Child sexual abuse (CSA) in sport remains a focal issue within Australia's national safeguarding agenda, prompting calls for more comprehensive, system-oriented prevention strategies. Football, the most widely participated organised sport among Australian children and adolescents, offers a representative context for examining CSA prevention and management across diverse communities and governance structures. The aim of this study was to understand the control structure of the current safeguarding system in football in Australia using the Systems Theoretic Accident Model and Processes (STAMP). A STAMP control structure was developed through a multi-phase validation process. Nineteen subject-matter experts (14 females, 5 males; mean age=46.1, SD=10.8) with an average of 5.8years (SD=7.6) in their current safeguarding roles and a further average 10years (SD=10.8) of related experience, recruited through targeted sampling across multiple levels of the safeguarding system, participated in the study. The resulting control structure model included 161 actors and organisations across 7 hierarchical levels of the broader sports system, 120 control mechanisms, and 94 feedback mechanisms across six hierarchical levels. The STAMP control structure supports a systems-thinking understanding of risk propagation and highlights how structural vulnerabilities and control mechanisms can contribute to safeguarding inadequacies. The developed control structure enables the identification of structural vulnerabilities, supports the detection of leading indicators of CSA, and informs systemic safeguarding reform. By integrating actionable feedback, the model promotes adaptive learning and a shift from compliance-driven reporting to proactive, system-wide responsiveness.

Probabilistic risk assessment for inert gas system on oil tanker ships using system theoretic accident model and process (STAMP) and Bayesian belief network (BBN)

Addressing Environmental and Societal Challenges through Systems Thinking: Lessons from Socially Sensitive Environmental Projects

The complexities of both technical and sociotechnical systems have increased in aviation over the years, and so have the causes of the accidents. In February 2018, there was an accident involving a helicopter crash in the Grand Canyon in the United States, causing the death of five passengers. According to the safety investigation report, the crash was due to the pilot’s inadequate controls during gusting tailwind conditions. Following the crash, people onboard could not evacuate on time due to the absence of the Crash-Resistant Fuel System test. Concluding an accident by blaming the pilot flying or the engineers cannot prevent similar accidents in the future. Accident investigators need a system-thinking approach to understand the accident and its causes systematically. Causal Analysis Based on System Theory (CAST) is an accident analysis method based on the Systems Theoretic Accident Model and Process (STAMP). It was selected as a preferred method to identify more causes of the Grand Canyon helicopter accident than those found in existing investigations. On top of the 8 recommendations proposed from the investigation report, the authors identified another 23 unique recommendations using CAST.

The primary objective of this paper is to conduct an exploratory, qualitative study in Industrial Asset Management, focusing on the development of an Integrated Decision-Making Framework. This framework is designed to evaluate performance variability caused by emerging technology risks and extreme, rare, and disruptive events. To achieve this, we integrate two robust decision-support tools: the Functional Resonance Analysis Method (FRAM) and the System-Theoretic Process Analysis (STPA). FRAM provides a comprehensive analysis of sociotechnical system functions, highlighting their interconnections and dependencies. In contrast, STPA, based on the System-Theoretic Accident Model and Processes (STAMP), takes a top-down approach to hazard assessment. The integration of FRAM and STPA aims to create a powerful decision-support framework. A case study on the LineDrone, which inspects high-voltage transmission lines without direct human interaction, demonstrates the framework's effectiveness in managing performance variability within complex sociotechnical environments.

Accidents are often attributed to frontline operator errors, overshadowing higher-level organizational and regulatory factors. This study integrates Systems-Theoretic Accident Model and Processes (STAMP) with fuzzy-set Qualitative Comparative Analysis (fsQCA) and Necessary Condition Analysis (NCA) – a configurational approach – to examine 80 major accident investigation reports from five high-risk Chinese industries (chemical, construction, transportation, coal mining, firefighting) spanning 2010–2022. Four systemic control elements (control activities errors, feedback errors, controller failures, controlled process errors) were assessed against three severity indicators (fatalities, injuries, direct economic losses). Results reveal distinct yet overlapping causal pathways. In chemical accidents, feedback errors are crucial for high fatalities. Construction and coal mining often link early controller/control activity failures to severe outcomes. Transportation highlights control activity errors for injuries, while firefighting points to the combination of control activity errors and controller failures. NCA corroborates key factors like feedback errors and controller failures as necessary conditions (effect sizes d > 0.1, p < 0.05). While supplementary statistical analysis confirmed these factors’ general importance, it faced data limitations (small N, collinearity); the fsQCA/NCA approach provided more robust insights into combinatorial pathways and necessity. Bottleneck analyses further indicate that even modest increments in key errors can trigger disproportionately large losses. These findings underscore the need for multi-level interventions—strengthening feedback loops, organizational oversight, and control processes—to mitigate accident severity in complex socio-technical systems, demonstrating the utility of configurational methods for understanding systemic failures.

