International Journal of Business and Management Invention (IJBMI) is an international journal intended for professionals and researchers in all fields of Business and Management. IJBMI publishes research articles and reviews within the whole field Business and Management, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
Introduction
Definition of Root Cause Analysis(RCA).
Benefits of RCA
Techniques and tools of RCA
Examples
Corrective Action (CA)
Preventive Action (PA)
CAPA management, corrective and preventive action, Rootcause analysis, RCA, Problem mapping, FMEA, Failure Mode effect and Analysis, Fault Tree analysis, Fishbone : ISHIKAWA, CTQ Tree (Critical to Quality Tree), AFFINITY DIAGRAM, 5 Why’s, Human errors,
Introduction
Definition of Root Cause Analysis(RCA).
Benefits of RCA
Techniques and tools of RCA
Examples
Corrective Action (CA)
Preventive Action (PA)
Hypothesis Testing: Central Tendency – Non-Normal (Compare 2+ Factors)Matt Hansen
An extension on hypothesis testing, this lesson reviews the Mood’s Median & Kruskal-Wallis tests as central tendency measurements for non-normal distributions.
I hope it will be simplified and powerful presentation for all. Rather than adding large texts, here you can find image and graphical presentation.
Happy Reading
Root cause analysis is a combination of the art and science used to find the underlying reasons for a given effect. One of the most widely used root cause analysis tools is the 5 Whys. It is a simple, effective method of problem solving that can help teams identify and eliminate the root cause of a problem
Hypothesis Testing: Central Tendency – Non-Normal (Compare 2+ Factors)Matt Hansen
An extension on hypothesis testing, this lesson reviews the Mood’s Median & Kruskal-Wallis tests as central tendency measurements for non-normal distributions.
I hope it will be simplified and powerful presentation for all. Rather than adding large texts, here you can find image and graphical presentation.
Happy Reading
Root cause analysis is a combination of the art and science used to find the underlying reasons for a given effect. One of the most widely used root cause analysis tools is the 5 Whys. It is a simple, effective method of problem solving that can help teams identify and eliminate the root cause of a problem
Corrective and Preventative Action (CAPA) is a system of quality procedures required to eliminate the causes of an existing nonconformity and to prevent recurrence of nonconforming product, processes, and other quality problems.
CAPA: Using Risk-Based Decision-Making Toward ClosureApril Bright
Implementing a risk‐based CAPA process within a QMS is a necessity in the improvement of controls aligned with product and process non-conformances, adverse events, audit findings, complaints, etc. Making decisions concerning scope and extent about these “defectives” is a modern and cost-saving approach to improvement and compliance. Every non-conformity does not force you to open a corrective action. While almost every problematic issue needs at least a correction, the biggest payback is to use corrective actions on systemically-driven problems that are repetitive and recurring.
Applying the methods of determining risk to the device’s complete life cycle will give your company a complete look at all of the device’s risks—including those relative to processes. Manufacturers should be able to justify that they have reduced the risks as far as possible as part of their risk management plan and ongoing corrective and preventive actions.
Cause and Effect Analysis is a technique for identifying all the possible causes (inputs) associated with a particular problem / effect (output) before narrowing down to the small number of main, root causes which need to be addressed.
Analyze phase of a six sigma dmaic projectKumar Satyam
The DMAIC is one of Six Sigma's most effective problem-solving methodologies. It is divided into five stages: Define, Measure, Analyze, Improve, and Control. This article will discuss the Analyze phase, which is the third phase of DMAIC. Specifically, we'll discuss what this phase entails and the tools that teams can use to identify potential causes and conduct root cause analysis (RCA).
Invented in the 1930’s by Toyota Founder Kiichiro Toyoda’s father Sakichi and made popular in the 1970s by the Toyota Production System, the 5 Whys strategy involves looking at any problem and asking: “Why?” and “What caused this problem?”
Operating Excellence is built on Corrective & Preventive ActionsAtanu Dhar
You see an issue and you simply set it right, but do you make the effort to find out what is the "corrective" action behind it, so that it never re-occurs?
And, do you take another extra step to come up with a "preventive" action - so that there is no other manner that issue comes up?
