Episode 57: TAROM Flight 371

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Summary:

In episode 57 of Take to the Sky: the Air Disaster Podcast, we explore the story of TAROM Flight 371, which crashed shortly after takeoff on March 31, 1995 in the small town of Balotești, Romania. The investigation soon uncovers a series of unfortunate events that unfolded in the cockpit: a faulty auto throttle system that created a power imbalance in the plane’s engines, an incapacitated captain who as unable to perform critical flight duties, and a first officer who found himself in an untenable situation and who quickly became too overwhelmed to perform corrective measures. Ultimately, these actions led to the worst plane crash on Romanian soil.



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What Made TAROM 371 Crash Shortly After Takeoff?

In episode 57 of Take to the Sky: the Air Disaster Podcast, we explore the story of TAROM Flight 371, which crashed shortly after takeoff on March 31, 1995 in the small town of Balotești, Romania. The investigation soon uncovers a series of unfortunate events that unfolded in the cockpit: a faulty auto throttle system that created a power imbalance in the plane’s engines, an incapacitated captain who as unable to perform critical flight duties, and a first officer who found himself in an untenable situation and who quickly became too overwhelmed to perform corrective measures. Ultimately, these actions led to the worst plane crash on Romanian soil. 

TAROM 371 Prepares for Takeoff from Bucharest-Otopeni Airport

On March 31, 1995, TAROM flight 371 is preparing to depart from Bucharest-Otopeni airport in Romania for a three-hour flight northwest to Brussels, Belgium. The aircraft is carrying 49 passengers and 11 crew members. Thirty-two of the passengers are from Belgium, nine are from Romania, three are from the United States, two are from Spain, and one passenger each is from France, Thailand, and the Netherlands.

Despite it being a snowy, wintry day in March, the flight is still running on time. To keep things running smoothly, the flight crew is busy running the necessary preflight checklists. After de-icing the plane, the flight is given clearance to begin its taxi. During taxi, the flight crew also carries out pre-takeoff checks including cockpit checks, the takeoff configuration check, and an auto-thrust system check. 

According to the accident report for the flight, the Captain of the flight is 48-year-old Liviu Bătănoiu, who has a total of 14,312 flying hours and 1,735 hours on the Airbus A310. He is a military aviation school graduate. The First Officer is 51-year-old Ionel Stoi who has a total of 8,988 flying hours total with 650 hours on the Airbus A310. He also graduated from the military aviation school. First Officer Stoi is the pilot flying on this leg of the trip.

Flight 371 is an Airbus A310. At the time in 1995, this aircraft is the leading edge of fully automated passenger jets. According to Wikipedia, the A310 was furnished with a two-crew glass cockpit configuration as standard, removing the requirement for a flight engineer; Airbus referred to this concept as the Forward-Facing Crew Cockpit. The company had developed the cockpit to significantly enhance the aircraft's man-machine interface, thereby improving operational safety. 

It was outfitted with an array of six computer-based  displays to provide the flight crew with centralized navigational, warning, monitoring, and general flight information, in place of the more traditional analogue instrumentation and dials. Overall, the aircraft is known for being pleasant for pilots to fly, and this model was considered to be very advanced for that time at TAROM, which had many older model aircraft in its fleet. 

TAROM airlines is currently the first and largest airline operating in Romania based on international destinations and international flights and is the third-largest measured by fleet size and passengers carried.

Back on the runway, Flight 371 is cleared for takeoff, and at 9:06 AM local time, the plane begins its takeoff roll. Seconds later, it lifts off into a gray sky while Captain Bătănoiu monitors the plane’s engine power to ensure the plane maintains its smooth liftoff and climb. 

The one notable factor in the takeoff was poor visibility. In fact, Flight 371 was climbing through thick, low clouds into zero visibility, and everything outside their cockpit windows would have blended together into whiteness without any physical indication of the horizon. This means that both pilots must rely on their instruments to fly, both of which who are experienced in doing so. 

