Investigation Summary
Flight RFT111 was a humanitarian mission intended to transport a medical team from Bucharest to Oradea for an organ recovery procedure. While transiting the Apuseni Mountains, the aircraft encountered severe icing conditions. The Britten-Norman Islander suffered a dual engine failure as ice accumulated in the induction systems, forcing the pilot to attempt an emergency landing in a heavily forested, mountainous area near Petreasa. The aircraft came to rest at an altitude of approximately 1,400 meters in deep snow and freezing temperatures. The subsequent search and rescue (SAR) operation became a national scandal in Romania. The aircraft's Artex C406-2 ELT failed to transmit a usable signal on the 406 MHz satellite frequency because the antenna cable was not found at the crash scene, preventing satellite detection. Consequently, authorities relied on cellular triangulation, which provided a search area of approximately 200 square kilometers. Local residents and foresters eventually located the wreckage at 21:13, over six hours after the crash, arriving before official emergency services. The delay was attributed to a lack of coordination between the Ministry of Internal Affairs, the Ministry of Transport, and ROMATSA.
Final Conclusions
The Center for Investigation and Analysis for Civil Aviation Security (CIAS) concluded that the primary cause of the accident was a dual engine failure due to carburetor icing. Contributing factors included the pilot's decision to continue the flight into known icing conditions, a lack of crew experience on the BN-2 aircraft type, and the decision to initiate the flight while the aircraft was above its Maximum Take-Off Weight (MTOW) with the Center of Gravity (CofG) outside prescribed limits. The investigation also highlighted the failure of the ELT system and significant procedural deficiencies in search and rescue coordination.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Died in the accident.
Co-pilot
Systems & Failure Modes
Artex C406-2 ELT
An Emergency Locator Transmitter designed to broadcast on 121.5, 243, and 406 MHz. The 406 MHz signal is essential for satellite localization via the COSPAS-SARSAT system.
Induction System
The engine air intake system which, in this event, suffered from icing, leading to a total loss of power in both engines.
Interesting Facts
- 01The aircraft was not equipped with a flight data recorder or cockpit voice recorder.
- 02The ELT was an Artex C406-2, but the 406 MHz antenna cable was missing from the wreckage site.
- 03One victim survived the crash but died of hypothermia due to the six-hour delay in rescue.
- 04The accident led to the resignations of the Romanian Interior Minister and the head of the General Inspectorate for Emergency Situations (IGSU).
- 05The three local villagers who first reached the site were later named honorary citizens of Cluj County.
- 06The aircraft was operating above its Maximum Take-Off Weight (MTOW) at the time of the accident.
Safety Actions & Advisories
SAR Coordination Overhaul
Improving interdepartmental communication and specifying tasks for air traffic controllers during search and rescue activities.
MEP Flight Interruption Rules
Tightening requirements for flight interruption and resuming operations for Multi Engine Piston (MEP) class airplanes after periods of inactivity.
ATC Procedural Training
Instructing air traffic controllers on procedures to follow when flight rules change to avoid ambiguity during emergencies.
Cockpit Position Definition
Defining the position of the main cockpit on Britten-Norman Islander planes.
Accident Reporting Training
Establishing an obligation for economic operators to ensure staff are trained in the procedures for reporting accidents and serious incidents to CIAS.
Known Controversies & Unanswered Questions
Search and Rescue Failure
Reference ↗A major political controversy erupted regarding the inability of the Special Telecommunications Service (STS) and ROMATSA to locate the aircraft, leading to multiple high-level resignations.