Improving the Efficacy of Root Cause AnalysisCognizant
When medical device organizations apply a relevant and appropriate level of automation to root cause analysis, they can ensure swift action on nonconformities and avoid issue reoccurrence.
Stream Analysis in Organizational Development.pptxAnonymousFQTgjf
This is invented by Prof. Jerry I. Porras of the Stanford Graduate School of Business. A new technique for managing the process of change in the organization from diagnosis to follow-up.
Methodological approach used to study and improve various processes within an organization
Involves the examination and evaluation of various processes, systems, and workflows within an organization to identify problems, inefficiencies, bottlenecks, and areas for improvement
Rooted on systems theory, organizations consist of sub-systems that are interconnected
Systems theory and social cognitive theory provide the conceptual foundation for stream analysis
Sequences of events or activities that take place in an organization, graphically represented as columns
Includes processes, communication flows, decision making procedures, and other inter-connected activities
Aims to understand how these streams operate and interact with each other, and how they contribute to the organization’s overall performance
Form a Change Management Team (CMT)
- A cross-sectional group of organization members to guide and monitor the change process
Collect Data
- to understand how each stream functions
- thru interviews with employees, questionnaires/surveys, direct observation, or analyzing existing data/company records (e.g. grievances, exit surveys, minutes of meetings, notice of decision, etc
3. Categorizing Problems (into Streams)
Streams denote issues or actions flowing over time
Shared understanding is a MUST among CMT
Problems are placed into columns called Streams
Identify Interconnectivity
Creating flowcharts or diagrams to visually identify relationships to identified streams
Analyzing the Problem chart
Identify Symptoms (problems caused by deeper problems)
Examining each stream’s efficiency, bottlenecks, duplication of efforts, and other issues
Formatting a plan of action
- involves reorganizing tasks/priorities, reallocating resources, implementing new technologies, organizational restructuring, changes in communication/collaboration methods, or workflow redesign
- Action plans are laid out similar to diagnostic chart but with time dimension
- some change instructions may affect more than one organization stream
- time bound but not too distant into the future
- laying out the action side by side provides rationale
Tracking the intervention process
- Continuous monitoring and evaluation are essential to gauge effectiveness
- Feedback from employees and stakeholders helps to identify further adjustments if necessary
Memorandum Of Association Constitution of Company.pptseri bangash
www.seribangash.com
A Memorandum of Association (MOA) is a legal document that outlines the fundamental principles and objectives upon which a company operates. It serves as the company's charter or constitution and defines the scope of its activities. Here's a detailed note on the MOA:
Contents of Memorandum of Association:
Name Clause: This clause states the name of the company, which should end with words like "Limited" or "Ltd." for a public limited company and "Private Limited" or "Pvt. Ltd." for a private limited company.
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Registered Office Clause: It specifies the location where the company's registered office is situated. This office is where all official communications and notices are sent.
Objective Clause: This clause delineates the main objectives for which the company is formed. It's important to define these objectives clearly, as the company cannot undertake activities beyond those mentioned in this clause.
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Liability Clause: It outlines the extent of liability of the company's members. In the case of companies limited by shares, the liability of members is limited to the amount unpaid on their shares. For companies limited by guarantee, members' liability is limited to the amount they undertake to contribute if the company is wound up.
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Capital Clause: This clause specifies the authorized capital of the company, i.e., the maximum amount of share capital the company is authorized to issue. It also mentions the division of this capital into shares and their respective nominal value.
Association Clause: It simply states that the subscribers wish to form a company and agree to become members of it, in accordance with the terms of the MOA.
Importance of Memorandum of Association:
Legal Requirement: The MOA is a legal requirement for the formation of a company. It must be filed with the Registrar of Companies during the incorporation process.
Constitutional Document: It serves as the company's constitutional document, defining its scope, powers, and limitations.
Protection of Members: It protects the interests of the company's members by clearly defining the objectives and limiting their liability.
External Communication: It provides clarity to external parties, such as investors, creditors, and regulatory authorities, regarding the company's objectives and powers.
https://seribangash.com/difference-public-and-private-company-law/
Binding Authority: The company and its members are bound by the provisions of the MOA. Any action taken beyond its scope may be considered ultra vires (beyond the powers) of the company and therefore void.
