Three disciplines — human factors, systems thinking, human-centred design — applied through one phased method. First, the loop we are usually called to break. Then how an engagement runs.
Standing on: Rasmussen · Hollnagel · Dekker · Leveson
Animated figure: a loop of five stages — pressure, adaptation, surprise, blame, repeat — tightening with every pass, until it is broken at the design stage rather than the blame stage.
The loop — and the breaking of it
Our approach — how an engagement runs
Diagnose. Co-design. Embed.
Phase 101
Diagnose
Discovery & diagnosis
We listen first — interviews, walkthroughs, document review, your own data. You receive a clear-eyed account of the system as it actually operates, with findings you can prioritise.
Phase 202
Co-design
Co-designed re-development
The system takes shape in workshops with the people who run the process — architecture, decisions and tools verified against your operations before anything is locked.
Phase 303
Embed
Embedding & sustainability
Training, internal audit, evaluation — and a roadmap your team owns. The measure of our work is what keeps working after we leave.
Scoped in writing · day-rate or retainer · a defined end, not an open engagement
“Incidents live in the gap between work as imagined and work as done. So do we.”
— Fig. 02, the two truths
ISO 9001:2026
The 2026 revision is the biggest change to the standard since 2015. Readiness is a design question, not a paperwork question — and having assessed a live system against the draft, we know the difference.