Understanding Fishbone Diagrams for Root Cause Analysis
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ScribdTranslationsUnderstanding Fishbone Diagrams for Root Cause Analysis
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ScribdTranslationsFISHBONE DIAGRAM:
What what is it?
The cause-effect diagram, also called a Fishbone diagram, is a way to organize and
represent the different causes of a problem. This diagram helps to graph the causes of the
problem being studied and analyze them. It is called “Fishbone” because of the way in
which each of the causes or reasons that cause a problem are placed. It has the advantage
that it allows you to visualize in a very quick and clear way the relationship that each of
the causes has with the other reasons that affect the origin of the problem. In some cases
they are independent causes and in others, there is an intimate relationship between
them, which may be acting in a chain. Graphically, it is made up of a central horizontal axis
that is known as the “central spine.” It has several inclined arrows that extend to the
central axis, in the direction of the mouth of the fish where the analyzed problem has
been placed. Each thorn contains and represents a group of causes that influence the
existence of the problem.
Why use a “Fishbone”?
Because it allows us to quickly identify, explore and represent in a group all the possible
causes of a problem in order to discover its roots. On the other hand, because it allows
you to focus on the content of the problem, not on the history or personal interests
associated with it. Furthermore, since it is a photograph of the problem prepared with the
participation of everyone, it becomes a support to seek solutions in a consensual manner.
How to use the tool
1. Identify the differences between the results (i.e. performance) necessary for the
proper functioning of the results chain of your programs/projects (logical
framework) and the current achievements to date.
2. State the need(s) clearly and concisely. Make sure that all group members agree
with the needs as stated. For example, the national administration has managed to
present 25% (on average) of requested reports on time in the last 10 years. Now,
the objective of your program/project is that 100% of the reports requested each
year are transmitted on time and that their content is informative and relevant.
3. On a long sheet of paper, draw a horizontal line along its entire length. This line will
represent the "backbone" of the fish. Write the need along this spine on the left
side.
4. Identify the main categories of causes of said need. Brainstorming is often an
effective technique for identifying cause categories. Represent each category of
cause with a "spine" - a line angled at 45 degrees from the fish's spine. Mark each
spine (see image 1).
5. With the help of brainstorming, the group must identify the factors that may affect
the cause and/or need. For each category of causes, ask the group "Why does this
happen?" Add each "reason" to the diagram, indicating it around the category of
the main cause it affects.
6. Repeat the procedure asking the question "Why does this happen?" for each effect,
until there are no more answers to the question (see image 2).
7. Once the group has established that the diagram contains enough information,
proceed to analyze the diagram. Look in particular for causes that appear in more
than one section of the diagram.
8. Draw a circle around all that appear to be root causes at the origin of the need.
Classify the causes in order of priority and define the action to be taken. Such action
may be a further study of the root causes.
Image 1: Basic Fishbone Diagram
Image 2: Annotated fishbone diagram
Advantages and disadvantages
Advantages
Fishbone diagrams allow in-depth analysis, thus avoiding leaving aside the possible
causes of a need.
The fishbone technique is easy to apply and creates an easy-to-understand visual
representation of causes, categories of causes, and needs.
Using a fishbone diagram, the group's attention can be drawn to the "whole situation"
from the point of view of the causes or factors that may have an effect on a
problem/need.
Even after the need is addressed, the fishbone diagram indicates weaknesses that can
be rectified – once presented – before they cause further difficulties.
Disadvantages
The simplicity of a fishbone diagram can represent both a strength and a weakness. A
weakness, because the simplicity of this type of diagram can make it difficult to
represent the very interdependent nature of problems and causes in very complex
situations.
Unless there is a large enough space to draw and develop the diagram, it may happen
that the necessary conditions are not available to delve into the cause-effect
relationships as would be desirable.
How do you make a “Fishbone”?
a) First we clearly define the problem that is going to be analyzed.
b) Once the problem has been identified, we draw the skeleton of the Fishbone on the
board or paper and place the identified problem on the fish's head, as simple and brief as
possible!
c) Then based on the observations, conversations and data collected, we all try to identify
the greatest number of causes that are contributing to generating this problem. The
question: Why is it happening...? It is our best ally.
d) Then we group the causes into categories
e) To better understand the problem we look for the subcauses or reasons for these main
causes. If necessary, construct a cause-effect diagram for each of the causes. Remember
that this is about obtaining a clearer and more precise understanding, however, use your
common sense to stop.
f) When we have a sufficient overview of the causes, we organize them into groups
according to categories that we can create collectively, to facilitate the search for
solutions.
g) Once organized into groups, we take each cause and collectively propose a solution.
5 WHY
What are “the five whys”?
The “5 whys” technique (also called the “ladder of whys” or “the 5 whys”) is an analysis
method based on asking questions to explore the cause-effect relationships that generate
a particular problem. The ultimate goal of the 5 Whys is to determine the root cause of a
defect or problem in order to solve it effectively.
This methodology is based on a traceability process, where questions are asked to analyze
the possible causes of the problem, walking backwards, until reaching the last cause that
originated the problem. Keep in mind that there does not have to be exactly 5 questions,
but this will depend on the length and complexity of the causal process of the problem.