Amendment of MOA:
While the MOA lays down the company's fundamental principles, it is not entirely immutable. It can be amended, but only under specific circumstances and in compliance with legal procedures. Amendments typically require shareholder
Attending a job Interview for B1 and B2 Englsih learnersErika906060
It is a sample of an interview for a business english class for pre-intermediate and intermediate english students with emphasis on the speking ability.
[Note: This is a partial preview. To download this presentation, visit:
https://www.oeconsulting.com.sg/training-presentations]
Sustainability has become an increasingly critical topic as the world recognizes the need to protect our planet and its resources for future generations. Sustainability means meeting our current needs without compromising the ability of future generations to meet theirs. It involves long-term planning and consideration of the consequences of our actions. The goal is to create strategies that ensure the long-term viability of People, Planet, and Profit.
Leading companies such as Nike, Toyota, and Siemens are prioritizing sustainable innovation in their business models, setting an example for others to follow. In this Sustainability training presentation, you will learn key concepts, principles, and practices of sustainability applicable across industries. This training aims to create awareness and educate employees, senior executives, consultants, and other key stakeholders, including investors, policymakers, and supply chain partners, on the importance and implementation of sustainability.
LEARNING OBJECTIVES
1. Develop a comprehensive understanding of the fundamental principles and concepts that form the foundation of sustainability within corporate environments.
2. Explore the sustainability implementation model, focusing on effective measures and reporting strategies to track and communicate sustainability efforts.
3. Identify and define best practices and critical success factors essential for achieving sustainability goals within organizations.
CONTENTS
1. Introduction and Key Concepts of Sustainability
2. Principles and Practices of Sustainability
3. Measures and Reporting in Sustainability
4. Sustainability Implementation & Best Practices
To download the complete presentation, visit: https://www.oeconsulting.com.sg/training-presentations
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Business Valuation Principles for EntrepreneursBen Wann
This insightful presentation is designed to equip entrepreneurs with the essential knowledge and tools needed to accurately value their businesses. Understanding business valuation is crucial for making informed decisions, whether you're seeking investment, planning to sell, or simply want to gauge your company's worth.
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RMD24 | Debunking the non-endemic revenue myth Marvin Vacquier Droop | First ...BBPMedia1
Marvin neemt je in deze presentatie mee in de voordelen van non-endemic advertising op retail media netwerken. Hij brengt ook de uitdagingen in beeld die de markt op dit moment heeft op het gebied van retail media voor niet-leveranciers.
Retail media wordt gezien als het nieuwe advertising-medium en ook mediabureaus richten massaal retail media-afdelingen op. Merken die niet in de betreffende winkel liggen staan ook nog niet in de rij om op de retail media netwerken te adverteren. Marvin belicht de uitdagingen die er zijn om echt aansluiting te vinden op die markt van non-endemic advertising.
What is the TDS Return Filing Due Date for FY 2024-25.pdfseoforlegalpillers
It is crucial for the taxpayers to understand about the TDS Return Filing Due Date, so that they can fulfill your TDS obligations efficiently. Taxpayers can avoid penalties by sticking to the deadlines and by accurate filing of TDS. Timely filing of TDS will make sure about the availability of tax credits. You can also seek the professional guidance of experts like Legal Pillers for timely filing of the TDS Return.
Putting the SPARK into Virtual Training.pptxCynthia Clay
This 60-minute webinar, sponsored by Adobe, was delivered for the Training Mag Network. It explored the five elements of SPARK: Storytelling, Purpose, Action, Relationships, and Kudos. Knowing how to tell a well-structured story is key to building long-term memory. Stating a clear purpose that doesn't take away from the discovery learning process is critical. Ensuring that people move from theory to practical application is imperative. Creating strong social learning is the key to commitment and engagement. Validating and affirming participants' comments is the way to create a positive learning environment.
