{'fraction_non_alphanumeric': 0.036057692307692304, 'fraction_numerical': 0.024839743589743588, 'mean_word_length': 4.947619047619048, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A STAMP ANALYSIS OF THE LEX COMAIR 5191 ACCIDENT

A new view, a holistic systems view, that sees individuals in systems, is growing. It is a view which sees “human error is an effect of trouble deeper inside the system....[where] we must turn to the system in which people work: the design of equipment, the usefulness of procedures, the existence of goal conflicts and production pressure” (Dekker, 2007, p. 131) A new, holistic systems perspective, accident model is used for analysis of the Comair 5191 accident in Lexington, KY on August 27, 2006. The new model is called: Systems—Theoretic Accident Modeling and Processes (STAMP). It incorporates three basic components: constraints, hierarchical levels of control, and process loops. Accidents are understood “in terms of why the controls that were in place did not prevent or detect maladaptive changes, that is, by identifying the safety constraints that were violated and determining why the controls were inadequate in enforcing them” (Leveson, 2002, p. 55). This STAMP analysis of the 5191 accident illustrates the usefulness of the STAMP model to foster evaluation of the whole system and uncover useful levers for elimination of future loss potential thereby making progress on safety.