Interorganizational risk management (IRM) in Canadian ports faces significant challenges due to the interconnected nature of operations and the interdependence of safety, security, environmental, organizational, and technological risks. Existing siloed risk management frameworks often fail to capture these dynamic interrelations, underscoring the need for a more integrated, systemic approach. This study introduces a Port Risk Control Structure (PRCS) designed specifically for Canadian Port Authorities (CPAs), based on the Systems-Theoretic Accident Model and Processes (STAMP). The PRCS maps control actions, feedback loops, and stakeholder roles across international, national, and local levels to better reflect the layered nature of port governance. The model aims to clarify the roles of key actors, such as the International Maritime Organization, Transport Canada, and local port stakeholders, and is designed to facilitate more structured risk identification, communication, and coordination across organizational levels. Although the model has not yet been empirically validated, its design suggests strong potential for scalability and adaptability across diverse port contexts. This research contributes to IRM literature by illustrating how STAMP principles can be operationalized within port systems. Future research will focus on integrating a taxonomy of IRM challenges to refine control structures and feedback mechanisms in response to evolving risks.

The System Theoretic Accident Model and Processes (STAMP) considers safety as a dynamic problem by focusing on interactions among system components rather than on component failure. However, analyzing complex system risks with STAMP can be challenging due to manual processes. Therefore, software tools supporting STAMP analysis have been developed. An evaluation of five tools (ASTAH, STPA, Capella, XSTAMPP, STPA Master Lite, and Visio Pro) was conducted, focusing on systems of systems (SoS) risk analysis. While all tools demonstrated compliance with the STAMP risk analysis procedure, with some tools offering additional features, a shortcoming in scalability limits the support for risk analysis of SoS. This makes risk analysis with the available STAMP tools challenging for SoS. Recommended enhancements include mechanisms to address SoS characteristics, scalability, collaboration, and improved usability. The study contributes to research on SoS risk analysis and provides direction for advancement in risk analysis tool support.

One key difference between the traditional probabilistic safety assessment (PSA) and multi-unit PSA (MU-PSA) is that the MU-PSA must consider interorganizational characteristics arising from deploying portable equipment. In this study, a systematic framework is proposed for the detailed sub-task analysis of human failure events (HFEs) involving portable equipment through utilization of STAMP (Systems-Theoretic Accident Model and Processes) and STPA (Systems-Theoretic Process Analysis). A case study was performed for a typical multi-unit emergency response involving a portable diesel generator. Through the proposed framework, detailed sub-tasks were identified for the HFE (“Failure of deploying the portable diesel generator”) in a form of unsafe control actions through a systemic approach. The results showed that the potential hazards that may not currently be analyzed in the traditional HRA enough include failed convocation of offsite workers, interorganizational communication between important EROs, and multi-unit decision making error on installing PDGs if there are conflict due to limited number of PDGs available. Results of the detailed HFE analysis using the proposed framework may be used as a basis to allow more realistic application of the HRA involving deployment of portable equipment (e.g., multi-unit accidents and beyond design-basis external events) that are better representative of the interorganizational characteristics.

With the burgeoning landscape of new enterprises and business paradigms, industrial and trade enterprises are facing escalating pressure to ensure operational safety. Conventional safety management mechanisms have proven to be inadequate for adapting to the dynamic market demands and intricacies of modern production environments. To improve safety management practices, this study integrates complex network theory to dissect the causal chains underlying accidents in industry and trade enterprises. A network model is established to elucidate the factors contributing to accidents and leverage datasets from safety inspections to construct a repository of latent safety risks. To address deficiencies in extant safety frameworks, a comprehensive safety management evaluation system is formulated, comprising ten primary evaluation indices and 30 secondary metrics. Based on the established frameworks, such as ISO 45001 for occupational health and safety management systems (OHSMS), standardized safety production protocols, and risk hierarchical management and control systems and hidden hazard identification and treatment systems (dual prevention systems), a holistic safety management system (SMS) is synthesized on the basis of system-theoretic accident model and process (STAMP) theory. This systematic approach culminates in a robust framework tailored to modern industrial and trade enterprises, fostering flexibility and efficacy in safety management capabilities. This case analysis underscores the model’s ability to enhance its safety management proficiency, thereby amplifying its relevance in fortifying enterprise operations and fostering sustainable growth. This study represents a pivotal step toward augmenting safety management capacities within the industrial and trade enterprises to safeguard enterprise vitality and advance sustainable business practices.

An integrated system theoretic accident model and process (STAMP)-Bayesian network (BN) for safety analysis of water mist system on tanker ships

Development of major process accident indicators based on Industrial Internet

This paper presents a systematic literature review of risk assessment methods in the chemical process industry (CPI), focusing on process safety, process security, and resilience. We analyzed peer-reviewed articles from 2000 to 2022 using the PRISMA methodology and identified twelve predominant methods. Our findings reveal a shift towards dynamic, systemic-based assessments like the Functional Resonance Analysis Method (FRAM) and System-Theoretic Accident Model and Processes (STAMP). These methods are particularly effective at capturing the complexities of sociotechnical systems in the CPI. However, a significant observation from our review is the limited emphasis on the resilience paradigm within many existing methods when addressing both process safety and process security risks, which is crucial for preventing and recovering from disruptions. Given the evolving challenges in system safety and security threats, there is an urgent need for holistic methods that integrate process safety, process security, and resilience. Our review highlights the opportunity for further research to better prepare the industry for future challenges, ensuring safer, more secure, reliable, and resilient operations.

