I had a feeling, but there was nowhere to put it.
Knowledge that never left someone's head
Someone noticed something important and it never got recorded. They didn't hold it back. Nothing in the workflow asked for it.
- Forms have boxes and dropdowns but no room for judgment.
- When you talk to people after the fact, they mention things nobody wrote down.
- The work moves too fast for anyone to stop and note what they saw.
Who: two people who do the hands-on work. Ask: "What did you notice on the last job that isn't written down anywhere?" Count: things mentioned that the next step would have used. You're probably looking at this pattern if they noticed things the next step needed and had no place to put them. Probably not if they had a place and chose not to use it. If not, compare it with No safe way to disagree.
No safe way to disagree. In that pattern, people stay quiet because speaking up is costly. In this pattern, nothing in the workflow asked them what they saw.
One expert, one real case, one question repeated at each turn: how did you know?
Create one shared, blame-free place to write down what almost happened and what caught it.
People know more than they can put into words (Polanyi, 1966). That the right question brings more of it out is our reasoning.