On 20 January 2014, Școala Superioară de Aviație Civilă 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.
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.
Search operations 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 Telecomunicaţii 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.
Aircraft The aircraft involved was a Britten-Norman BN-2A-27 Islander, registration YR-BNP.
Passengers 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 Cătălin 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 Beiuș and was part of transplant team of Oradea County Emergency Clinical Hospital. Ianceu had graduated at the Iuliu Hațieganu University of Medicine and Pharmacy and specialized in transplants.
Victims
Aurelia Ion 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 18.6°C.)
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 Dușa, 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 Dușa.
Adrian Iovan 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.
Investigation 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 Nițu, said he was considering investigating the authorities' handling of the plane crash.
In addition 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 Lazăr, 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.
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 the GPS system allowed the reconstruction of the flight profile. The flight plan called for a flight on instruments 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 conditions favorable 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 below the maximum allowed, but exceeded the allowed weight according to the standard calculating method, that provides 96 kg for men and 78 kg for women. 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.