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Root Cause Analysis – A Practice to Understanding and Control the Failure Management in Manufacturing Industry
1. International Journal of Business and Management Invention
ISSN (Online): 2319 – 8028, ISSN (Print): 2319 – 801X
www.ijbmi.org Volume 3 Issue 10 ǁ October. 2014 ǁ PP.12-20
www.ijbmi.org 12 | Page
Root Cause Analysis – A Practice to Understanding and Control
the Failure Management in Manufacturing Industry
Joymalya Bhattacharya, M.Pharm (Pharmaceutics), MBA (HRM),
M.Phil (Management)
Senior Chemist, Albert David Limited.5/11,D.Gupta lane, Kolkata-700 050, India
ABSTRACT: This paper seeks to examine the root cause analysis management for a manufacturing industry.
Root cause analysis is one cause of the best processes to eliminate failure management in industry. This paper
highlights about the tools which are use in root cause analysis and the methodology of root cause analysis. The
procedural approach is one of the most important thinking for root analysis, because without selecting perfect
tools it is not possible to analysis the perfect root cause.
KEYWORDS: Root cause analysis (RCA), Failure modes and effects analysis (FMEA), Fishbone Diagram
I. INTRODUCTION OF ROOT CAUSE ANALYSIS
Root Cause is the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence
of the problem Root cause analysis is a problem solving process for conducting an investigation into an
identified incident, problem, concern or non-conformity. Root cause analysis is a completely separate process to
incident management and immediate corrective action, although they are often completed in close proximity.
Root cause analysis requires the investigator(s) to look beyond the solution to the immediate problem and
understand the fundamental or underlying cause(s) of the situation and put them right, thereby preventing re-
occurrence of the same issue. This may involve the identification and management of processes, procedures,
activities, inactivity, behaviors or conditions.
The benefits of comprehensive root cause analysis include:
Identification of permanent solutions
Prevention of recurring failures
Introduction of a logical problem solving process applicable to issues and non-conformities of all sizes
Root Cause Analysis is a method that is used to address a problem or non-conformance, in order to get to the
"root cause" of the problem. It is used to correct or eliminate the cause, and prevent the problem from recurring.
RootCausc is the fundamental breakdown or failure of a process which, when resolved, prevents a recurrence of
the problem.
II. METHODOLOGY OF ROOT CAUSE ANALYSIS
The root cause management strategy is established through the following methodology:
Investigation of the incident
Identification of the root cause by using Root cause analysis tools
Effect of that cause
Corrective actions to prevent recurrence
Approval of corrective actions
Implementation of actions
Training of personnel on root cause management system
Closure of the root cause by Root cause analysis Team leader
III. Benefits of Root Cause Analysis
The removal of reoccurring failures
Empowerment of the maintenance staff
The development of the "close to zero tolerance culture"
Recording of failure data
Improved understanding on failure mechanism Reliability and cost improvement
2. Root Cause Analysis – A Practice…
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Higher customer satisfaction
Root cause analysis is a learning process to follow for thorough understandings of relationships, causes and
effect and solutions. By practicing Root cause analysis, eliminate taking action on possible causes, and
delay a response to the last responsible moment when the actual root cause of an effect is identified.
IV. PROCEDURAL APPROACH OF ROOT CAUSE ANALYSIS
Step 1: Select tool:
After deciding the objectives select the most appropriate Root cause analysis tools/Methods
Step 2: Collect data:
Data shall be collected on the basis of:
a. How many readings do we need?
b. Over what period should we collect the data?
c. How should we stratify the data?
d. What sampling or measurement methods should we use?
e. Who should collect the data, when should they collect it and that process should they collect it from?
Step 3: Analyze data using Root cause analysis tools/Methods:
In this step, we analyze the data using the tool selected in Step 2.
Procedure of carry out Root Cause Analysis:
Root cause Analysis is asking why the problem occurs. And then continuing to ask why that happens until we
reach the fundamental process element that failed.
Step 4: Consider results & derive conclusions:
We shall consider the results of the previous step in conjunction with other information &experience and draw
conclusions.
Step 5: Act
In this step, we shall take some specific action.
Understood the situation for improvement of targets.
We shall identified the cause of a problem to counter measures for prevent re-occurrence.
Confirm the results & standardize.
Found dispute by inspection
Adjust the process to bring it within the control limits.
