We first noticed the pattern in a cannabis cultivation operation. A harvest came in right on schedule. But the purchase order for child-resistant packaging never went out — the person who normally triggered it had left the company two months earlier, and nobody else knew that job was hers. Product sat curing three weeks past its window while packaging caught up. By the time it reached shelves, potency had dropped enough to bump it to the discount tier. Nobody upstream noticed. Nobody downstream noticed. The first person to catch it was the CFO, looking at margin.

We saw the same thing a year later somewhere much smaller: a coffee order placed with a local roaster, in the same state, took two weeks to arrive. No status update. No apology. When the customer finally asked, the owner answered from his personal iPhone. Checkout had charged a premium shipping fee that made no difference to delivery time, and the site never mentioned they only roast once a week.

Neither of those is a packaging problem or a coffee problem. They’re the same problem: nobody owned the handoff, so work just stopped moving until the CFO found out the hard way. The coffee order is the one that made us build something about it.