In emotion-driven organizations, where the safety culture is biased by accountability, incidence investigation often follows the "blame and punish" script, attributing the incidence to the operators.
If a person blames the operators, then it may be the case that this person wants to distract the blame, or his/her impotence, to shift it to those who cannot protect themselves (see Dekker's book about Just Culture).
The awareness of the operators changes over time, especially following an incidence. In routine operation operation the operation is typically automatic, based on skilled acquired in daily operation. Following an incidence, operators often reconsider and restore the event flow, and acquire better awareness of the error and its sources.
Updated on 09 Mar 2017.