ACCIDENT / INCIDENT INVESTIGATION

STAMP (Systems Theoretic Accident Modeling and Processes) focuses on the role of constraints in safety management. Instead of defining safety in terms of preventing component failure events, safety is defined as a continuous control task to impose the constraints necessary to limit system behaviour to ensure only safe changes and adaptations. Accidents are seen as resulting from inadequate control or enforcement of constraints on safety-related behaviour at each level of the system development and system operations control structures. Therefore, accidents can be understood in terms of why the controls that were in place did not prevent or detect maladaptive changes.