Shortly After Takeoff, TAROM 371 Veers Off Course and Crashes 

As Flight 371 continues to climb, the plane next makes a left turn toward its first navigation point. This is when, suddenly, control notices something is wrong – the plane is banking sharply to the left and veering off its flight path. At this exact moment, the plane should be in a steep climb, but in addition to veering off course, it is now diving toward the ground. 

The approach controller, seeing the plane rapidly losing altitude on the radar screen, attempts to contact Flight 371, asking the flight crew to confirm altitude. But control receives no response from the flight crew. Control then asks a nearby plane to also contact Flight 371, but again, no response is received. Seeing that the plane is now no longer on radar, control issues a "distress phase" on the flight. Search and rescue teams are assembled by authorities and soon discover the reason for the lack of response. 

TAROM Flight 371, with 49 passengers and 11 crew members, has crashed into a field in a small city outside of Bucharest called Balotești. The crash is the deadliest to have happened on Romanian soil. 

According to the accident report, at the moment of impact, the aircraft was at a speed of over 330 kts, a pitch angle of about 80 degrees – it was almost completely vertical. The plane was also very heavy, weighing about 230,000 pounds, of which more than 42,000 pounds of unused jet fuel. Due to this fact, at the moment of the impact, a huge energy wave developed when the jet smashed into the solid ground surface, rapidly disintegrating and compressing the fuselage and generating a massive explosion from the fuel tanks. Ambulances and fire fight brigades arrive at the accident site within 30 minutes of the crash. It takes crews an hour and a half to contain the fire. 

It is evident based on the wreckage that there are no survivors. The field is littered with human remains and material fragments of the aircraft. Once the fire has been reduced to a smolder, the debris field can be surveyed by officials – and the carnage is absolutely horrific. The wreckage of what used to be Flight 371 is spread over a wide area of about 525 feet by 197 feet wide. The deepest part of the wreckage is buried within a 20-foot-deep crater – the plane basically got buried into the ground. 

Investigation into the Plane Crash Begins With Great Sense of Urgency 

Investigators begin the painstaking process of recovering all pieces of the fuselage, and receive assistance from the Romanian army, who have been called in to help transport wreckage to a secured facility. At the site of the impact, a central crater approximately 20 feet deep was created containing the greatest part of the fuselage, the wings and the two engines (the right one at a depth of 16 feet and the left one at a depth of 13 feet). The other part of the fuselage split into pieces and spread over the ground in an almost elliptical pattern, 262 feet wide and 656 feet long area.

In addition to the wreckage, of course, is the need to recover human remains and prepare them for identification. Based on the analysis issued by the Forensic Institute on the causes of death, officials conclude that all aircraft passengers and crew members died due to the physical shockwave generated by the aircraft impacting with the ground. While there are no survivors to corroborate what the passengers went through, it is known that they were all still alive as the plane plummeted earthward and likely knew the plane was in grave trouble, but no one would have known why. Passengers and cabin crew would have been helplessly strapped into their seats, likely holding on to hope until the very end. 

Investigators immediately sense the urgency and pressure that exists on the part of the public and the Romanian and Belgium governments to find the cause of the crash since there are hundreds of A310s currently in service. Remember, most of the passengers were Belgian nationals. Shortly afterwards, the President of Romania, Ion Iliescu, published a message declaring himself "shaken by the air catastrophe in Otopeni". The Prime Minister Nicolae Văcăroiu and many other government ministers arrive at the scene of the tragedy. They call for a commission of inquiry to be opened, one that is empowered to investigate the cause of the catastrophe. 

Bombing, Weather Ruled Out as Cause of Plane Crash

One of the first and most pressing questions the commission must answer is, did the plane get blown up by a bomb or did an explosion tear a hole in the fuselage, which caused the crash? There is palpable panic on the part of the public that it could have been a bomb, in part due to the coverage in the press that feeds the speculation. Rumors abound that say it the Mafia. Others fear Islamic fundamentalists. And immediate reports in the press back in 1995 reveal that witnesses say they saw an explosion before the plane hit the ground. In fact, many of the officials speaking on behalf of the investigation say right after the crash that they are looking into the issue of one or more midair explosions. 

