Școala Superioară de Aviație Civilă Flight 111

On 20 January 2014, Școala Superioară de Aviație Civilă Flight 111, a Britten-Norman Islander operated by Romania's Superior School of Aviation (Școala Superioară de Aviație Civilă), crashed in the Apuseni Mountains, at an altitude of approximately 1400 m, 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 (Centrul de Investigații și Analiză pentru Siguranța Aviației Civile) 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.

Accident

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 Răzvan Petrescu. On board were Dr Radu Zamfir from Fundeni Hospital, Dr Valentin Calu from Elias Hospital, Dr Cătălin Pivniceru from Saint Mary Hospital, Dr Sorin Ianceu from yjr municipal hospital in Beiuș, 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 Mureș could not be used.

The pilot and the student died and the copilot was in a critical state, doctors Valentin Calu, Cătălin 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 Județean de Urgență Cluj) and were admitted to the Intensive Care Unit.

Flight

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 Răzvan 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 Băneasa 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.