Mechanism and early warning of coal mine rockburst accident based on SD-STAMP-DEMATEL

This paper provides a bibliometric analysis and literature review to explore the current application landscape of the Systems Theoretic Accident Model and Processes (STAMP) principles and techniques in the railway transportation domain. Following PRISMA guidelines, we systematically reviewed 118 research documents retrieved from prominent bibliographic databases, covering the period from 2008 to September 2023. The investigated research works, involving STAMP, mainly focus on two topics: 1) applications of STAMP to railway accident modeling/analysis and 2) applications of Systems Theoretic Process Analysis (STPA) to railway hazard analysis and risk assessment. In this paper, while the STAMP related studies are discussed with respect to the considered railway accidents, the studies related to STPA analysis are discussed with respect to three subjects, STPA applications, STPA comparative studies, and STPA extensions and improvements. Ultimately, this review aims to provide academic researchers and railway practitioners with a comprehensive exploration and analysis of the current state of knowledge on STAMP within the railway sector.

This study addresses the inadequacy of conventional failure analyses, which, in addition to regulatory and customer requirements, often neglect organizational needs. It emphasizes the importance of a systemic approach to mitigating hazards in complex space program management. This article proposes a new approach to addressing security issues that adds the management of security-related organizational needs to systemic engineering analysis. The case study of the catastrophic event involving SpaceX’s Starship SN10 prototype used publicly available information to build the system-theoretic accident model and processes (STAMP) model and identify organizational needs. The causal analysis based on systems theory (CAST) method was then applied to identify possible causes. Finally, the system-theoretic process analysis (STPA) method was used to determine design-related organizational needs and formulate recommendations for the design of the autogenous pressurization system. The presented method considered organizational needs to identify the key elements involved in the accident, the primary causes, and the actions to mitigate the associated hazards. This study proposed that managing organizational needs for system safety requires recognizing the current situation and constructing prospective scenarios to prevent failures, while emphasizing the importance of management’s proactive measures, clear responsibilities, and active involvement of all members to ensure system reliability.

In environments involving a variety of connected devices and systems, there is an ever-increasing demand for automated adaptation. To ensure that all threats are identified and manageable in such environments, quality assurance activities including testing and inspections in design-time should focus on assessing the reliability of critical adaptations, which may threaten life, economic property, or important information. This paper proposes an approach for identifying and evaluating critical adaptations on the basis of their automation level, reliability, detectability, and recoverability by decomposing adaptations into four stages: monitor, analyze, plan, and execute. This paper also empirically evaluates the effectiveness of the proposed approach by assessing a real safety-critical telecommunication system with critical adaptation features and comparing the results with the STAMP (System Theoretic Accident Model and Processes)/STPA (System-Theoretic Process Analysis) approach. The results of the evaluation indicated that the proposed approach could assess critical adaptation features provided by the system with reasonable effort. Additionally, structured views provided by the proposed approach enable efficient quality assurance activities. In the evaluation, the proposed approach achieves similar results to the STAMP/STPA approach but requires 33% less effort.

A STAMP-Game model for accident analysis in oil and gas industry

The way the road transport system is developed in a country affects safety. This study aims to identify the roles and relationships of road transport stakeholders and to explore the understanding of control and feedback mechanisms and associated gaps influencing road safety. A System-Theoretic Accident Model and Processes (STAMP) model was applied to document and interview data (n = 30). Participants emphasised the hindrance of overlapping mandates among stakeholders on the road transport system’s operations and underlined the roles of coalitions for road safety as system enablers. Further, the withdrawal of some controls by international agencies can increase system vulnerability. Most importantly, critical control and feedback gaps were shown to increase risks for safety within the road transport system. The findings underscore the complexity of the road transport system and add to the discussion on a system’s approach to road safety. Practitioner summary: Using a STAMP methodology, we extensively studied the road transport system in Tanzania. Road transport stakeholders were identified through the review of documents, interviews were conducted, and the main findings were discussed. Control and feedback mechanisms and associated gaps were critically presented, recommendations were proposed, and policy implications were suggested.

Catapult takeoff has become the main way for carrier-based aircraft to take off. However, as a complex process of multi-system coupling and multi-control actions link, it is an important task to ensure the safety of catapult takeoff. Therefore, this paper adopts the System-Theoretic Process Analysis (STPA) and establishes a model of catapult takeoff using the Systems Theoretic Accident Model and Process(STAMP) model. To carry out safety analysis, identify unsafe control actions and extract the causes of unsafe behavior, simulation analysis is also carried out for typical unsafe actions. The results show that using STPA to make safety analysis, combined with simulation, can comprehensively analyze and evaluate the safety of catapult takeoff, which helps identify the risk before the flight test and reduce the flight test risk.