Last week, I was at Hannover Airport waiting to pick up Wolfgang after he had been away performing a supplier audit for one of our customers. I had arrived a little early and his flight was due in about half an hour, so I ordered two coffees and a muffin from one of the cafés in the terminal.
The order was placed electronically and appeared on the screen as number 207. There were a few orders ahead of mine, and while I was waiting I noticed that order 166 and my own order 207 were both shown as being prepared. When 166 was called, however, 207 disappeared from the screen at exactly the same moment. It was not shown as ready or collected; it was simply gone. Orders 208, 209 and 210 then continued through the system normally.
I went to the counter and explained that my order had disappeared from the screen even though I had not received anything. The response was essentially that I should wait, so I did.
Eventually Wolfgang’s flight landed and the thirty minutes I had available were almost gone. I returned to the counter and explained that I could no longer wait for the muffin, but that I did need the two coffees immediately. The employee turned around and handed me two coffees that had apparently been standing behind the counter for some time. The muffin was there as well.
I had to laugh, because the actual mistake was not particularly interesting. Orders go wrong, systems glitch, people press the wrong button and information occasionally disappears. What stayed with me was something else: the system and physical reality had visibly stopped telling the same story, and even after that discrepancy had been pointed out, nobody appeared particularly curious about why.
That made me think about how we look at problems in our own processes.
We are generally very good at noticing things that are present. A deviation appears, an alarm is triggered, a batch is delayed, a test fails, a complaint is received or a signature is missing. Something happens, it becomes visible, and therefore it attracts our attention.
What we are often less good at noticing is what does not happen.
A result that normally arrives but does not. A status change that should occur but never appears. A handover that everybody assumes took place. An escalation that never comes. A question that nobody asks. A recurring deviation that suddenly disappears.
Absence can be information too, and sometimes it can be more important than the things we can easily see.
This becomes especially relevant in environments where processes are increasingly represented through systems, dashboards, trackers and electronic workflows. We rely on a status to tell us where something is, on a workflow to tell us that something has been completed, and on a system to tell us that an action has taken place. Most of the time that representation is useful and necessary, but the representation is still not the process itself.
A batch is not its status field, a material does not physically move because somebody changes a value in a system, and an activity has not necessarily happened simply because the workflow says it has. The opposite can also be true: something may have happened even though the system suggests that it has not.
At Hannover Airport this resulted in two coffees standing behind a counter. In GMP and radiopharmaceutical operations, the consequences can obviously be very different.
Imagine a process where a sample normally produces a result before the next decision is made. What happens when the result is not there? Does somebody notice the absence, or does the process continue because everything else appears normal?
A recurring deviation may suddenly stop appearing, which at first sounds positive. The more interesting question, however, is whether the underlying problem actually disappeared or whether people simply developed a workaround that prevented it from becoming visible.
A planner may maintain an unofficial spreadsheet because the formal system does not provide the necessary information quickly enough. An experienced operator may quietly correct the same issue every day. Quality may receive fewer questions, not because the process has improved, but because people have stopped asking and found another way to make the work function.
The absence of a signal therefore does not automatically mean that the system improved. Sometimes it means that we stopped seeing the signal.
This is where professional curiosity becomes such an important control. It is not about being suspicious or immediately assuming that something is wrong. It is about noticing when reality does not match what we expected to see and being curious enough to ask why.
That question is useful during an audit, qualification, process review, investigation or operational improvement initiative because good process understanding is not only about following what happens. It is also about recognising what should have happened, but did not.
Perhaps this is also one of the reasons why supplier audits can be so valuable when they are done well. Their purpose is not simply to confirm whether the expected procedures, records and controls exist. A good audit also tries to understand how the system actually works, where the formal representation may differ from operational reality, and which questions are not answered by the evidence immediately in front of us.
The coffees eventually reached me, Wolfgang came through arrivals, and compared with the supplier audit he had just performed, order 207 was probably not the most important process issue of the day. Still, it stayed with me because it was such a simple reminder that the most interesting part of a process is not always what happened.
Sometimes it is the gap where something should have happened, but did not.
What are we missing because we are looking only at what happened, rather than also at what should have happened but didn’t?
