ANALISIS FAKTOR ACCIDENT CONTROLLED FLIGHT INTO OR TOWARD TERRAIN DI INDONESIA TAHUN 2015 – 2024 DENGAN SHELL MODEL

Keselamatan penerbangan merupakan prioritas utama dalam industri aviasi, salah satu jenis accident yang menjadi perhatian adalah Controlled Flight Into or Toward Terrain (CFIT), yaitu accident ketika pesawat yang sepenuhnya terkendali justru menabrak medan tanpa indikasi kegagalan teknis sebelumnya. Penelitian ini bertujuan mengidentifikasi faktor-faktor penyebab CFIT di Indonesia pada periode 2015–2024. Analisis dilakukan terhadap tujuh Final Report investigasi KNKT yang memenuhi kriteria CFIT, menggunakan pendekatan SHELL Model (Software, Hardware, Environment, Liveware) untuk mengkaji interaksi antar elemen. Untuk memperkuat validitas, peneliti melakukan wawancara dengan pakar keselamatan penerbangan dan investigator kecelakaan.
Hasil penelitian menunjukkan bahwa interaksi Liveware–Hardware (manusia–perangkat keras) menjadi faktor dominan, berkontribusi sebesar 37% dari total interaksi penyebab yang diidentifikasi. Dari faktor ini, 86% berkaitan dengan tidak berfungsinya Enhanced Ground Proximity Warning System (EGPWS) baik akibat kerusakan teknis maupun dinonaktifkan oleh awak pesawat dan 14% disebabkan oleh kegagalan instrumen navigasi atau indikator penerbangan lainnya.
Temuan Cockpit Voice Recorder (CVR) memberikan gambaran penting tentang dinamika di kokpit. Rekaman tidak menunjukkan adanya suara hasil self-test terhadap EGPWS hal ini membuat peneliti tidak dapat menentukan apakah sistem EGPWS rusak atau di-inhibit. Peneliti merekomendasikan peningkatan pelatihan awak pesawat terkait penggunaan dan pemantauan sistem avionik, khususnya EGPWS, penyesuaian pre-flight checklist dan pelarangan penggunaan fungsi inhibit pada EGPWS tanpa justifikasi teknis yang valid.

Aviation safety is a top priority in the aviation industry. One type of accident that has gained significant attention is Controlled Flight Into or Toward Terrain (CFIT), which occurs when an airworthy aircraft, under complete control, unintentionally collides with terrain without prior indication of technical failure. This study aims to identify the factors contributing to CFIT accidents in Indonesia during the period 2015–2024. Analysis was conducted on seven final investigation reports from the National Transportation Safety Committee (KNKT) that met the CFIT criteria, using the SHELL Model (Software, Hardware, Environment, Liveware) to examine the interactions among its elements. To strengthen validity, interviews were conducted with aviation safety experts and accident investigators.
The findings indicate that the Liveware–Hardware (human–hardware) interaction was the dominant factor, contributing 37% of the identified causal interactions. Of these, 86% were related to the malfunction of the Enhanced Ground Proximity Warning System (EGPWS) either due to technical failure or deliberate inhibition by the flight crew while 14% were caused by the failure of navigation instruments or other flight indicators.
Cockpit Voice Recorder (CVR) findings provided valuable insights into cockpit dynamics. The recordings did not capture any self-test sounds from the EGPWS, preventing the researcher from determining whether the system was malfunctioning or inhibited. Recommendations include improving flight crew training on the use and monitoring of avionics systems, particularly EGPWS, revising the pre-flight checklist, and prohibiting the use of the EGPWS inhibit function without valid technical justification.