V. TOOLS/METHODS USED IN ROOT CAUSE ANALYSIS
Events and Causal Factor Charting
This is a complicated process that first identifies a sequence of events and aligns the events with the
conditions that caused them. These events and respective condition are aligned along a time line. Events and
conditions that have evidence are shown in a solid line but evidence is not listed; all other observations are
shown in dashed lines. After this representation of the problem is complete, an assessment is made by "walking"
the chart and asking if the problem would be different if the events or conditions were changed. This leads to
identifying causal factors such as training not adequate, management less than adequate, or barrier failed, which
are identified by evaluating a tree diagram. Events and Causal Factor Charting can provide the time line to help
discover the action causes, and is generally inefficient and ineffective because it mixes storytelling with
conditional causes, thus it produces complicated relationships that are not necessarily causal and this only serves
to add confusion rather than clarity. Instead of identifying the many causal relationships of a given event, events
and causal factor charting resorts to categorizing the important causes as causal factors, which are then
evaluated as solution candidates using the same method as the categorization schemes. Events and Causal Factor
Charting does not follow the principles of cause and effect.
Change Analysis
This is a six-step process that describes the event or problem, then describes the same situation without the
problem, compares the two situations, documents all the differences, analyzes the differences, and identifies the
consequences of the differences.The results of the change analysis identifies the cause of the change and will
frequently be tied to the passage of time and, therefore, easily fits into an events and causal factors chart,
showing when and what existed before, during, and after the change.Change analysis is nearly always used in
conjunction with another RCA method to provide a specific cause, not necessarily a root cause.Change Analysis
is a very good tool to help determine specific causes or causal elements, but it does not provide a clear
3. Root Cause Analysis – A Practice…
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understanding of the causal relationships of a given event. Unfortunately, many people who use this method
simply ask why the change occurred and fail to complete a comprehensive analysis.
Barrier Analysis
This incident analysis identifies barriers used to protect a target from harm and analyzes the event to see if
the barriers held, failed, or were compromised in some way by tracing the path to the threat from the harmful
action to the target.Barrier analysis can provide an excellent tool for determining where to start your root cause
analysis, but it is not a method for finding effective solutions because it does not identify why a barrier failed or
was missing. This is beyond the scope of the barrier analysis. To determine root causes, the findings of the
barrier analysis must be fed into a principle based method to discover why the barrier failed.
Storytelling
This is not really a root cause analysis method but is often passed off as one, so it is included for
completeness. It is the single most common incident investigation method and is used by nearly every business
and government entity. It typically uses predefined forms that include problem definition, a description of the
event, who made a mistake, and what is going to be done to prevent recurrence. There is often a short list of root
causes to choose from so a Pareto chart can be created to show where most problems originate.
Also known as the fill-out-a-form method, storytelling should never be used to find effective solutions. The
primary difficulty with this approach is that you are relying completely on the experience and judgment of the
report authors in assuring that the recommended solutions connect to the causes of the problems. Because they
do not know, let alone follow, the principles of causation, the authors often fail to find effective solutions.
The primary purpose of this method is to document the investigation findings and corrective actions. These
forms usually do a good job of capturing the what, when, and where of the event, but little or no analysis occurs.
Consequently, the corrective actions fail to prevent recurrence most of the time.
With such poor results, you might be wondering why organizations continue to use this method. The answer is
two fold. First, most organizations do not measure the effectiveness of their corrective actions, so they don’t
know they are ineffective. Second, there is a false belief that everyone is a good problem solver, and all they
need to do is document it on a form. For those organizations that recognize they are having repeat events, a
more detailed form is often created that forces the users to follow a specified line of questions with the belief
that an effective solution will emerge.
This is a false promise because the human thinking process cannot be reduced to a form. In our attempt to
standardize the thinking process, we restrict our thinking to a predefined set of causes and solutions. The form
tacitly signals the user to turn off their mind, fill in the blanks, and check the boxes. Because effective problem
solving has been short circuited, the reports are incomplete and the problems keep occurring.
Fault Tree Analysis
Fault Tree Analysis (FTA) is a quantitative causal diagram used to identify possible failures in a system. It
is a common engineering tool used in the design stages of a project and works well to identify possible causal
relationships.
It requires the use of specific data regarding known failure rates of components. Causal relationships can be
identified with "and" and "or" relationships or various combinations thereof.
