A HFACS-Based Safety Learning Analysis of a CFIT Accident in Tropical Mountain Flight Operations

Abstract

Controlled Flight Into Terrain (CFIT) remains a serious safety concern in tropical mountain flight operations, where changing weather, limited terrain clearance, and reduced visual references can narrow the options available during flight. This study examines the PK-SWW CFIT accident using the Human Factors Analysis and Classification System (HFACS) and framework-guided thematic analysis. The analysis used the final accident investigation report issued by the Indonesian National Transportation Safety Committee (KNKT). Relevant findings were extracted from the report, assigned descriptive codes, and classified into the four HFACS levels. The classified findings were then examined for recurring patterns and grouped into four analytical themes: degraded terrain awareness under deteriorating visual conditions; escalating VFR risk through flight-path and altitude decisions; TAWS effectiveness limitations as a safety barrier; and safety assurance deficiencies following aircraft modification. The case shows that the accident involved interacting environmental, human, technological, and organizational conditions rather than a single operational failure. These findings were further organized into a Safety Learning Matrix linking the identified risks with organizational learning objectives and recommended safety actions for tropical mountain flight operations.