A semi-chronological list of (good?) ideas that I have had the opportunity - or good luck - to work on and/or contribute to.

Cognitive Systems Engineering (CSE). CSE was the result of my first collaboration with David Woods, which has been going on for 40 years. CSE can now be seen as a flawed attempt to a universal paradigm for humna-machine systems, but some parts of CSE are still higly relevant today.

Goals-Means Task Analysis (GMTA). In retrospect this is probably a kind of precursor to FRAM in the sense that it describes a principle for systematically identifying functions and their prerequisites.

Phenotypes and genotypes (of erroneous actions). This was an early (and futile) attempt to get rid of "human error" as a concept - and certainly as a cause. It resulted in a couple of papers in the early 1990s. More important is, however, an unpublished position paper for a NATO ASI on Human Error (1983). The book from the NATO ASI wrote this about the position paper. Much has happened since then, as nicely summarised here:

Sic transit ...

CREAM (Cognitive Reliability and Error Analysis Method)  - in retrospect clearly a big mistake!

COCOM (Contextual Control Model)

ECOM (Extended Control Model)

Resilience Engineering (with David Woods and others)

The ETTO Principle

FRAM (the Functional Resonance Analysis Method)

The purpose of FRAM, as a method, is not to find the cause/causes for something that has happened, but instead to develop or build a model of how something happened / happens / or could happen. This can then be used to understand why something happened.

  • The FRAM has its own web page here.
  • The FRAMily also has its own group on LinkedIn.

Systemic Potentials Management (SPM) - formerly called the Resilience Assessment Grid (RAG)

Resilient Health Care Net - which now has become the Resilient Health Care Society

  • The Resilient Health Care Net has its own web page here.
  • The Resilient Health Care Net also has its own group on LinkedIn.
  • And you might also want to look at the following books: Resilient Health Care, The Resilience of Everyday Clinical Work, and Reconciling Work-As-Imagine and Work-As-Done.

Safety-I and Safety-II

  • An introduction to Safety-I and Safety-II can be found here.
  • And of course in the book "Safety-I and Safety-II". You may also want to check the Safety Synthesis webpage.

Safety Synthesis

  • Safety Synthesis has its own web page here. Safety synthesis seemed like a good idea at the time, but it was of course a mistake to keep the word "safety". You can find a recent comment on that here. Synesis tries to avoid repeating that mistake.


  • Still under development but the basic idea can be found here. And there is also the book.

Half-baked ideas are a kind of memory dump. These are things that I have started to work on but then either suspended due to a lack of time or because they no longer seem relevant.