We just fix it ourselves and keep going.
Workarounds the system never learns from
People hit a problem, patch it, and move on. Because the immediate work still gets done, the underlying problem often goes unreported, and the same patch gets applied every week. Because the people doing the work keep things running, nobody above them sees what's broken.
- Side spreadsheets and manual steps nobody official knows about.
- The official process map doesn't match how the work actually runs.
- The same small fix comes up again and again.
Who: the people who do the work, with managers out of the room. Ask: "What do you do that isn't in the official process, and why?" Count: workarounds, and how many were ever reported to someone who could fix the cause. You're probably looking at this pattern if there are several and few were reported. Probably not if they were reported and accepted as fine. If not, compare it with Warning signs get filed as normal.
Warning signs get filed as normal. In that pattern, the problem is known and has been accepted. In this pattern, it's been patched quietly and never reported at all.
Create one shared, blame-free place to write down what almost happened and what caught it.
Ninety minutes. Each person names one thing that is not working and one idea to fix it. Write them where everyone can see. That version surfaces plenty.
In a study of hospital nurses, most problems in daily work were handled with quick fixes and rarely reported. The work got done, and the hospital never learned from the problems (Tucker and Edmondson, 2003). Established pattern.