It is not normally used as a root cause analysis method, primarily because it does not work well when human
actions are inserted as a cause. This is because the wide variance of possible human failure rates prevents
accurate results. But it works extremely well at defining engineered systems and can be used to supplement an
RCA in the following ways:
Finding causes by reviewing the assumptions and design decisions made during the system’s original
design.
Determining if certain causal scenarios are probable
4. Root Cause Analysis – A Practice…
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Failure Modes and Effect Analysis
Failure modes and effects analysis (FMEA) is similar to fault tree analysis in that it is primarily used in the
design of engineered systems rather than root cause analysis. Like the name implies, it identifies a component,
subjectively lists all the possible failures (modes) that could happen, and then makes an assessment of the
consequences (effect) of each failure. Sometimes a relative score is given to how critical the failure mode is to
the operability of the system or component. FMEA is sometimes used to find the cause of a component failure.
Like many of the other tools discussed herein, it can be used to help you find a causal element within a Reality
chart. However, it does not work well on systems or complex problems because it cannot show evidence-based
causal relationships beyond the specific failure mode being analyzed.
VI. DIAGRAM AND CHARTS USED IN ROOT CAUSE ANALYSIS
Pareto diagram
Description: a diagram which associated with undesirable events associated with items such as quality (c.g.
number of defects or non- conforming products), productivity, cost, safety and so on arc stratified according to
their causes or manifestations and plotted in order of importance.
Method of use: There may be a large number of undesirable phenomena or causes of trouble. The Pareto
diagram makes it easy to see which of these have the most serious effect on quality, productivity, cost, safety
etc., together with their relative proportions
Figure 1Example of Pareto diagram
Graphs
Description: Diagrams for plotting data and showing temporal changes, Statistical breakdowns and
relationships between different quantities.
Method of use: Used for organizing data. Use line graphs for showing time trends, bar graphs for comparing
quantities and pie charts for showing relative proportions
Figure 2 Examples of Graphs
Check sheets
Description: Forms specially prepared to enable data to be collected simply by making check marks.
Method of use: Used for tallying the occurrences of the defects or causes being addressed and graphing of
charting them directly.
Histograms
Description: Prepared by dividing the data range into subgroups and counting the number of points in each
subgroup. The number of points (the frequency) is then plotted as a height on the diagram.
Method of use: Prepare separate, stratified histograms for each of the 4Ms and examine the relationships
between tile shapes of the distributions and the specifications.
5. Root Cause Analysis – A Practice…
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Figure 3 Examples of Histograms
Scatter diagrams
Description: Prepared by plotting paired sets of data. If investigating dependence, set the independent
variable on the x-axis and the dependent variable on the y-axis.
Method of use: Collect paired sets of data on causes and effects and use scatter diagrams to check for correlation
between the sets of data.
Figure 4 Examples of Scatter diagrams
Control charts
Description: Prepared by plotting time along the horizontal axis and a characteristic value on the vertical
axis. Unlike line graphs they also show the control limit lines.
Method of use: Use to check whether there are too many chronic detects, too much variation, values lying
outside the control limits or undesirable trends or cycles. Control charts are used to assess whether a process is
stable and in-control; not whether it is in-spec.
Figure 5 Examples of Control charts
6. Root Cause Analysis – A Practice…
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VII. FISH BONE DIAGRAM –VERY COMMON TOOL USED IN ROOT CAUSE
ANALYSIS
How to Use the Fishbone Tool for Root Cause Analysis
Root cause analysis is a structured team process that assists in identifying underlying factors or causes of an
adverse event or near-miss. Understanding the contributing factors or causes of a system failure can help
develop actions that sustain the correction.
A cause and effect diagram, often called a ―fishbone‖ diagram, can help in brainstorming to identify possible
causes of a problem and in sorting ideas into useful categories. A fishbone diagram is a visual way to look at
cause and effect. It is a more structured approach than some other tools available for brainstorming causes of a
problem (e.g., the Five Whys tool). The problem or effect is displayed at the head or mouth of the fish. Possible
contributing causes are listed on the smaller ―bones‖ under various cause categories. A fishbone diagram can be
helpful in identifying possible causes for a problem that might not otherwise be considered by directing the team
to look at the categories and think of alternative causes. Include team members who have personal knowledge of
the processes and systems involved in the problem or event to be investigated.