And to make matters worse and to further feed the bomb frenzy, just two weeks earlier, a bomb threat had been called in on the same flight but was never carried out. Many wonder, was this the bomb?

Out of precaution, and due to their expertise in identifying evidence of bombings of planes, the American Federal Bureau of Investigation (or FBI) is brought in to examine the wreckage. FBI experts conduct a fly over of the wreckage, following the same flight route as Flight 371 took, looking for wreckage that might have been blown off the plane. The team also examines the wreckage for evidence of burn marks and etchings that indicate an explosion from a bomb. Lastly, they conduct a chemical analysis to detect bomb residue on parts of the fuselage. Ultimately, zero evidence exists to indicate a bomb or inflight explosion caused the crash. The FBI also rules out any other criminal cause of the crash. Additionally, agencies from both the US and France conducted parallel investigations and also do not find any evidence of a bomb or inflight explosion. 

Another potential cause of the crash that must be ruled out is the weather. This day was a snowy, wintry morning, but investigators are able to quickly rule out weather or ice since the snowfall was too light to have caused any issues and any buildup of ice on the wings was eliminated when the pilots de-iced the plane prior to takeoff. 

A key possibility for what did make Flight 371 crash to the ground may be engine failure. Following the crash, both engines were buried deep in the ground because of the intense impact and had to carefully be retrieved. The engines were severely dented and burnt, but investigators can find no burn marks inside – which means they were not on fire in the air. The blades are also badly damaged (which is no surprise to investigators), but the damage is from the impact, not from any damage that happened while the plane was still in the air. In all, there are no indications of engine damage or engine fire prior to the impact with the ground, and so, investigators rule out engine failure as the cause. 

The real clue to the cause of the crash comes once investigators interview the air traffic controllers on duty at the time of the crash. While the controller handling Flight 371 reports that everything about the takeoff was normal, the controller shares that shortly after takeoff, Flight 371 slightly veered off from its intended course. Instead of making a left turn and then straightening out, the plane continued to turn toward a 170-degree angle. Investigators find this change in course to be curious, and it leads them to investigate potential flight control problems as a reason for why the flight would have veered off course. 

TAROM 371 Maintenance Records Reveal History of Auto Throttle Issue 

The investigative team examines maintenance activities performed on Flight 371 and the plane’s overall operational performance. When reviewing the logbook, which details all the flight and service history for the plane as well as any repairs it has undergone, they confirm all required maintenance has been performed. 

But a key performance problem with the plane does emerge – investigators discover a repeat issue with the plane’s auto throttle system, which is a system that automatically controls the plane’s engine thrust at the different phases of a flight (takeoff, climb, descent, and landing). At takeoff, throttle is at max power and the levers move fully forward. Once the climb is completed, the engines need less power, and the auto throttle should slightly move back automatically. But investigators find that during several flights before the day of the crash, there was an uncontrolled reduction tendency of the left throttle lever, meaning, the system’s lever for the left engine moved all the way back instead of moving slightly back, drastically reducing the left engine’s power to idle instead of slightly reducing the engine’s power while the plane was still climbing. 

When this occurred, there was a power imbalance in the engines, which makes the plane more vulnerable to flight control problems as this imbalance can make an aircraft yaw (or turn) in one direction. 

To complicate the issue even more, when the thrust lever would move all the way back to idle power, it did not happen the same way and under the same flight conditions every time – it happened at random. And when investigators questioned why the auto throttle issue had not been fixed on this particular aircraft, the TAROM maintenance team said they tried repeatedly, but mechanics were never able to re-create the problem on the ground. Without being able to analyze the malfunction on the ground, they would not be able to come up with a solution. 

Instead of doing nothing, TAROM issued a briefing card inside the cockpit logbook alerting pilots of the problem. Pilots were advised to keep a hand on the throttle lever to block it from moving too far back, an action called “guarding the throttles”. 

In the preceding 25 hours before the crash, the same throttle malfunction happened twice: for the first time on the same day during takeoff on the flight preceding the accident flight, which was not reported by the crew in the logbook; and the second time during the accident flight. 

