates came from the STS.
Always in the report, Ramona MÃÂnescu affirmed that the ministerial committee for emergency was not called up because have not been satisfied a series of conditions specified on a ministerial ordinance signed by Ovidiu Silaghi on 2012, but that ordinance contraddicts another governative decision that approved the regulament on the conduct of emergency situations generated from the occurrence of a civil aviation accident, a superior rule which established the obligations of the Ministry of Transport. The practical effect of the committee's failure to convene was poor communication between STS, ISU, and ROMATSA, which delayed the research.
As a direct result of the crash of flight RFT111 and the response to it, the head of the national emergency response department, IGSU, resigned. One day later, also as a result, the Interior Minister Radu Stroe resigned. A passenger on board had died of hypothermia after surviving the crash because of the long emergency response. This has led to an overhaul of the country's emergency response methods.
The three rescuers arrived for first on the scene of the accident at 21.13, Argentin Todea, Gheorghe Giurgiu and Gheorghe Trif, residents in Horea (Petreasa and DârleÃÂti villages), received the title of onorary citizen of Cluj county.
For their voluntary commitment, civic conscience and the solidarity demonstrated on rescue of the victims, Transylvania Off-Road Sports Club, SMURD Cluj and the team of doctors, assistants and paramedics of the Cluj County Emergency Clinical Hospital received diplomas of merit.
The Secretary of State, Constantin Chiper (PNL) of Ministry of Internal Affairs was fired. Prime minister Victor Ponta requested the replacement of the general director and the operating director of ROMATSA and the director of STS, Marcel OpriÃÂ. IGSU head, Ion Burlui, resigned, following the situation regarding the intervention of rescue teams at the scene of the accident.
General manager of ROMASTA, Aleodor Frâncu resigned but pleaded not guilty. Also Bogdan Donciu is resigned, chief operating officer of the company, that at the moment of the accident he was taking an exam at the Polytechnic University of Bucharest, where he was a professor, that regards also radar systems and air navigation. Minister Radu Stroe resigned.
CÃÂtÃÂlin Predoiu (PDL) accused ministers of negligence in their duties, Radu Stroe because a crisis unit was not immediately organized at the Ministry of the Interior, Ramona MÃÂnescu because didn't coordinated ROMATSA and Eugen NicolÃÂescu because didn't worry of how these transplant actions were performed.