Why does so much stuff seem to slip through the cracks?
Is it because stuff is slippery or is it because there are so many cracks.
I suspect that it is a little bit of both.
Most systems have both known and unknown cracks. Manual processes or overrides try to address the known cracks.
But these manual processes create cracks of their own which are also both known and unknown.
Processes are devised to deal with these known cracks….and so on…
Some of these processes are documented and others live in the heads of long time workers who have learned through experience. It is hard to write down everything they know about every situation that comes up and more to the point who would study and make the effort to learn what to do when something doesn’t quite fit the norm.
And even daunting is that this problem is repeated in different ways across the organization.
It is the humans that create these systems and it is the humans that try to work through and around all of these cracks.