Analisis penyebab kegagalan sistem pengereman pada kejadian runway excursion pesawat cessna-208b di bandar udara ilaga

Abstract

Aviation safety is a primary and absolute aspect of air transportation operations. Optimal performance of aircraft mechanical systems is an absolute requirement for the prevention of aviation accidents. One of the most critical components is the braking system, particularly during the landing roll phase. The failure of the braking system to adequately absorb kinetic energy can be fatal, especially at pioneer airports such as Ilaga Airport (WAYL), which has a very short runway and extreme elevation. This research is motivated by the runway excursion incident involving a Cessna 208B aircraft registered as PK-PPI on August 25, 2025. Based on Mandatory Occurrence Report (MOR) data, the aircraft failed to decelerate post-landing and continued to travel freely even though the pilot had applied the brakes and reverse thrust. This study aims to deeply analyze the mechanical condition of the braking system prior to the incident, assess the compliance level of the brake lining component maintenance execution with applicable regulations, and identify the primary causal factors and systemic root causes of the reduction in braking effectiveness that led to the incident.This study employed a descriptive qualitative approach with a documentary study and open-ended questionnaire design. The research object focused on the technical maintenance track record of the PK-PPI fleet's braking system and personnel compliance with airworthiness regulations. Secondary data sources were obtained from official Directorate General of Civil Aviation documents, which include the MOR report, Cessna 208 Series Aircraft Maintenance Manual (AMM) Chapter 32, Aircraft Flight and Maintenance Log (AFML) documents, and Circular Letter of the Director General of Civil Aviation Number SE 01 of 2023. To validate factual findings scientifically, Data Triangulation was conducted through Expert Judgement involving practitioners holding an Aircraft Maintenance Engineer License (AMEL). The data analysis technique was carried out using Root Cause Analysis (RCA) through a Fishbone Diagram mapping to dissect the dimensions of Manpower, Method, Material, Measurement, and Environment. After static factors were set aside, the analysis continued vertically using the 5 Whys Analysis method to find the deepest causality chain of the deviations that triggered the systemic failure.The research results through the Fishbone Diagram mapping showed that the braking failure was triggered by three interconnected operational deviations. In the Method dimension, there was a delegation of brake component testing work instructions to the pilot without a standardized technical handover Standard Operating Procedure (SOP). In the Manpower dimension, this procedural weakness was exacerbated by the lack of supervision, physical verification, and direct assistance by the mechanic (LAME) on the ground. In the Measurement dimension, administrative validation of the aircraft's airworthiness documents was neglected. Based on the 5 Whys Analysis, the systemic root cause of this incident was the collapse of the Quality Gate system (Final Airworthiness Supervision). LAME prematurely issued a Return to Service (RTS) approval even though there was no specific recording log regarding the New Brake Burn-In testing, and the absence of a validation signature from the pilot in command (PIC) in the AFML Rectification column was ignored. This direct violation of Circular Letter SE 01 of 2023 became a fatal flaw that allowed the aircraft to fly in an un-airworthy condition, thereby triggering the Brake Glazing phenomenon on the runway. As a mitigation measure, it is recommended to enforce discipline in filling out the AFML through strict field inspections by Quality Assurance, optimize Refresher Training related to the Circular Letter and AMM mandates, and supervise the obligation of the technician's physical presence to validate component effectiveness on the apron before the airworthiness document is signed and issued.