Welcome to the second issue of Failsafe's new NETLETTER.

LATENCY is an increasingly talked-about subject in varying industries and other circles. In many cases, LATENT causes are thought to be the same as "Management System Causes." The intent of this edition of Failsafe's Netletter is to divorse the two phrases. Latency and Management Systems are NOT one- in- the same. The former is the CAUSE of the latter.

Amongst the multitude of Root Cause Analysis ideas that have sprung-up in the last 30 years, one of the most practical and popular has been the quest to identify PHYSICAL, HUMAN, and LATENT causes. Although this 3-layered-approach was developed by Failsafe in the early 1980's, it has been embraced by many other providers since then.

Because of the large number of people using this 3- layered terminology, misunderstandings were bound to occur. The use of the phrases PHYSICAL and HUMAN causes are fairly straight-forward -- seldom do people disagree on their meaning. But LATENT causes are a different story! Beware of those who use the term, including myself! We're all talking about different things. PLEASE, be sure you understand the potential of LATENCY (the way it is defined by Failsafe). Focusing on it could literally change the way you see life.

LATENCY is best described via analogy and metaphor. It is like living on the Leaning Tower of Pisa, or being born (and then living) on a Merry-Go-Round. It's more or less invisible, and yet affects everything a person does. It's like culture, but is even more than "concepts, habits, skills, arts, instruments, and institutions of a given people in a given period." Latent Causes acknowledge "the errant way of seeing life," as revealed by the failure itself.

Latent Causes are certainly NOT the same thing as Management Systems Causes. Most would agree that "management systems" are "the official way of doing business," and include flowcharts, organizational charts, procedures, practices, and other documentable things. When flaws occur within these systems, they are certainly to be identified and then fixed. But if this is the FOCUS of your investigative efforts, you'll end up with more checklists and flowcharts INSTEAD OF "changing the way you see life."

If you hear someone say "the Latent Cause is lack of training," or "inadequate lighting," or "a faulty procedure," or "inadequate maintenance," CHALLENGE THEM!! These are NOT Latent Causes (as defined by Failsafe). Instead, they are manifestations of the real Latent Causes. Everything we do, all that we develop, all that we allow is due to the WAY we see ourselves and our existence. Latent Causes ought to acknowledge "what about the way we SEE life is flawed?"

Latent Causes must be expressed (verbalized) by the people whose sight (vision) is flawed. Here are the typical steps:

1. An incident (or series of incidents) occurs.
2. An evidence team gathers evidence.
3. The evidence team identifies stakeholders by asking themselves "who needs to see this evidence?"
4. The evidence team presents the evidence to the stakeholders.
5. The stakeholders reflect on the evidence, then answer the question:
6. "What about the way we ARE (or way we see life) lead to this incident?"

In essence, the identification of Latent Causes is analogous to "confession." Whether you are "religious" or not is irrelevant, it's a fact-of-life: in order for people to change they must first inwardly and honestly admit "fault." Latent Causes are this admission of fault; not an admission of wrong- DOING, but rather wrong-THINKING; not criminally-wrong thinking, but rather something that we all get caught- up within, as in the Merry-Go-Round. Latent Causes rarely (if ever) pinpoint only one person's flawed thinking. It's usually a mass of people, "living on the Leaning Tower," that must see things differently.

If you are reading this thinking "this is too philosophical-sounding," or "impractical," then, well, "you just don't get it do you?" The way we see life is the cause of all our successes, and all our failures. I know from personal experience that the most PRACTICAL and EFFECTIVE way to change things for the better is to use the FAILURES of our lives to acknowledge and then CHANGE the way we think.

In the present climate of doing more and more with less and less, I would think the suggestion to focus on LATENCY (as defined by Failsafe) would be embraced enthusiastically. Instead of an investigative approach that will result in mountains of action items addressing procedures, checklists, addition training needs, and the like LATENCY (as defined by Failsafe) will focus people on THEMSELVES.

If this subject interests you, please consider downloading "The Management Systems Dilemma," a 114 KB PDF file that was the basis for a presentation made to the HPRCT meeting in 2001.

Whereas other approaches will help you change your physical and management SYSTEMS, we'll go one step further: We will help you change your PEOPLE. After all, we (the way we think about things) are the real root causes of our failures.