Denise Robitaille  |  03/31/2009

The Things That You Know That You Know

What you think you know may not always be right.

A couple of months back I was watching “Are You Smarter Than a Fifth Grader?”--one of the more enjoyable game shows in recent memory. The premise is that the contestants should be able to answer the questions, since it’s stuff we learned during or prior to the fifth grade--nothing deceptively clever or arcane; just facts and information, history, science, grammar, and current geography. The questions get harder as you move from the first to the fifth grade, with correspondingly higher monetary prizes.

This night the contestant made it to the $1-million level. If you win at this point, you get the million; if you lose you go back to a measly $25,000 and you have to face the camera and admit that you’re not smarter than a fifth grader.

The question was, “Who was the longest reigning monarch of England?” Well, I knew this answer hands down. Oh, how I wished I was on that stage. I’d become a millionaire. I would be smarter than a fifth grader. I was absolutely sure of it. Except… I was dead wrong. I would have lost thousands of dollars and I would have had to make the humiliating admission as to my diminished level of smartness.

So what does this all have to do with quality standards? It relates directly to the integrity of documentation. So often people assume they know what a work instruction or a specification states. They’re disinclined to access or review the documents because they’re positive that they know the procedure or what the drawing shows. Similarly, they’ll eschew trending data, preferring to rely on their own memory regarding previous occurrence or pervasiveness of negative indicators. The assumption is that we know our stuff so we shouldn’t have to look things up.

It’s those presumptions of knowledge that get us into the most trouble. We make decisions on product acceptability, need for additional resources, criticality of impending changes, and continued conformity of processes in the face of evolving customer requirements and international standards. We rely on our memories as to how many times a defect has been detected or a process has exceeded control limits.

When coaching on root cause analysis I teach people to start at the beginning by revisiting the documents that describe the requirements. These are various tools that we use to know what “right” is supposed to look like. The sequence of steps in a process, accepted methodology, necessary precautions, and the correct tools to use are all detailed. Regardless if it’s a process or a product, the documents define the requirements. Reviewing the documents often leads to several realizations. These are some of the revelations that come to light:

The process changed but no one revised the work instructions. In the meantime, you’ve hired five technicians, three who trained on the process as documented and two who trained using the latest--but undocumented--improvements. You now have an uncontrolled process.

The procedure is correct but lacks adequate detail. It was written seven years ago by a process owner who performed the function for 10 years. At her level of experience she assumed that certain things would be self-evident and would not require explicit instructions. Unfortunately, the succeeding generation of workers lacked her expertise and, in the absence of detailed instructions, made up their own rules for certain steps in the process. In this scenario, a workers’ decision can easily lead to an uncontrolled process or product defects, which in turn can lead to time-consuming rework and expensive scrap.

The data you thought was being gathered on in-process defects isn’t complete because no one explained data collection methodologies to the machine operators or let them know how important the information is. Rather, the shift supervisor relies on her memory as to the number of defect occurrences until someone notices a spike in the scrap rate or customers start to complain.


The commonality of these examples is individuals’ certainty as to their know-ledge and recollection. They are sure that they know what they know.

Internal audits provide an optimum vehicle for periodic assessment of documents. Repeat orders from customers should include a review of specifications. Analysis of key indicators should be performed at defined intervals, even if there doesn’t seem to be anything wrong. These kinds of practices help to prevent the pitfalls that accompany the presumption that we always know what we think we know.

By the way, the longest reigning British monarch was Queen Victoria.


About The Author

Denise Robitaille’s picture

Denise Robitaille

Denise E. Robitaille is a member of the U.S. TAG to ISO/TC 176, the committee responsible for updating the ISO 9000 family of standards. She is committed to making your quality system meaningful. Through training, Robitaille helps you turn audits, corrective actions, management reviews, and processes of implementing ISO 9001 into value-added features of your company. She’s an RABQSA-certified lead assessor, ASQ-certified quality auditor, and ASQ Fellow. She’s the author of numerous articles and several books, including The Corrective Action Handbook and The Preventive Action Handbook, and a co-author of The Insider’s Guide to ISO 9001:2008, all published by Paton Professional.