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

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 More important is, however, an unpublished position paper for a NATO ASI on Human Error (1983).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 FRAM has its own web page here.
  • The FRAMily also has its own group on LinkedIn.

RAG/SPM (the Resilience Assessment Grid which now is called the Systemic Potentials Management)

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 beginnings can be found here.

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.