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\begin{section}{Introduction}  Preliminary efforts and literature review led to the creation of Narrative Descriptions. The user was asked to describe an event, and associated emotions. Then a discussion was added with three points of view, personal, interpersonal-communicative, and organizational. Originally these were for discussion within our group. Later we suggested a written narrative focus be added with consideration of probable uses: editing and re-reading, a naive reader, a teaching file, a categorization or an ontology. These could be characterized as goals or \emph{work points} \emph{WorkPoints}  Work with Narrative Discussions revealed complexity that required additions for a complete examination of events. We discovered John Flanagan’s early work on the Critical Incident Technique (CIT) \cite{Flanagan1953}, His goal was finding scientific basis for assessment of WWII student pilots who failed in training. Reasons given by examiners were often cliches or lacked depth. The large careful study with well defined goals led to many other applications both in aviation and later in manufacturing, business, management and nursing \cite{Fivars198012}. (PubMed alone has 2543 articles and 231 review articles on CIT in Nursing.) Early attempts to cope with medical error tended to focus on a model of Blame and Train. Considering safety studies from other fields suggested there was greater complexity. To a psychiatrist it appeared there was little attempt to search for problems out of awareness, due to unconscious, denied or unobserved detail. We combined the approach of examining specific events (CIT) with pushing the user to consider emotional reactions and states in our Complex Context Critical Incident Report (CCCIR). The user applies multiple points of view. They include the nature of communication, or lack thereof, and systemic/organizational factors.  We asked users of our reflection tools to include any possible relevant associations: what comes to mind, even if it was a tune, a book, a movie, a distant memory of an event. \cite{Devlin2014} 
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\subsection{Complexity}  Complex systems have multiple parts. Human use the technical parts and interact with other humans, introducing communication. All this is in constant change over time. I stumbled upon this example on the internet. We could consider the magnets as non-human parts of the system, marbles as humans, and sticks and pieces of wood as designed control factors to keep the components in a safe range. We can see there are many ways things can go wrong and how hard it is to modify one part without unexpected results elsewhere. \marginnote{Marbles and Magnets \url{http://www.eetimes.com/author.asp?section_id=216&doc_id=1329692}}  \subsection{Investigating and Defining Complex Systems Failre} This area has been investigated extensively and from many points of view. A summary of important considerations concerning health care is found at the Cognitve Technologies Lab in a handout by Richard I. Cook:\emph{How Cook:\emph{ How  Complex Systems Fail} accessible as full text through Research Gate. \marginnote{\url{https://www.researchgate.net/publication/228797158} Many additional papers are available through Research Gate where you can select those appropriate to your own interests.} \subsection{Extending an Investigation}  While we began with specific incidents we found in order to have an adequate context we needed both a wider and a deeper look. In the literature this is called \emph {thick description} an idea introduced by Gilbert Ryle, a philosopher of Mind \cite{Ryle_2003},and ,\cite{Ryle1971a}and  popularized by Clifford Geertz, an anthropologist, who applied the idea in field work in Bali. \cite{Ryle_2003} \cite{Geertz1973}. In our reflection tools the deeper look is expressed in the Narrative Report, the wider look is the result of the Complex Context Critcal Incident Report. The SwampNote is the basic description of one view of an incident and the author's view including their feeling state. In repeated use observation and description are sharpened. Several notes may contribute to a narrative of CCCIR.  \end{section}