Fishbone Diagram for Root Cause Analysis - Revision history

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	==The Big Idea: The Fishbone Diagram ==		==The Big Idea: The Fishbone Diagram ==

	The Fishbone diagram, also known as cause-and-effect diagram or Ishikawa diagram, is a technique for root cause analysis and was invented by Kaoru Ishikawa, an engineer from Japan in the 1960s. The technique was then published in his book, Introduction to Quality Control, in 1990. Kaoru Ishikawa also defined the 7 quality management tools. He did not invent them all but was the first to combine them all in order to solve problems. The Fishbone diagram is commonly used in product designing or quality defect prevention to find the probable causes and identify potential factors that cause an overall effect. A problem or effect to the organizations objectives is stated and the goal of the Fishbone diagram is to identify all factors to that problem/effect and all causes to those factors. There can be more than one cause and one effect in risks and the diagram will assist in identifying those possible causes and help the organization identify the root cause of the problem or effect. When all root causes have then been removed, the problem is solved.		The Fishbone diagram, also known as cause-and-effect diagram or Ishikawa diagram, is a technique for root cause analysis and was invented by Kaoru Ishikawa, an engineer from Japan in the 1960s. The technique was then published in his book, Introduction to Quality Control, in 1990. Kaoru Ishikawa also defined the 7 quality management tools. He did not invent them all but was the first to combine them all in order to solve problems. The Fishbone diagram is commonly used in product designing or quality defect prevention to find the probable causes and identify potential factors that cause an overall effect. A problem or effect to the organizations objectives is stated and the goal of the Fishbone diagram is to identify all factors to that problem/effect and all causes to those factors. There can be more than one cause and one effect in risks and the diagram will assist in identifying those possible causes and help the organization identify the root cause of the problem or effect. When all root causes have then been removed, the problem is solved <ref name="mindt"> Cause and Effect Analysis. MindTools. https://www.mindtools.com/pages/article/newTMC_03.htm </ref>.

	According to the PMBOK® Guide the technique of The Fishbone Diagram is used in both the Manage Quality process and the Control Quality process <ref name="BodyKnow">Project Management Institute, Inc.. (2017). Guide to the Project Management Body of Knowledge (PMBOK® Guide) (6th Edition). Project Management Institute, Inc. (PMI). Retrieved from		According to the PMBOK® Guide the technique of The Fishbone Diagram is used in both the Manage Quality process and the Control Quality process <ref name="BodyKnow">Project Management Institute, Inc.. (2017). Guide to the Project Management Body of Knowledge (PMBOK® Guide) (6th Edition). Project Management Institute, Inc. (PMI). Retrieved from
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	In this section a step-by-step guide to develop a Fishbone diagram in a team setting is described. The section also includes models and methods that can be helpful to use in conjunction with the Fishbone diagram.		In this section a step-by-step guide to develop a Fishbone diagram in a team setting is described. The section also includes models and methods that can be helpful to use in conjunction with the Fishbone diagram.
	===Step 1: Identify the problem ===		===Step 1: Identify the problem ===
	The first step for the team is to define a problem or effect that the team wants to analyse. For a successful Fishbone diagram, it is critical to define the problem correctly. Have the team think, consider and identify who is involved, what the problem is, and when and where it occurs. When the problem has been identified it is written in a box on the center right-hand side with a horizontal arrow running to it, e.g., on a large sheet of paper or whiteboard. It is also possible to write the problem statement on the center left hand side, whichever you prefer. Resembling a head and spine of a fish, this layout, will give you space to develop ideas in the next steps <ref name="mindt"~~> Cause and Effect Analysis. MindTools. https:~~/~~/www.mindtools.com/pages/article/newTMC_03.htm </ref~~>.		The first step for the team is to define a problem or effect that the team wants to analyse. For a successful Fishbone diagram, it is critical to define the problem correctly. Have the team think, consider and identify who is involved, what the problem is, and when and where it occurs. When the problem has been identified it is written in a box on the center right-hand side with a horizontal arrow running to it, e.g., on a large sheet of paper or whiteboard. It is also possible to write the problem statement on the center left hand side, whichever you prefer. Resembling a head and spine of a fish, this layout, will give you space to develop ideas in the next steps <ref name="mindt" />.

