The essay's worked example is a composite town-versus-court story with no evidentiary weight. Horizon is the documented version.
Over more than a decade the Post Office prosecuted hundreds of subpostmasters on Fujitsu Horizon figures treated as proof of theft. Fraser J in Bates v Post Office [2019] EWHC 3408 (QB) found the system contained bugs, errors and defects capable of causing apparent shortfalls. The Court of Appeal in Hamilton [2021] EWCA Crim 577 held that, where Horizon data was essential and there was no independent evidence of an actual loss, the trial could not have been fair, and the prosecutions were an affront to the public conscience. Sir Wyn Williams's Volume 1 (July 2025) put it as the Post Office having "maintained the fiction that its data was always accurate."
You do not need all twelve domains. Three recode the repair. Measurement: Horizon was treated as territory, not as a proxy — the spend is independent evidence of an actual loss, which is the Hamilton cut. Purpose: the Post Office succeeded at defending the system and recovering "losses"; it failed at legal-civic legitimacy. Conversion between systems: Fujitsu's instrument, the Post Office as prosecutor of its own agents, and the criminal courts each ran. Nobody owned importing known defects into disclosure. That is the collision the essay names and says it has no primitive for.
Safety already has maps for this. Reason's Swiss cheese (Managing the Risks of Organisational Accidents, 1997) wants a hazard punching through aligned holes in sequential barriers. Leveson's STAMP (Safety Science, 2004; Engineering a Safer World, 2012) treats the loss as inadequate enforcement of a safety constraint inside a hierarchical control structure. Perrow's Normal Accidents (1984) says some systems fail because of interactive complexity plus tight coupling; he later noted that most famous disasters are the prosaic kind — ignored warnings, production pressure, poor regulation — and that Three Mile Island was the rare true "normal" accident.
Horizon is not Swiss cheese. Adding another slice is what the 2010 Ismay report was: an internal paper tasked with listing "reasons for assurance," which also warned that a real investigation "would need to be disclosed in court" and that any perception of doubt would stay prosecutions (POL00107129, 2 August 2010, on the inquiry site). The holes were not waiting to align; the barrier was built to keep the trajectory closed. Hollnagel's ETTO (2009) also misses: this was not counter staff trading thoroughness for speed. It was fiction-maintenance at the centre. Perrow would file it as the common case, not as his object.
STAMP gets closer — you can draw Post Office, Fujitsu, the shareholder department, and the courts as controllers. Horizon had two systems succeeding locally: the Post Office at mandate-defence, the courts at processing the case they were given. The essay's first move is to name the reference purpose before naming the failed domain. Whether STAMP/CAST already has a slot for "success under T1, failure under T2" is the comparison, not a result. Apply CAST to the same Williams/Bates/Hamilton bundle, then report what changes — a missing slot, an equivalent representation, or a difference in usability. Multiple-controller interaction is already in the STPA literature; that is not enough, by itself, to claim a gap.
The experiment is sitting in public. Williams's inquiry has published the Ismay memo, the hearing transcripts, and Volume 1. Leveson's CAST handbook (2019) is a worked method for coding the same kind of bundle into a control structure.
Code the Horizon file twice: once as CAST (controllers, constraints, why controls were ineffective), once as a Stack walk that is allowed to emit "collision between systems" instead of a layer. The discriminator is the repair each emits. If both say "strengthen the Post Office's control of Fujitsu," the maps agree and the missing primitive is decorative. If CAST strengthens one hierarchy and the Stack names an import duty — whose finding the criminal process is obliged to take — they disagree on the artifact. That is a weekend with the inquiry PDFs, not a new theory.