Latent Conditions vs Active Failures: The ICAM Investigator’s Guide to Seeing the Whole Picture

Introduction – The Tip of the Iceberg Problem

In the world of workplace incident investigations, most people see only what’s right in front of them:

• The operator pressed the wrong button.

• The mechanic forgot to tighten the bolts.

• The supervisor didn’t follow the procedure.

These are active failures — the human actions (or inactions) that have an immediate and visible link to the incident. They’re dramatic, easy to point to, and they make for simple headlines in reports.

But here’s the problem: if we stop there, we’re only looking at the tip of the iceberg. Below the surface lie latent conditions —the organisational, cultural, and system-level weaknesses that set the stage for active failures to occur in the first place.

ICAM (Incident Cause Analysis Method) exists to connect these dots. It pushes us beyond finger-pointing and towards systemic learning, by analysing both latent conditions and active failures, and how they interact to produce incidents.

1. Understanding the Language: ICAM’s View on Failures and Conditions

Active Failures

In ICAM, active failures refer to unsafe acts committed by individuals in direct contact with the system at the time of the incident. They are:

• Observable in the moment.

• Often, the final “trigger” in the chain of events.

• Committed by operators, technicians, supervisors, drivers, pilots — anyone on the front line.

Examples:

• An operator bypassing a safety interlock to save time.

• A driver misreads a stop sign.

• A crane operator lifting without a tag line.

They’re called “active” because their effects are immediate — you see them in the incident timeline right before the event occurs.

Latent Conditions

Latent conditions are the hidden, dormant system weaknesses that have been present for some time, often unnoticed until they interact with active failures to cause harm.

They originate higher up in the organisation — in design decisions, policy gaps, resourcing issues, or cultural norms. They can lie in wait for months or even years before aligning with the wrong set of circumstances.

Examples:

• Poor equipment design makes it easy to misread controls.

• Inadequate staffing levels lead to chronic fatigue.

• A culture where shortcutting is normalised to meet production targets.

James Reason (whose work underpins much of ICAM) described them as “resident pathogens” in the system — ever-present, but not always visible.

2. Why the Distinction Matters in ICAM Investigations

When incidents happen, there’s an overwhelming temptation to focus only on the active failure because:

• It’s visible and easy to explain.

• It can be “fixed” quickly by retraining or disciplining someone.

• It satisfies pressure from leaders to identify “what went wrong.”

But in ICAM, stopping at the active failure means you’ve missed the real story.

Example: An incident where a worker enters a confined space without a permit.

• Active failure: The Worker did not follow the procedure.

• Latent condition: Supervisors were regularly authorising verbal permits to meet deadlines because the permit system was overly complex and slow.

The deeper insight? This isn’t just about one worker’s behaviour — it’s about a systemic breakdown in the permit-to-work process.

3. The Swiss Cheese Model in Action

ICAM incorporates Reason’s Swiss Cheese Model to show how multiple layers of defence can be breached. Each slice of cheese represents a barrier (procedures, training, supervision, equipment design), and the holes are latent conditions or active failures.

When the holes in multiple slices line up, the hazard passes through all defences, and an incident occurs.

Key point:

• Latent conditions create the holes in the cheese long before the event.

• Active failures are the moment when all those holes align.

4. Real-World Examples of Interaction

Case Study 1 – Aviation Maintenance Error

Event: Aircraft takes off with unsecured engine cowlings.

Active failure: Maintenance crew forgot to latch the cowlings after inspection.

Latent conditions:

• Poor design: Latch position difficult to verify visually.

• Shift turnover process lacked mandatory double-checks.

• Pressure to release aircraft quickly to avoid flight delays.

In ICAM terms, the true cause is a combination of human error and the system conditions that made it more likely.

Case Study 2 – Manufacturing Injury

Event: Operator’s hand caught in press machine.

Active failure: Operator reached into machine without lockout.

Latent conditions:

• Machine guard frequently jammed and was left bypassed.

• Maintenance requests for the guard had been backlogged for 6 months.

• No refresher training on lockout in over 3 years.

Again — the unsafe act was visible, but the investigation’s real value lies in uncovering the conditions that allowed the act to be possible and likely.

5. Investigative Traps to Avoid

Trap 1 – The “Human Error” Full Stop

If your ICAM report concludes “The worker made a mistake” and stops there, you’ve effectively blamed the person and missed the system learning.

Better: Use the active failure as the starting point, then apply ICAM’s Organisational Factors and Task & Behavioural Analysis to dig deeper.

Trap 2 – Overloading the Latent Side

The opposite mistake is to over-theorise latent conditions without linking them to the actual event. ICAM requires a clear causal pathway from latent to active to outcome.

Trap 3 – Treating Latent Conditions as Unfixable

Some organisations think latent conditions are “too big” to address because they involve culture, budget, or leadership priorities.

But ICAM encourages breaking these down into actionable improvements, even if they start small.

6. How ICAM Structures the Analysis

ICAM explicitly integrates latent conditions and active failures into its four key analyses:

1. Events and Conditions Analysis – What happened and what factors were present?

2. Barrier Analysis – Which defences failed and why?

3. Task and Behavioural Analysis – Active failures identified.

4. Organisational Factors Analysis – Latent conditions identified.

The beauty of ICAM is that it doesn’t treat these as separate universes — it maps how they interact in a cause-and-effect chain.

7. Leadership Implications

For leaders, the latent–active distinction changes the entire conversation about accountability:

• Instead of asking “Who messed up?”, they ask “What in our system set them up to fail?”

• Instead of quick fixes (extra training, new sign), they invest in system resilience.

It’s also a shift from reactive to proactive: if you can spot and address latent conditions before they align with an active failure, you prevent the incident altogether.

8. Building Investigator Skill in Spotting Latent Conditions

Not every investigator is naturally attuned to latent conditions. Practical tips:

• Always interview at multiple organisational levels, not just front-line staff.

• Look for patterns in previous incidents or near misses.

• Challenge procedural workarounds — they often reveal latent weaknesses.

• Review resourcing, equipment design, and leadership messaging.

9. Closing the Loop: From Findings to Learning

The most valuable ICAM investigations don’t just report what happened, they translate insights into meaningful change.

For active failures, that might mean:

• Job-specific training.

• Task redesign.

• Immediate procedural reinforcement.

For latent conditions, that might mean:

• Simplifying overly complex processes.

• Addressing staffing shortages.

• Redesigning equipment.

• Adjusting KPIs that unintentionally promote unsafe behaviours.

10. Conclusion – Don’t Just Patch the Hole in the Cheese

If you only fix the active failure, you’ve patched the hole in one slice of cheese — but all the other holes remain.

ICAM’s power lies in its ability to reveal how latent conditions and active failures combine to create incidents. That’s where lasting safety improvements come from, and where your credibility as an investigator is earned.

Next time you’re reviewing an incident report, ask yourself:

• Have we identified the active failures?

• Have we gone further to find the latent conditions?

• Have we shown the causal link between the two?

If the answer to any of these is “no”, the investigation isn’t done yet.

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