By Julius DeSilva

Most organizations have two management systems. The one in the manual and the one people actually use to get the job done. Work imagined versus work done!

I’ve seen them used at sea often and later in my career as well. These were the unwritten ways the crew got things done; the tweaks, the shortcuts, the unspoken understandings. They rarely made it into the operating procedures, but they kept the ship running. On land, in factories, offices, and manufacturing plants, the same thing happens. It’s the things people do to get the job done. The quick fixes taken when competing priorities cause them to choose.

I call them ghost processes.

What Are Ghost Processes?

Ghost processes are the informal, undocumented workarounds that quietly shape how work really gets done in your organization. They’re invisible in your flowcharts and they never make it into the SOPs, but they’re alive and active every day. Some are just tiny like a skipped step or a slight adjustment. Others are entire shadow systems that run in parallel to the “official” one.

I’ve seen them everywhere:

• On the production floor: Operators nudging machine settings “by feel” instead of sticking to the specified tolerances. They’ll tell you the book values slow the line down or waste material.
• In assembly: Skipping a second inspection step when the courier deadline looms. The reasoning? “We’ve built this part a hundred times, it’s fine.”
• In maintenance: Swapping in a non-standard part that “works just as well” because the approved one is on backorder and the machine needs to be running by morning.
• In design: Engineers pulling up an old CAD template because the updated version takes longer to load or requires retraining on new dimensioning standards.
• In quality checks: Inspectors using their personal calipers or gauges because they’re faster or more comfortable than the calibrated company ones.
• In change control: Skipping MOC (Management of Change) procedures because “this tweak is too small to matter” or because a customer’s deadline leaves no time for paperwork.

None of these are necessarily malicious. In fact, they usually come from pride, experience, and the will to keep things moving. But intent doesn’t erase risk.

Why Do Ghost Processes Emerge?

Ghost processes are not necessarily acts of rebellion. They’re a natural response to the pressures people face every day. In an audit I came across a form consistently partially completed. On asking why the operators were not doing it consistently, they said they filled the same information elsewhere. They never thought to update the form.

Ghost processes happen because (and this is not an exhaustive list):

• The documented process is too slow, clunky, or unrealistic.
• People want to help, to be efficient, to deliver.
• And most of all, because the pressure of deadlines, KPIs, and performance review metrics often outweighs the organizational process goals.

That last one is the silent driver. If an operator knows their appraisal depends on throughput or on-time delivery, process discipline becomes a negotiable commodity. When the customer’s ship date is at risk, the decision to “just get it done” feels justifiable. But that risk of speed today at the cost of conformity tomorrow can quietly undermine safety, compliance, and long-term reliability.

I’ve seen managers celebrate a shipment that went out “on time,” only to deal with warranty claims weeks later when a defect slipped through the cracks. The short-term win masked a long-term failure. That’s the true cost of ghost processes.

Ghost Processes: Risk or Opportunity?

From an ISO lens, ghost processes are paradoxical. They are both:

• A Risk: Workarounds that bypass critical controls can compromise safety, create nonconformances, and expose the organization to regulatory penalties. One missed step can ripple downstream in ways no one anticipated.
• An Opportunity: At the same time, ghost processes are feedback. They tell you exactly where the documented system doesn’t align with how work is really performed. If the workaround saves time without compromising safety or quality, it may point the way toward a leaner, more effective process.

In other words, ghost processes are diagnostic clues. They reveal the friction points in your system. Ignore them, and you stay blind. Investigate them, and you learn where your system can evolve.

How Do You Find Ghost Processes?

Not by reviewing documents in an office away from where the work is done. You find them by being present where the work happens. On the floor. In the design office. In the maintenance shop.

You’ll hear them in phrases like:

• “We don’t really do it that way anymore.”
• “Here’s the shortcut we use when things get busy.”
• “That step slows us down, so we…”

It takes trust for people to share ghost processes. If they think you’re there to punish, they’ll hide them. In an organization I worked with a procurement SOP had been written without inputs from the procurement department. The doers didn’t even know an SOP required them to do something.

Can Ghost Processes Be Eliminated Completely?

The straight answer? No. But should they be eliminated? Does your team when competent need such specific and detailed steps or can you create a boundary that they can operate within using their judgement? How critical is the process? What is the outcome of a risk materializing and what is the probability of a risk?

Workarounds are inevitable in dynamic operations. No SOP can predict every situation, every supply chain delay, every quirky machine behavior, or every last-minute customer request. Humans adapt, it’s what we do. So perhaps the goal isn’t to stamp out ghost processes like pests.

The real goal is to:

• Eliminate the ones that introduce unacceptable risk. Explain to people what the risk is.
• Validate and adopt the ones that improve efficiency or safety.
• Foster a culture where people don’t feel they have to hide ghost processes but can bring them forward for review.

Without input from the workforce the system cannot truly improve. Their input allows organizations to deal with reality. To recognize the risks and take actions on them. To drive continual improvement.

What To Do When You Find One

When you uncover a ghost process, your first instinct might be to clamp down: “That’s not the process. Stop immediately! Follow the SOP.” But that kills learning.

A better approach:

1. If it’s unsafe or noncompliant – Stop it immediately, yes. But then ask why. Was the MOC process too slow? Was the tool unavailable? Was the procedure impractical under real production conditions? Fix the cause(s), not just the symptom.
2. If it’s better than the documented process – Don’t dismiss it. Test it. Validate it. If it holds up, integrate it. That’s not weakness; that’s a living management system.

The Leadership Imperative

Clause 5 of ISO 9001 talks about leadership commitment. But it’s more than a statement in the quality manual. It’s showing up. It’s walking the floor. It’s listening. The best leaders don’t just enforce the rulebook. They shape it to fit the realities of the voyage. Manufacturing leaders must do the same.

Ghost processes show you where the system on paper diverges from the system in practice. Treat them as warning lights. Investigate them without blame. Some you’ll need to shut down. Others may be the smarter course you didn’t know you had.

Bottom line: Ghost processes will never disappear completely. But with the right mindset, you can turn them from hidden risks into powerful opportunities for improvement. They are not ghosts to be feared, but signals to be heeded.

About the author

Julius DeSilva is the CEO of Quality Management International Inc. A former merchant marine officer, he has assisted organizations of varied sizes across a wide spectrum of industries implement process-based management systems conforming to ISO and other standards. He is well versed in the following standards: maritime safety/security, aerospace, environmental, supply chain security, and quality. He teaches, consults, and audits in these disciplines, including process improvement and leadership-related topics. DeSilva received his MBA from the Darden School of Business, University of Virginia. He is an Exemplar Global certified lead auditor to various ISO Standard including ISO 9001 and is an Associate Fellow of the Nautical Institute.

This article first appeared on Julius DeSilva’s LinkedIn page and is published here with permission.