Who We Are

Fundamental Principles

GAMA rejects linear and deterministic approaches to accident causation based exclusively on identifying individual errors or isolated failures.

Instead, GAMA adopts the following guiding principles:

1. Accidents emerge from complex interactions within sociotechnical systems

Marine casualties commonly result from multiple dynamic interactions between people, technologies, organisations, procedures, the operational environment and the regulatory framework.

Human actions observed at the scene of an occurrence are often visible manifestations of conditions and influences distributed throughout the system.

Accordingly, the investigation seeks to understand the network of interactions that created the conditions for the occurrence, rather than focusing solely on the events closest to the outcome.

1. Human error is a phenomenon to be investigated, not a sufficient causal explanation.

GAMA considers that expressions such as "human error", "operator failure" or "error of judgement" do not constitute sufficient explanations for an accident.

Whenever a human action contributes to the observed outcome, the investigation seeks to understand:

why that action appeared appropriate when it was taken;

what information was available;

which operational objectives were in conflict;

which cognitive, organisational and technical limitations existed;

which systemic factors shaped the decision.

From this perspective, error is treated as a starting point for analysis and not as the conclusion of the investigation.

1. Professionals create safety every day

In accordance with Safety-II principles, GAMA recognises that seafarers produce safe outcomes every day in environments characterised by variability, uncertainty, time pressure and limited resources.

Most maritime operations are completed without adverse consequences because professionals continuously adjust their performance to the actual circumstances of the work.

GAMA’s maritime safety investigations seek to understand both the mechanisms that contributed to an unsuccessful outcome and those that normally enable operational success.

1. Decisions must be understood from the perspective of those involved

GAMA maritime safety investigators seek to reconstruct the situation as it was perceived before the occurrence.

This approach requires an understanding of:

the situational awareness that existed;

the expectations of those involved;

the signals considered relevant;

the interpretations developed in real time;

the uncertainties present at the time of the decision.

The objective is therefore not to assess decisions in the light of knowledge acquired subsequently, but to understand why those decisions were considered reasonable within that specific context.

1. GAMA’s maritime safety investigations prioritise systemic and holistic thinking

GAMA considers safety to be an emergent property of systems. Consequently, the investigation adopts an integrated view of the phenomena observed, seeking to understand how different elements of the system interact with and influence one another.

The analytical focus is not placed exclusively on individuals, equipment or isolated procedures, but on the relationships between all relevant components of the system.

1. Operational variability is both a source of success and a source of risk

Human adaptation to operational demands is a necessary condition for the effective functioning of the maritime system.

The same adaptive mechanisms that normally make it possible to achieve safe outcomes may, in certain circumstances, contribute to unwanted outcomes.

For this reason, the investigation seeks to understand the patterns of adaptation within the system, rather than merely identifying deviations from prescribed requirements.

1. Human factors analysis must encompass every level of the system

Drawing on the principles of the Human Factors Analysis and Classification System¹ and the systemic analysis of human factors, GAMA examines influences present:

at the level of operational actions;

at the level of preconditions for human performance;

at the supervisory level;

at the organisational level;

at the level of external regulatory, economic and institutional influences.

This approach makes it possible to identify latent mechanisms that would be difficult to observe through analyses focused solely on the operators involved.

1. Investigation seeks to strengthen the system’s capacity for learning

The safety recommendations issued by GAMA are intended to promote organisational learning, increase the maritime system’s adaptive capacity and strengthen its resilience to future disruptions.

The fundamental objective is not to eliminate human variability, but to improve the conditions in which that variability is managed and used to produce safe operations.

Final Statement

GAMA considers that marine casualties cannot be adequately explained through linear cause-and-effect models or through the simple attribution of errors to individuals.

Maritime safety investigation must seek to understand how people, organisations, technologies and the operational context interact within a complex and dynamic system.

Through this approach, GAMA seeks to produce useful, credible and independent knowledge that contributes to maritime transport that is safer, more resilient and better able to learn from operational experience.

¹HFACS (Human Factors Analysis and Classification System) – a human factors classification framework developed by Wiegmann and Shappell (2003), based on James Reason’s "Swiss cheese" model, used to identify and analyse human, supervisory, organisational and institutional contributions to accidents.

GAMA’s mission is to investigate maritime casualties and incidents, with the aim of identifying their causes and contributing factors, preparing and publishing the corresponding maritime safety investigation reports, conducting studies, formulating maritime safety recommendations intended to reduce maritime casualties and ensuring participation in national or international committees, bodies or activities.

Under the legal framework referred to above and the International Maritime Organization’s Casualty Investigation Code (IMO Resolution MSC.255(84)), GAMA is the authority responsible for maritime safety investigation in Portugal, entrusted with determining causes and contributing factors and issuing safety recommendations intended to prevent and mitigate maritime casualties and incidents. Maritime safety investigations conducted by GAMA are not intended to determine blame and/or liability, and the data and information collected during such investigations may not be used in other proceedings, including judicial proceedings.

As the maritime safety investigation authority, GAMA must be notified, in accordance with Article 7 of Law No. 18/2012 of 7 May, of all occurrences that come to the attention of the entities to which this Circular is addressed.

The duty to notify includes notifications concerning maritime incidents and near misses, which are classified as maritime incidents within the context of maritime safety investigation.

The occurrence notification form template (annexed to this Circular) is available on GAMA’s website at www.gama.gov.pt and must be submitted electronically to iam@gama.gov.pt .

It is also possible to notify GAMA of any occurrence through the European Marine Casualty Information Platform (EMCIP) by using the EMCIP link

The telephone number (+351) 967 852 458 is also available 24 hours a day.

Following an occurrence, and as provided for in Directive 2009/18/EC of the European Parliament and of the Council of 23 April 2009, establishing the fundamental principles governing the investigation of accidents in the maritime transport sector, as amended, notification to GAMA must be made without delay, with the initial notification being submitted within 24 hours of the occurrence.

Failure to comply with the duty to notify, or any delay in notification, constitutes an administrative offence, as provided for in Article 24 of Law No. 18/2012 of 7 May.

Yours faithfully,

Lisbon, 31 March 2026

The Director-General of GAMA
Tiago Sarandes Teixeira