Although outcomes in labour-and-delivery are generally good, the danger of rare catastrophic events is always present. Two fetal deaths in the labour-and-delivery suite in Jönköping had been analysed with root cause analysis (RCA). Those RCA’s did not identify common causes and RCA-derived countermeasures seemed narrowly reactive and insufficiently robust. The variable, unpredictable workload and high stakes found in a labour-and-delivery suite creates critical dependencies, and vulnerabilities that vary over time. The potential for resonance etween these dependencies is a systemic problem that is missed by RCA. In general RCA  does not lead to a deeper understanding of how systems function and how systems usually  works to prevent catastrophic outcomes. RCA might therefore not work as a system improvement tool. The aim of this study was to explore if a FRAM analysis could give better nderstanding of circumstances important for patient safety in labour-and-delivery not evident from previous RCA’s.