	[[File:Fishbonedia_1.png\|600px\|thumb\|centre\|Figure 2: The first step of the Fishbone diagram - The identified problem is added to the model.]]		[[File:Fishbonedia_1.png\|600px\|thumb\|centre\|Figure 2: The first step of the Fishbone diagram - The identified problem is added to the model.]]

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			''Developed by Brynja Ran Gudmundsdottir''
	==Abstract==		==Abstract==

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	The first step for the team is to define a problem or effect that the team wants to analyse. For a successful Fishbone diagram, it is critical to define the problem correctly. Have the team think, consider and identify who is involved, what the problem is, and when and where it occurs. When the problem has been identified it is written in a box on the center right-hand side with a horizontal arrow running to it, e.g., on a large sheet of paper or whiteboard. It is also possible to write the problem statement on the center left hand side, whichever you prefer. Resembling a head and spine of a fish, this layout, will give you space to develop ideas in the next steps <ref name="mindt"> Cause and Effect Analysis. MindTools. https://www.mindtools.com/pages/article/newTMC_03.htm </ref>.		The first step for the team is to define a problem or effect that the team wants to analyse. For a successful Fishbone diagram, it is critical to define the problem correctly. Have the team think, consider and identify who is involved, what the problem is, and when and where it occurs. When the problem has been identified it is written in a box on the center right-hand side with a horizontal arrow running to it, e.g., on a large sheet of paper or whiteboard. It is also possible to write the problem statement on the center left hand side, whichever you prefer. Resembling a head and spine of a fish, this layout, will give you space to develop ideas in the next steps <ref name="mindt"> Cause and Effect Analysis. MindTools. https://www.mindtools.com/pages/article/newTMC_03.htm </ref>.

	[[File:Fishbonedia_1.png\|600px\|thumb\|centre\|Figure 2: The first step of the Fishbone diagram - The identified problem id added to the model.]]		[[File:Fishbonedia_1.png\|600px\|thumb\|centre\|Figure 2: The first step of the Fishbone diagram - The identified problem is added to the model.]]

	===Step 2: Work out the Major Factors Involved===		===Step 2: Work out the Major Factors Involved===

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	The first step for the team is to define a problem or effect that the team wants to analyse. For a successful Fishbone diagram, it is critical to define the problem correctly. Have the team think, consider and identify who is involved, what the problem is, and when and where it occurs. When the problem has been identified it is written in a box on the center right-hand side with a horizontal arrow running to it, e.g., on a large sheet of paper or whiteboard. It is also possible to write the problem statement on the center left hand side, whichever you prefer. Resembling a head and spine of a fish, this layout, will give you space to develop ideas in the next steps <ref name="mindt"> Cause and Effect Analysis. MindTools. https://www.mindtools.com/pages/article/newTMC_03.htm </ref>.		The first step for the team is to define a problem or effect that the team wants to analyse. For a successful Fishbone diagram, it is critical to define the problem correctly. Have the team think, consider and identify who is involved, what the problem is, and when and where it occurs. When the problem has been identified it is written in a box on the center right-hand side with a horizontal arrow running to it, e.g., on a large sheet of paper or whiteboard. It is also possible to write the problem statement on the center left hand side, whichever you prefer. Resembling a head and spine of a fish, this layout, will give you space to develop ideas in the next steps <ref name="mindt"> Cause and Effect Analysis. MindTools. https://www.mindtools.com/pages/article/newTMC_03.htm </ref>.

	[[File:Fishbonedia_1.png\|600px\|thumb\|centre\|Figure 2: The first step of the Fishbone diagram - ~~Identify~~ the ~~Problem~~.]]		[[File:Fishbonedia_1.png\|600px\|thumb\|centre\|Figure 2: The first step of the Fishbone diagram - The identified problem id added to the model.]]

	===Step 2: Work out the Major Factors Involved===		===Step 2: Work out the Major Factors Involved===
	In the next step the team identifies the factors involved in the problem or effect. In this step it can be helpful to use brainstorming techniques as described above. An example of these factors are Site, Task, People, Equipment and Control. To achieve the best outcome, try to identify as many of these factors as possible. Then, they are written down as branches off the spine of the diagram and resemble the bones <ref name="mindt" />.		In the next step the team identifies the factors involved in the problem or effect. In this step it can be helpful to use brainstorming techniques as described above. An example of these factors are Site, Task, People, Equipment and Control. To achieve the best outcome, try to identify as many of these factors as possible. Then, they are written down as branches off the spine of the diagram and resemble the bones <ref name="mindt" />.

