What they don’t tell you in Safety 101: “when operator error is not a mistake”

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

Which 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 the task environment demonstrates 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. Indeed, it is a regulatory function of critical infrastructures to correct for error by the regulator of record.

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