<![CDATA[Faktor sistemik merupakan defisiensi yang melekat pada desain, kebijakan, prosedur, atau budaya organisasi dan Loss of Control In-Flight (LOC-I) merupakan salah satu penyebab utama kecelakaan pesawat udara di Indonesia, yang memerlukan analisis mendalam terhadap faktor sistemik di baliknya. Penelitian ini bertujuan untuk mengidentifikasi faktor-faktor sistemik yang berkontribusi terhadap LOC-I dengan menggunakan dua model analisis, yaitu Swiss Cheese Model dan SHELL Model. Data diambil dari laporan investigasi kecelakaan yang dipublikasikan oleh Komite Nasional Keselamatan Transportasi (KNKT) periode 2010–2023. Metode penelitian yang digunakan adalah kualitatif deskriptif dengan pendekatan studi kasus, di mana faktor-faktor seperti human error, desain sistem, prosedur operasi, dan lingkungan dianalisis secara holistik. Hasil penelitian menunjukkan bahwa interaksi kegagalan pada berbagai lapisan pertahanan (latent failures dan active failures) dalam Swiss Cheese Model serta ketidaksesuaian dalam komponen Software, Hardware, Environment, Liveware (SHELL) menjadi pemicu utama LOC-I. Berdasarkan temuan tersebut, penelitian ini memberikan rekomendasi mitigasi berbasis sistem untuk regulator (Kemenhub, DGCA) berupa peningkatan Regulasi pelatihan Upset Prevention and Recovery Training dan penguatan Safety Oversight berbasis resiko, operator (maskapai penerbangan) berupa peningkatan Crew Resource Management (CRM) dan Peningkatan efektivitas pelatihan simulator berbasis data, dan stakeholder aviasi lainnya, termasuk peningkatan pelatihan human factors, optimasi safety management system (SMS), dan penguatan regulasi operasional. Implikasi penelitian ini diharapkan dapat mendukung upaya pencegahan kecelakaan serupa di masa depan. Systemic factors are inherent deficiencies in design, policies, procedures, or organizational culture, and Loss of Control In-Flight (LOC-I) is a primary cause of aircraft accidents in Indonesia, which requires an in-depth analysis of the systemic factors behind it. This research aims to identify the systemic factors that contribute to LOC-I by using two analysis models: the Swiss Cheese Model and the SHELL Model. Data were taken from accident investigation reports published by the National Transportation Safety Committee (KNKT) for the period 2010–2023. The research method used is descriptive qualitative with a case study approach, wherein factors such as human error, system design, operating procedures, and the environment are analyzed holistically. The research findings indicate that the interaction of failures across various defense layers (latent failures and active failures) in the Swiss Cheese Model, as well as incompatibilities within the Software, Hardware, Environment, and Liveware (SHELL) components, are the primary triggers for LOC-I. Based on these findings, this research provides system-based mitigation recommendations for regulators (Ministry of Transportation, DGCA) in the form of enhancing Upset Prevention and Recovery Training regulations and strengthening risk-based Safety Oversight; for operators (airlines) in the form of improving Crew Resource Management (CRM) and increasing the effectiveness of data-driven simulator training; and for other aviation stakeholders, including enhancing human factors training, optimizing the Safety Management System (SMS), and strengthening operational regulations. The implications of this research are expected to support efforts to prevent similar accidents in the future. ]]>