			[[File:Fishbonedia_2.png\|600px\|thumb\|centre\|Figure 3: The second step of the Fishbone diagram - The identified factors involved are added to the model.]]

	====Useful models====		====Useful models====
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	* Systems		* Systems
	* Skills		* Skills

	~~[[File:Fishbonedia_2.png\|600px\|thumb\|centre\|Figure 3: The second step of the Fishbone diagram - Identify the Factors involved.]]~~

	===Step 3: Identify Possible Causes ===		===Step 3: Identify Possible Causes ===
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	* (Mother Nature was not used in this Fishbone diagram example)		* (Mother Nature was not used in this Fishbone diagram example)

	[[File:Fishbonedia_3.png\|600px\|thumb\|centre\|Figure 4: The third step of the Fishbone diagram - ~~Identify Possible Causes~~.]]		[[File:Fishbonedia_3.png\|600px\|thumb\|centre\|Figure 4: The third step of the Fishbone diagram - The identified possible causes are added to the model.]]

	====The 5 Why's & The Fishbone Diagram====		====The 5 Why's & The Fishbone Diagram====

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	Individual project risk is an uncertain event or condition within the project and if it occurs it can have either a positive or a negative outcome. The objective of project risk management is to find the positive outcomes and minimize the negative outcomes. Unmanaged threats may result in delay, extra cost, bad performance overall and loss in reputation. While the Positive outcomes can be opportunities which can lead to great benefits such as reduced time, less cost and increased performance <ref name="BodyKnow" /> (p.397).		Individual project risk is an uncertain event or condition within the project and if it occurs it can have either a positive or a negative outcome. The objective of project risk management is to find the positive outcomes and minimize the negative outcomes. Unmanaged threats may result in delay, extra cost, bad performance overall and loss in reputation. While the Positive outcomes can be opportunities which can lead to great benefits such as reduced time, less cost and increased performance <ref name="BodyKnow" /> (p.397).
	Overall project risk is the effect of uncertainty on the whole project. This can come from all sides of the project, including individual risk and is the perception from stakeholders to the implications of variations in the project. The overall project risk can also have either a positive or negative outcome. The objective of management of overall project risk is to keep the exposed risk within acceptable range and drive the positive outcome which can benefit the project overall <ref name="BodyKnow" /> (p.397).		Overall project risk is the effect of uncertainty on the whole project. This can come from all sides of the project, including individual risk and is the perception from stakeholders to the implications of variations in the project. The overall project risk can also have either a positive or negative outcome. The objective of management of overall project risk is to keep the exposed risk within acceptable range and drive the positive outcome which can benefit the project overall <ref name="BodyKnow" /> (p.397).

	The main advantages for using the Fishbone diagram are that it is highly visual, quickly identifies the risks associated within the project itself and clearly stated the main problem or effect. It also has good visualization properties for individuals who enter the project later on and for presenting to stakeholder. The technique is also easy to use and both simple to learn and apply.		The main advantages for using the Fishbone diagram are that it is highly visual, quickly identifies the risks associated within the project itself and clearly stated the main problem or effect. It also has good visualization properties for individuals who enter the project later on and for presenting to stakeholder. The technique is also easy to use and both simple to learn and apply.

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	===Step 3: Identify Possible Causes ===		===Step 3: Identify Possible Causes ===
	In the third step, the team identifies the possible causes associated to each factor determined in the previous step. Again, the team should use brainstorming techniques to identify these causes, and if the problem or effect is large/complex it may be effective to also break down the causes into sub-causes. Have the team think about “Why does this happen?”. Then, the causes and sub-causes are written down as lines coming off each factor branch. If the cause applies to more than one factor it can be added to several branches <ref name="mindt" />.		In the third step, the team identifies the possible causes associated to each factor determined in the previous step. Again, the team should use brainstorming techniques to identify these causes, and if the problem or effect is large/complex it may be effective to also break down the causes into sub-causes. Have the team think about “Why does this happen?”. Then, the causes and sub-causes are written down as lines coming off each factor branch. If the cause applies to more than one factor it can be added to several branches <ref name="mindt" />.

