ABSTRACT
Latent failures require a trigger, that is, an initiating or enabling event that activates its effects or consequences. The latent failures themselves are, or contribute to, broken layers of defense. Some of the factors that combine to produce a disaster are latent in the sense that they were present before the incident began. The latent failure model has helped redirect the focus away from front-line operators and towards the upstream conditions that influenced and constrained their work. The latent failure model broadens the story of error. The latent factors involved multiple people in different jobs and the procedures and conditions established for the tasks at the sharp end. The latent failure model also reserves a special place for violations. Consistent with the idea of a linear chain of events is the notion of a root cause – a trigger at the beginning of the chain that sets everything in motion.