But issues with the auto throttle system on this plane go back the year prior to the accident flight. In all, there were about two dozen pilot complaints of the same issue, including a complaint from Captain Bătănoiu himself in the months prior. And during that flight, when he experienced the auto throttle issue, he followed the recommended procedure in the briefing card, and nothing went wrong on that flight. This fact leaves investigators to wonder, did he not follow this same procedure on this flight, or were other factors at play?

Flight Recorders Tell Story of the Plane Crash 

The full picture is ultimately completed by both of the flight’s recorders. According to the flight data recorder (or FDR), as soon as the plane climbs and begins its planned left turn, instead of straightening out of the turn, it banks and banks even more, reaching 170 degrees. This also aligns with what the controller reported to investigators. Then, the nose dips down and the plane rapidly begins to lose altitude. This results in a colossal loss of control, with the plane turning until it was almost vertical, careening toward the earth at well over 330 knots. In all, it takes just 19 seconds for the plane to hit the ground. The flight, from takeoff to crash, lasted just around 2 minutes. 

While the engines showed no performance problems when investigators physically examined them, their data tells a different story. The FDR gives a breakdown moment by moment of each engine’s performance. Both are near max power at takeoff (as it should be) but then as the plane reaches 2,000 feet altitude, the left engine begins to lose power. As it does, and the plane is turning at the same time the engines become asymmetrical in power, the plane banks farther left than it should. At 1,500 feet the throttles should have reduced engine power from takeoff power to climb power. But the auto throttle powered all the way back instead of slightly reducing power at this very same moment. This creates a huge power imbalance between the right and left engines, which forces the plane into a sharp left turn – and then the extreme bank. 

But investigators know not only was there a briefing card that explained how to manage the auto throttle issue, but Captain Bătănoiu also had successfully followed the procedure before. Why then was the throttle lever not guarded and why did the pilots not take control and save the plane? 

This leaves investigators to consider pilot error as a potential contributor. As we discussed, both the Captain and First Officer graduated from military flight school. The Captain had an impressive experience record. The First Officer also had an excellent training record. They both held valid licenses; valid medical and psychological fitness certificates; and they had never been involved in an aviation accident or incident before this fatal crash. Investigators find no issues to cause concern – both pilots are fit to fly.

The final answer comes from the second flight recorder, the cockpit voice recorder (or CVR). And what it reveals is a series of unimaginably ill-timed events that ultimately, in combination with one another, brought down Taron flight 371.

TAROM 371 Captain Incapacitated, First Officer Loses Control of Flight 

The flight begins normally all the way through takeoff. As a reminder, First Officer Stoi is the pilot flying. Captain Bătănoiu tells the First Officer he will guard the throttle, which as the non-flying pilot is exactly what he was supposed to be doing. 

When airborne, the First Officer requested the Captain to retract the landing gear, which he does. Flight 371 reaches 1,700 feet and begins its left turn. Shortly thereafter, an engine thrust asymmetry starts to develop with continuous decrease of the left engine thrust.

First Officer Stoi then asks the Captain to retract flaps, which he does. At that moment, the engines thrust asymmetry begins to increase as the left engine power continues to decrease.

Next, the First Officer asks the Captain to retract the slats, but this time, the Captain doesn’t respond. Sensing something is wrong, First Officer Stoi asks the Captain, "Are you all right?" The aircraft is now passing through 4,200 ft altitude, and the left bank angle is increasing. 

The CVR picks up a noise that sounds like what a person would make when they are in pain. Captain Bătănoiu falls silent from now until the end of the flight. Investigators believe this is the moment he either experienced a fatal heart attack or lost consciousness. The captain’s incapacitation now leaves the First Officer all on his own in the cockpit. And as any human would be, the First Officer’s attention is drawn to the captain, trying to revive him. But what the First Officer is not aware of is that he’s rapidly losing control of the plane. 