	In the example below the problem is stated: „12% of product fails inspection for screw alignment“. The model of 6M‘s is then used to identify the factors in this manufacturing problem, and the identified causes by the team are: <ref name="tulip"> Fishbone (Ishikawa) Diagram Template for Root Cause Analysis. (2018). Tulip Interfaces, Inc. https://tulip.co/blog/lean-manufacturing/fishbone-ishikawa-diagram-for-root-cause-analysis/#:~:text=Here%2C%20the%20causes%20are%20categorized,%E2%80%9Cribs%E2%80%9D%20of%20the%20fish. </ref>		In the example below the problem is stated: „12% of product fails inspection for screw alignment“. The model of 6M‘s is then used to identify the factors in this manufacturing problem, and the identified causes by the team are: <ref name="tulip"> Fishbone (Ishikawa) Diagram Template for Root Cause Analysis. (2018). Tulip Interfaces, Inc. https://tulip.co/blog/lean-manufacturing/fishbone-ishikawa-diagram-for-root-cause-analysis/#:~:text=Here%2C%20the%20causes%20are%20categorized,%E2%80%9Cribs%E2%80%9D%20of%20the%20fish. </ref>
	Method: Instructions were not clear and/or Instructions were not followed		* Method: Instructions were not clear and/or Instructions were not followed
	Man: Employee has not bee trained and/or Employee fatigue		* Man: Employee has not bee trained and/or Employee fatigue
	Machine: Tools are worn and/or Tools are not the right size		* Machine: Tools are worn and/or Tools are not the right size
	Materials: Screws were worn and/or Screws were the wrong size		* Materials: Screws were worn and/or Screws were the wrong size
	Measurement: The correct gauge was not used to measure the parts and/or The gauge was not zeroed before measuring the part		* Measurement: The correct gauge was not used to measure the parts and/or The gauge was not zeroed before measuring the part
	(Mother Nature was not used in this Fishbone diagram example)		* (Mother Nature was not used in this Fishbone diagram example)

	[[File:Fishbonedia_3.png\|600px\|thumb\|centre\|Figure 4: The third step of the Fishbone diagram - Identify Possible Causes.]]		[[File:Fishbonedia_3.png\|600px\|thumb\|centre\|Figure 4: The third step of the Fishbone diagram - Identify Possible Causes.]]

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	To help in this step of the diagram teams often use common models of factors, if applicable, to start the process. The models here below are set up for problems within a specific aspect but the factors can also be relevant to use in other cases. The factors mentioned in each model below are added as branches to the model as described in step 2.		To help in this step of the diagram teams often use common models of factors, if applicable, to start the process. The models here below are set up for problems within a specific aspect but the factors can also be relevant to use in other cases. The factors mentioned in each model below are added as branches to the model as described in step 2.

	5M used in the Fishbone diagram - mainly for Manufacturing <ref name="edraw">A complete Guide for Fishbone Diagram (Ishikawa Diagram).EdrawMax Online. https://www.edrawmax.com/fishbone-diagram/ </ref>.		5M used in the Fishbone diagram - mainly for Manufacturing <ref name="edraw">A complete Guide for Fishbone Diagram (Ishikawa Diagram).EdrawMax Online. https://www.edrawmax.com/fishbone-diagram/ </ref>.
	* Method		* Method

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	[[File:riskmanpro.png\|250px\|thumb\|right\|Figure 1: The process of Risk Management. <ref name="hpaudit"> How to improve risk management in your business. HP Audit. https://hpaudit.co.za/how-to-improve-risk-management-in-your-business/ </ref>.]]		[[File:riskmanpro.png\|250px\|thumb\|right\|Figure 1: The process of Risk Management. <ref name="hpaudit"> How to improve risk management in your business. HP Audit. https://hpaudit.co.za/how-to-improve-risk-management-in-your-business/ </ref>.]]

