What they don’t tell you in Safety Culture: when operator error is not a mistake

There is a key but under-appreciated virtue in control room operators working within their shared comfort zone of team situation awareness: their knowing when it is a mistake to comply with a regulation or protocol that would work against system reliability and safety.

Which just goes to show that it’s a mistake to think all errors are mistakes.

Noncompliance may be a regulatory error for the regulator of record; the same noncompliance may be an important option for system reliability when circumstances indicate the regulation to be defective. It’s not a control room mistake if system high reliability compels the real-time commission of a noncompliance error.

What needs to be distinguished are the volatility conditions and reliability mandates under which “operator error” is forced. You can’t un-ring the bell once rung, but it’s always been more complex than that.

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