They are normal people, who follow normal psychological patterns.
In your root cause analysis, 99% of the time the answer should not be "human error". An error that one human makes will be repeated in the future by another human.
The problem is setting up patterns and processes in the working environment that are aware of these human limitations and that work around them. The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake.
> The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake.
Contrast to my company:
Our phones require you to dial "9" to get out of the building, and then "1" to dial long distance. A lot of my coworkers are foreign and in the process of trying to dial a cell phone number (international or otherwise) accidentally dial "911". When they realize their mistake, they hang up, not having grown up in America and learning to stay on the line and tell the operator that you made a mistake.
Company response? Threatening emails, verbal and written company-wide wrist slaps, and stickers on every phone that say not to hang up if you dial 911 or you'll get in trouble.
As a result people are now afraid of dialing long-distance numbers and so they simply avoid it.
Imagine if the company had instead tried to correct the true issue causing the errors (poor phone routing numbers)?
In many (all?) parts of the US, even if you stay on the line and tell the operator that the call was a mistake, you'll still get a visit from the police. The thinking is that someone who got a chance to dial 911 but then is discovered by a captor might be coerced into saying the call was a mistake. So they send the police to invesitigate ALL 911 calls -- hangups, mistakes, everything.
Another fun fact is that 911 in almost any dial sequence will dial 911. One of my colleagues discovered this when he was testing some dial plan thing years ago. I think he called 911 a few thousand times.
Interesting. I definitely made this mistake as a child. My dad's cell phone number started was 915-XXXX. I misdialed once and dialed "911".
I explained that it was a mistake, and they said not to worry about it and hung up. No officer was dispatched.
I wonder if something has changed since I made that mistake, if it's just inconsistent across the country, or if there is some discretion of the dispatcher to decide that the child probably did make a mistake.
I don't think anything has changed; I made test-calls to 911 (to confirm the call was routed properly) when commissioning new phone systems and never had police dispatched. I'd tell the operator that I was testing and wanted to confirm that they were showing the correct phone # and address.
In your root cause analysis, 99% of the time the answer should not be "human error". An error that one human makes will be repeated in the future by another human.
The problem is setting up patterns and processes in the working environment that are aware of these human limitations and that work around them. The air travel industry is a _great_ example of what happens when you don't simply blame the human, but look to fix the true problems that caused the human to make a mistake.