	'''Risk Management''' is the process of identifying, monitoring and managing the potential risks to all levels of the organization, from portfolios through programs, projects, and operations. Uncertainty in organizations is inevitable but risk management can provide information to limit the impact of uncertainty to the organization objectives. Individual risk can have a positive effect and a negative effect on objectives and is described as an uncertain event or condition. To assess how serious the risk is to the organization they need to consider both uncertainty, often described as probability, and the effect, often referred to as impact, on objectives <ref name="riskman"> Project Management Institute, Inc. (PMI). (2019). Standard for Risk Management in Portfolios, Programs, and Projects - 7.1.3 Project Risk Response Strategies. Project Management Institute, Inc. (PMI). Retrieved from		[[Risk Management Overview\|'''Risk Management''']] is the process of identifying, monitoring and managing the potential risks to all levels of the organization, from portfolios through programs, projects, and operations. Uncertainty in organizations is inevitable but risk management can provide information to limit the impact of uncertainty to the organization objectives. Individual risk can have a positive effect and a negative effect on objectives and is described as an uncertain event or condition. To assess how serious the risk is to the organization they need to consider both uncertainty, often described as probability, and the effect, often referred to as impact, on objectives <ref name="riskman"> Project Management Institute, Inc. (PMI). (2019). Standard for Risk Management in Portfolios, Programs, and Projects - 7.1.3 Project Risk Response Strategies. Project Management Institute, Inc. (PMI). Retrieved from
	https://app.knovel.com/hotlink/pdf/id:kt011VVUA4/standard-risk-management/project-risk-response </ref>. Identifying risks from risk-related features is important. “Causes are events or circumstances that currently exist or are certain to exist in the future, which might give rise to risks. Effects are conditional future events or conditions that directly affect one or more objectives if the associated risk occurs” <ref name="riskman"/> (p.11).		https://app.knovel.com/hotlink/pdf/id:kt011VVUA4/standard-risk-management/project-risk-response </ref>. Identifying risks from risk-related features is important. “Causes are events or circumstances that currently exist or are certain to exist in the future, which might give rise to risks. Effects are conditional future events or conditions that directly affect one or more objectives if the associated risk occurs” <ref name="riskman"/> (p.11).

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	According to the PMBOK® Guide the technique of The Fishbone Diagram is used in both the Manage Quality process and the Control Quality process <ref name="BodyKnow">Project Management Institute, Inc.. (2017). Guide to the Project Management Body of Knowledge (PMBOK® Guide) (6th Edition). Project Management Institute, Inc. (PMI). Retrieved from		According to the PMBOK® Guide the technique of The Fishbone Diagram is used in both the Manage Quality process and the Control Quality process <ref name="BodyKnow">Project Management Institute, Inc.. (2017). Guide to the Project Management Body of Knowledge (PMBOK® Guide) (6th Edition). Project Management Institute, Inc. (PMI). Retrieved from
	https://app.knovel.com/hotlink/toc/id:kpGPMBKP02/guide-project-management/guide-project-management </ref> (p.293, 304), but the tool can also be used to identify the risks associated with a project. In Risk Management, The Fishbone diagram is used in risk identification to identify the many potential causes (root cause analysis) for an effect or problem and can be practical in sorting ideas into useful categories through brainstorming sessions <ref name="asq">Fishbone Diagram. ASQ. https://asq.org/quality-resources/fishbone </ref>.		https://app.knovel.com/hotlink/toc/id:kpGPMBKP02/guide-project-management/guide-project-management </ref> (p.293, 304), but the tool can also be used to identify the risks associated with a project. In Risk Management, The Fishbone diagram is used in risk identification to identify the many potential causes (root cause analysis) for an effect or problem and can be practical in sorting ideas into useful categories through brainstorming sessions <ref name="asq">Fishbone Diagram. ASQ. https://asq.org/quality-resources/fishbone </ref>.
	[[Brainstorming\|~~Effective~~ Brainstorming]] is a tool that is used in risk management to gather comprehensive information about the risk/problem, both individual risks and risks that affect the project as whole. Brainstorming can be identified as free-brainstorming or brainstorming session where some structure is set beforehand. The Fishbone diagram is most often done in teams, and the discussion is set up as a structure using brainstorming to identify the problem or effect and the factors and causes to that problem. Brainstorming does not give solutions to the risk itself rather identifies the risk and gives a good idea what risks could arise within the project <ref name="BodyKnow" /> (p.414).		[[Effective Brainstorming\|Brainstorming]] is a tool that is used in risk management to gather comprehensive information about the risk/problem, both individual risks and risks that affect the project as whole. Brainstorming can be identified as free-brainstorming or brainstorming session where some structure is set beforehand. The Fishbone diagram is most often done in teams, and the discussion is set up as a structure using brainstorming to identify the problem or effect and the factors and causes to that problem. Brainstorming does not give solutions to the risk itself rather identifies the risk and gives a good idea what risks could arise within the project <ref name="BodyKnow" /> (p.414).