In this way, with each question “why?” and its respective response, we will go deeper into
the problem and its causes, until we reach the origin or root cause.
The goal of this technique is to help us discover vital information in a systematic way,
analyze hidden causes and develop solutions to the questions raised. This analysis can be
applied to resolve a conflict, diagnose a problem or make decisions.
For more information, read the article Root Cause Analysis , which explains how to use
this methodology and others similar.
This technique was first used at Toyota during the evolution of its manufacturing
methodologies, which would later culminate in the Toyota Production System (TPS). This
technique is currently used in many areas, and is also used within Six Sigma.
Example
The following simple example shows us the use of this method. We start from a postulate:
My car won't start. (the problem)
Why doesn't it start? Because the battery is dead.
Why is the battery dead? Because the alternator doesn't work.
Why is the alternator not working? Because the tape broke.
Why did the tape break? Because the alternator is beyond its useful life and was not
replaced.
Why wasn't it replaced? Because I am not maintaining my car according to the
manufacturer's recommendations.
Obviously, this example could be followed further, with more questions. This would be
correct, since the "five" in the "Five Whys" technique is not fixed, but rather an
encouragement to do several iterations to find the root cause.
Root cause analysis
A root cause is the initial cause of a chain of causes that lead to an effect of interest.
Generally, the root cause is used to describe the place in the chain of causes where an
intervention could be implemented to prevent undesirable outcomes.
It is important to know when to stop the analysis. In the previous example, one could
continue asking why the car did not have maintenance, and then why the vehicle had a
design that needed this type of maintenance.
In general, it is the analyst's own framework that determines when the analysis should
stop. For example, if viewed from the point of view of the car owner, then the analysis
might stop at the fifth why. However, if the frame of reference is the car manufacturer,
who is responding to thousands of complaints about this problem, the stopping point of
the analysis would have to reach the scope of design.
Common questions
Powered by AIThe '5 Whys' technique can be used alongside Fishbone diagrams to delve deeper into each identified cause's root causes. After categorizing the causes in a Fishbone diagram, applying the '5 Whys' method to each category can systematically trace back to the root causative factors, enhancing the depth of analysis . This integration allows comprehensive exploration beyond surface causes, thus facilitating effective solutions development for complex problem scenarios .
The '5 Whys' technique, as applied at Toyota, emphasizes iterative questioning to reach root causes. Contemporary industries can adapt this by embedding it in quality control and process improvement frameworks like Six Sigma. By adjusting the questioning scope to contemporary issues such as digital errors in IT or service failures in customer relations, industries can apply culturally and contextually relevant questions to unravel complex issues systematically .
Identifying a stopping point in a '5 Whys' analysis is essential due to differing complexity levels and objectives within organizational contexts. For an owner resolving low-complexity issues, stopping after addressing immediate causes may suffice, whereas manufacturers facing widespread defects might extend analysis further, addressing design or systemic issues. Efficient resource use and contextual relevance guide where to halt, preventing overextension or under-analysis .
A Fishbone diagram, also known as a cause-effect diagram, helps organize and represent different causes contributing to a problem. It allows visualization of the relationships between causes, distinguishing between independent causes and those acting in a chain . The diagram's structure comprises a central spine and several angled lines representing categories of causes, which enables quick identification, exploration, and group representation of potential problem causes .
In Fishbone diagram analysis, prioritizing causes involves evaluating identified causes to determine which are most critical to address first. This is crucial for effective resource allocation and action planning. By focusing on prioritized causes, especially those recurrent across multiple areas, organizations can strategically target interventions to achieve significant impact and more efficiently resolve or mitigate the problem .
Fishbone diagrams aid in identifying common root causes by visually mapping causes in various sections, allowing analysts to detect repeating causes across these sections. By highlighting these overlaps, analysts can focus on these persistent issues as potential root causes, guiding them to prioritize these for further investigation and action, thereby streamlining the root cause analysis process .
A Fishbone diagram differs from similar techniques by its structured visual approach that categorizes and highlights cause relationships leading to defects or needs, unlike linear methods such as '5 Whys' which primarily focus on tracing back a single problem's root cause. The diagram’s organization facilitates the identification of interconnected causes beyond a single causal chain, providing a comprehensive overview .
Group consensus is crucial in the Fishbone diagram technique as it ensures a shared understanding and agreement on the identified problems and causes. This collective participation supports a comprehensive diagram creation that reflects everyone’s insights, helping drive consensual decision-making and solution development, while ensuring the analysis is balanced and robustly supported by multiple perspectives .
In complex problem scenarios, the Fishbone diagram's simplicity can hinder its efficacy by insufficiently representing the intricate cause-and-effect interdependencies. The limited space available in a diagram may also restrict the thorough documentation of such detailed relationships, leading to potentially incomplete analysis that misses critical interacting factors .
Advantages of Fishbone diagrams include in-depth analysis of potential problem causes, easy application, and the creation of a visual representation that facilitates group focus on the entire problem's situation . However, disadvantages include possible oversimplification, which might not effectively represent complex interdependent problem causes, and space constraints which can impede detailed cause-effect relationship exploration .