The plane's left engine moved back to idle, resulting in asymmetric thrust as the right engine remained at climb power. The speed of the aircraft began to decrease, and the aircraft banked to the left. Preoccupied with trying to wake Captain Bătănoiu, the First Officer did not notice the rapidly increasing left roll. And to make things worse, the cloud cover prevented First Officer Stoi from visually noticing the roll.

The engine thrust asymmetry reached its maximum value, and the aircraft was banking severely to the left at an angle of 45 degrees. The FDR recorded an attempt to engage the autopilot. The autopilot is unable to connect under these current conditions, and the aircraft begins to lose altitude rapidly. Flight 371 begins to dive to the ground. The aircraft rolled as its airspeed continued to increase. At the time, the aircraft was nose diving with a pitch angle of -61.5 degrees. 

The First Officer cried something which is not intelligible. Those who have listened to the CVR say that First Officer Stoi is heard shouting up until the moment of impact. The aircraft eventually crashed into the ground at 09:08:34 near Balotești with a speed of 324 knots (373 mph). 

In the official air accident report, there is an unsettling sentence about the First Officer’s actions in the cockpit. It says, “The pilot's maneuvers and the control surfaces position cannot be explained on the basis of the data and elements available.” Basically, this sounds like investigators have no explanation for why the First Officer did what he did at this point. 

Investigators deduce that the First Officer, distracted by the incapacitation of the Captain, did not know how serious the situation was until the plane broke through the clouds. And at this point, TAROM Flight 371 was less than 2,000 feet from the ground. He must see the ground coming up towards them. There is not enough space left to recover from the descent. Investigators think that if he had been able to see outside it would have made all the difference. The First Officer literally could not see his way out of this rapidly deteriorating situation.  

Three Main Contributors Caused Crash of TAROM 371

When the official accident report is finally released, investigators identify three main contributors to the crash of Flight 371:

  • A faulty auto throttle which created an imbalance in engine power. 
  • The incapacitation of the captain (who was unable to complete critical flight tasks).
  • The First Officer’s inability to regain control (and not being able to react quickly enough in the clouds).

After the report was submitted by the Romanian Administrative Investigative Commission, The Ministry of Transport in Belgium, who reviewed the report, disagreed that all three contributing factors were equal causes. They felt more blame should have been placed on the First Officer. 

They said in a letter back to the commission, “We consider that the primary cause of the accident is a loss of control over the aircraft brought about by inadequate actions of the pilot flying in manual mode even though all the flight control systems were available. However, they were not used in an optimum way by the pilot who was facing a reduction of power of one engine resulting from failure of the auto throttle system. A possible contributing factor is an incapacitation of the pilot-in-command. We believe that this is an objective explanation for the causes of the accident. It would indeed be difficult to convince the international aeronautical community of the fact that the failure of the ATS and a possible incapacitation of one flight crew member led to such a disaster.”

Nine months after the plane crash, Airbus issued two service bulletins that instructed Maintenance how to fix the auto throttle issue once and for all. The fixes then became mandatory on all A310s. And since Flight 371, no other crashes have ever been caused by this same auto throttle issue. 

In 1996, near the site of the tragedy, a monument was erected in memory of the victims, whose names are inscribed in black and gray marble.

And THAT is the unbelievable story of the crash of TAROM Flight 371.

Show Notes:

In this week's episode we talk about the return of brunch, Zoom weddings, an how we're doing with our quarantine hobbies. Let us know if you have been up to anything similar- and what you're looking forward to in the coming months!

Credits:

Written and produced by: Shelly Price and Stephanie Hubka
Directed and engineered at: Snow Monster Studios
Sound editor: Stephanie Hubka
Producer: Adam Hubka
Music by: Mike Dunn
Tarom Flight 371

The actual accident aircraft. Source: Aero Icarus

A Belgian expert searches through the debris of Tarom Flight 371. Source: Aviation24.be

Tarom Flight 371

Wreckage of Tarom Flight 371. Source: aviation-accidents.net

Tarom Flight 371

Tarom Flight 371 memorial stone near the crash site. Source: Adriano on Flickr