	[[File:riskmanpro.png\|250px\|thumb\|right\|Figure 1: The process of Risk Management. <ref name="hpaudit"> How to improve risk management in your business. HP Audit. https://hpaudit.co.za/how-to-improve-risk-management-in-your-business/ </ref>.]]		[[File:riskmanpro.png\|250px\|thumb\|right\|Figure 1: The process of Risk Management. <ref name="hpaudit"> How to improve risk management in your business. HP Audit. https://hpaudit.co.za/how-to-improve-risk-management-in-your-business/ </ref>.]]

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	According to the PMBOK® Guide the technique of The Fishbone Diagram is used in both the Manage Quality process and the Control Quality process <ref name="BodyKnow">Project Management Institute, Inc.. (2017). Guide to the Project Management Body of Knowledge (PMBOK® Guide) (6th Edition). Project Management Institute, Inc. (PMI). Retrieved from		According to the PMBOK® Guide the technique of The Fishbone Diagram is used in both the Manage Quality process and the Control Quality process <ref name="BodyKnow">Project Management Institute, Inc.. (2017). Guide to the Project Management Body of Knowledge (PMBOK® Guide) (6th Edition). Project Management Institute, Inc. (PMI). Retrieved from
	https://app.knovel.com/hotlink/toc/id:kpGPMBKP02/guide-project-management/guide-project-management </ref> (p.293, 304), but the tool can also be used to identify the risks associated with a project. In Risk Management, The Fishbone diagram is used in risk identification to identify the many potential causes (root cause analysis) for an effect or problem and can be practical in sorting ideas into useful categories through brainstorming sessions <ref name="asq">Fishbone Diagram. ASQ. https://asq.org/quality-resources/fishbone </ref>. Brainstorming is a tool that is used in risk management to gather comprehensive information about the risk/problem, both individual risks and risks that affect the project as whole. Brainstorming can be identified as free-brainstorming or brainstorming session where some structure is set beforehand. The Fishbone diagram is most often done in teams, and the discussion is set up as a structure using brainstorming to identify the problem or effect and the factors and causes to that problem. Brainstorming does not give solutions to the risk itself rather identifies the risk and gives a good idea what risks could arise within the project <ref name="BodyKnow" /> (p.414).		https://app.knovel.com/hotlink/toc/id:kpGPMBKP02/guide-project-management/guide-project-management </ref> (p.293, 304), but the tool can also be used to identify the risks associated with a project. In Risk Management, The Fishbone diagram is used in risk identification to identify the many potential causes (root cause analysis) for an effect or problem and can be practical in sorting ideas into useful categories through brainstorming sessions <ref name="asq">Fishbone Diagram. ASQ. https://asq.org/quality-resources/fishbone </ref>.
			[[Brainstorming\|Effective Brainstorming]] is a tool that is used in risk management to gather comprehensive information about the risk/problem, both individual risks and risks that affect the project as whole. Brainstorming can be identified as free-brainstorming or brainstorming session where some structure is set beforehand. The Fishbone diagram is most often done in teams, and the discussion is set up as a structure using brainstorming to identify the problem or effect and the factors and causes to that problem. Brainstorming does not give solutions to the risk itself rather identifies the risk and gives a good idea what risks could arise within the project <ref name="BodyKnow" /> (p.414).

	[[File:riskmanpro.png\|250px\|thumb\|right\|Figure 1: The process of Risk Management. <ref name="hpaudit"> How to improve risk management in your business. HP Audit. https://hpaudit.co.za/how-to-improve-risk-management-in-your-business/ </ref>.]]		[[File:riskmanpro.png\|250px\|thumb\|right\|Figure 1: The process of Risk Management. <ref name="hpaudit"> How to improve risk management in your business. HP Audit. https://hpaudit.co.za/how-to-improve-risk-management-in-your-business/ </ref>.]]