My favorite football team lost at the weekend


Active:

The team played poorly, star player didn't score

Latent:

The team didn't practice
Bad tactics
Lack of Management
They often got drunk before a game

Hi Jasonkav
One of many is the Herald of Free Enterprise capsizing.
Active failure or immediate cause is the crew member who neglected to lower the bow doors[apparently he was reportedly off shift] But that's another story
Latent failures include such things as the design of the ferry which was unstable with even a little water taken on board the car decks [2-3 inches][I seem to recollect that when taken into service in the Falklands that barriers were set up on car decks to prevent this]/the ship was trimmed bow down to access the dock side/ there was a high tide running/there was a demand by head office for very quick turnrounds/ there could have been an indicator on the bridge concerning the position of the bow doors [although to a mere landlubber these seem big enough to spot]-cost apparently £400-rejected reportedly. And reports of responses to complaints/requests being 'If you cant do it we'll find someone who can' [uncorroborated-however, once when I was using this example most of it was supported by a course delegate-ex Merchant Marine and crew member of said boat]
Most of these, of course are at the hands of management
Whose fault is remembered?
James Reasons book Human Error looks at some others-Kings Cross Fire-Moorgate crash-Space Shuttle Challenger Crash etc from the active/latent perspective. HSG 48 covers this too.
I think its really important to get over the differences and pitch responsibility where it should be.
The case did at least give rise, at a remove, to the Corporate Manslaughter etc Act but that's a terribly damp squib which ought to be revisited and strengthened considerably with imprisonment for Directors and senior managers usual and for actions to be taken against big business not the current smaller businesses. I do appreciate that much tougher penalties are now currently available accompanied by massive fines [peut etre] -not before time
Regards
Mike

In short, an active failure equals - human error, sometimes referred to - operator error. Whilst a latent failure is a management failure, which could be a lack of training, supervision, proper procedures, wrong or faulty equipment and so on.

As the previous poster alludes, there is often not such a clear cut distinction between active and latent failures. A good recent example is the Alton Towers Smiler Ride (roller-coaster) where the owner Merlin Attractions Operations Ltd claimed the accident was caused by human error. Meanwhile the HSE have since prosecuted the company for health and safety failures - which presumably means latent failures were identified in the course of the HSE investigation.

andybz

I will bow to your superior knowledge. My understanding of active/latent failures derive from Reason's philosophy being the doyen of accident causation, which I learnt at Uni whilst doing my MSc. Some things have probably moved on since then.

Whilst we are talking esoteric matters, I prefer the concept of 'Organisational failures' and specifically your explanation of latent errors in your second paragraph. Every day is a school day - Lol.

Re andybz. I reckon you are almost on your own.
I have found that active/latent failures are relatively easy to distinguish as causes of accidents I have investigated [not always of course] And very useful to show that management failures are much more likely than the worker responsible for the active error, triggering the disaster due to the 'lurking' connected latent failures [with you on the lurking aspect]. In addition using HSG48 helps in identifying appropriate control measures to deal with slips, lapses mistakes and violations too.
Tracking down latent failures before they bite would be much more worthwhile in Behavioural Safety initiatives rather than only or mainly addressing the activities of workers as is usual-you know the Unions usual complaint about BS being used to bash the workers.
I would be interested in what human factors stuff you use if these are not to your taste?
Great chat though
Regards
Mike
Ray, I did this on my master's too-and taught it elsewhere

I to have (until now) subscribed to the Swiss cheese, domino theories etc..

However, andybz has certainly got me thinking and his post make perfect sense.

Most models don't actually fly. A fact that too many academics overlook.

John

I never use the term Root cause, most notable accidents and incidents have multiple causes. There is often not enough distinction for a Root cause. Immediate cause - yes.

I have read this thread with interest, May I suggest a good book for you all which would challenge the way you use certain models and multiple causation theories.

Redressing the balance by Paul Difford. Not expensive but extremely useful.