If you know me, you will have heard this story multiple times. But I felt it worth telling one more time for this article. In the early 90s, when TQMS was primarily a consulting firm specializing in ISO 9001, I was invited to a black-tie event. I stopped at Harry Rosen to get a bowtie to go with my Prince Charlie outfit, since I’m Scottish. They offered me a clip-on bowtie, which I refused because at the time I was always wearing a tie, so I purchased a real bowtie, which came with six simple instructions on how to tie it. 

When I got home, I attempted to tie the bowtie, looking in the mirror, without any success. The following day I gave the instructions and the bowtie to my six consultants working in the office and threatened them with pink slips if they didn’t figure out how to tie a bowtie by the end of the day. No pink slips were issued, but no one was able to tie the bowtie, even though they tried against doorknobs, against each other, and they even thought of going down the hall to a notary who wore a bowtie, only to find out that his was a clip-on.

Later that night, my daughter, who was seven, took the bowtie and tied a bow around her ankle, slipped it off her foot, and gave it to me. She asked me if this is what I wanted, and I told her yes. Her comment at the time was that they should call it “tie a bow” instead of “bowtie,” because that’s all she did: tie a bow around her ankle.

Later that evening, I started to think about the bowtie instructions and how they mirrored the work instructions and process procedures that we write for our customers every day. It suddenly dawned on me that perhaps we understood how to do a process, but the people reading our instructions could not comprehend them like we did. Much like the bowtie instructions. I then started to wonder how many owners of companies sleep well at night, thinking that everything is under control because everything is documented from A to Z. They had a bowtie instruction for every process within the organization.

The bowtie instructions come with diagrams, simple steps, and little procedures for each step, and they have not changed since the 1930s. I bet that there are many procedures and work instructions within your organization that were also written 6 to 8 years ago and have not changed since. Perhaps they need to be verified in a slightly different manner, to ensure that anyone reading the procedure can understand it and do the process.

The interesting part about this story is how I went about trying to tie the bowtie from reading the instructions, as opposed to a seven-year-old who simply took the bowtie and figured it out. This is a good example of tacit versus explicit knowledge. A huge amount of what makes someone competent at a task is procedural and physical, learned by doing and correcting, not something that survives translation into text and diagrams. A bowtie has been documented the same way since the 1930s. It’s technically correct, yet it still fails as a way of passing the skill on, because tying it is a spatial, tactile sequence and not a declarative fact.

Often, words and static diagrams are the wrong medium for a moving, feel-based task, which is exactly why my daughter cracked it in seconds by treating it as something to physically manipulate and hand back, not something to read.

This maps perfectly onto manufacturing and work instructions. A document can be 100% technically accurate yet still transmit almost nothing, because the person who wrote it already has the tacit knowledge and unconsciously left out the parts that feel too obvious to write down, such as the exact pressure, the angle, the moment you feel it click into place.

This is what’s called the curse of knowledge: once you know something well, you lose the ability to remember what it’s like not to know it, so your instructions quietly assume a prior understanding that the reader simply doesn’t have.

In the 90s, I travelled throughout the United States and Canada demonstrating the bowtie approach, and everyone I pulled up on stage, whether they were owners of a company, managers, or other consultants, could not tie the bowtie with the instructions presented on a large screen in front of them. However, once I put the bowtie around my neck and showed them how to simply tie a bow with their eyes closed, just like you do with your shoelaces, they were all able to do it.

The work instruction is just part of the problem, in my opinion, and the second part of the problem is the trainer themselves. For example, a forklift operator with 15 years’ experience usually operates at an unconsciously competent level. They execute correctly without consciously thinking through the steps anymore, which is exactly what makes them good at their job, yet it may also make them bad at explaining it. To teach well requires the ability to reconstruct the steps back into conscious, sequential language, which is a separate skill from doing the task itself. That is why picking the tenured expert as the trainer by default is common but flawed. Technical mastery and instructional ability are two different skills, and organizations often mix them up because “who else would train it” feels like the obvious answer.

Where this connects back to corrective action and preventive action is that it gives you a much sharper root cause hypothesis than “operator wasn’t trained” or “operator error.” The real question then becomes whether the instruction and the training method are even capable of transmitting the tacit component of the task at all, and whether the trainer was selected for training ability or just tenure.

This is a genuinely defensible, evidence-based root cause to bring into a management meeting. Instead of simply saying “training is bad,” you can show why a technically compliant instruction, and training program can still fail to produce competence, and how to verify it. You’re diagnosing a mechanism, not assigning blame.

The real tension in Corrective Action and Preventive Action (CAPA) work is sharper than almost anywhere else in a quality role, because the pressure to converge on a comfortable root cause is highest exactly when the group is under scrutiny, such as after an audit finding, a customer complaint, or a recall. That’s precisely the “tight, unanimous group” Rolf Dobelli describes in The Art of Thinking Clearly. Leadership often wants a root cause that’s fast, cheap, and doesn’t implicate a process they own. Groupthink shows up as premature closure: the room settles on operator error or a supplier defect because it’s the least threatening answer, not because the 5-whys actually got there.

Dobelli doesn’t stop at telling people to speak up. He goes further and says if you lead a group, appoint someone as devil’s advocate. I think that’s the part most CAPA meetings miss. We ask individuals to personally absorb the risk of pushing back on a comfortable root cause, when the better fix is to build that pushback into the process itself. If your CAPA review has a standing role, whether it rotates weekly or sits permanently with the quality function, whose job is to ask ‘have we actually ruled this out’ before the room signs off, then questioning the root cause stops being an act of defiance. It becomes part of doing the job properly, and nobody gets labeled difficult for doing what they were assigned to do.

This is when it’s important to stand up in that room and question the work instruction and the training effectiveness. I like to call this the bowtie approach to quality: if someone is trained to tie the bowtie properly, they can do it with their eyes closed. Not that we want our employees working with their eyes closed, but they should be doing it as second nature. I dare say that if the training was done properly on a process, the work instruction may not even be necessary for employees; it may become a training manual instead.