Directions:
The team using the fishbone diagram tool should carry out the steps listed below.
● Agree on the problem statement (also referred to as the effect). This is written at the mouth of the ―fish.‖ Be as
clear and specific as you can about the problem. Beware of defining the problem in terms of a solution (e.g., we
need more of something).
● Agree on the major categories of causes of the problem (written as branches from the main arrow). Major
categories often include: equipment or supply factors, environmental factors, rules/policy/procedure factors, and
people/staff factors.
● Brainstorm all the possible causes of the problem. Ask ―Why does this happen?‖ As each idea is given, the
facilitator writes the causal factor as a branch from the appropriate category (places it on the fishbone diagram).
Causes can be written in several places if they relate to several categories.
● Again asks ―Why does this happen?‖ about each cause. Write sub-causes branching off the cause branches.
● Continues to ask ―Why?‖ and generate deeper levels of causes and continue organizing them under related
causes or categories. This will help you to identify and then address root causes to prevent future problems.
Tips:
● Use the fishbone diagram tool to keep the team focused on the causes of the problem, rather than the
symptoms.
● Consider drawing your fish on a flip chart or large dry erase board.
● Make sure to leave enough space between the major categories on the diagram so that you can add minor
detailed causes later.
● When you are brainstorming causes, consider having team members write each cause on sticky notes, going
around the group asking each person for one cause. Continue going through the rounds, getting more causes,
until all ideas are exhausted.
● Encourage each person to participate in the brainstorming activity and to voice their own opinions.
● Note that the ―five-whys‖ technique is often used in conjunction with the fishbone diagram – keep asking why
until you get to the root cause.
● To help identify the root causes from all the ideas generated, consider a multi-voting technique such as having
each team member identify the top three root causes. Ask each team member to place three tally marks or
colored sticky dots on the fishbone next to what they believe are the root causes that could potentially be
addressed.
The root causes of the event are the underlying process and system problems that allowed the
contributing factors to culminate in a harmful event. As this example illustrates, there can be more than one root
cause. Once you have identified root causes and contributing factors, you will then need to address each root
cause and contributing factor as appropriate. For additional guidance on following up on your fishbone diagram
findings, see the Guidance for Performing RCA with Performance Improvement Projects tool.
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Figure 6 Fishbone Diagram
VIII. CONCLUSION
To be effective, root cause analysis must be performed systematically, usually as part of an
investigation, with conclusions and root causes that are identified backed up by documented evidence.
Usually a team effort is required. Aiming performance improvement measures at root causes is more
effective than merely treating the symptoms of a problem. To be effective, RCA must be performed
systematically, with conclusions and causes backed up by documented evidence. There is usually more than
one root cause for any given problem. To be effective the analysis must establish all known causal
relationships between the root cause(s) and the defined problem
IX. Appendix
Root Cause Analysis Template
Root Cause Analysis for <Project name>
Section 1. Symptoms
In this section list all the points of pain that have led to this project request. Knowing this enables you and
your team to prioritize project goals and determine what the scope of the project will be given your time
limits, skills, and other relevant constraints.
A symptom is a point of pain for users.
List all the complaints from your team, clients, other users, and your own observations.
Do not include underlying system problems here—those go in the next section.
If your team is proposing a new system that is an opportunity to improve services or take advantage of
an opportunity to make money, then your symptoms should be what is lacking or a cause of
dissatisfaction with an existing system or a competitor.
Section 2. Problem Chain
In this section list all the problems associated with each of the symptoms above. A series of problems
underlying symptoms is called a problem chain.
List all the problems that are the likely cause of each of the symptoms above.
Symptom 1 Xxxxxxxxx
Problem a
Problem b
Problem c
Etc.
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List at least one underlying problem for each symptom.
Group symptoms when an underlying problem is the likely cause of several symptoms.
Symptom 1, Symptom 3 & Symptom 4
Problem b
Problem c
Problem f
NOTE: Remember to ask ―Why‖ after identifying each symptom. This will enable you to determine if there
is another symptom or if you have found the root cause.
Section 3. Root Cause(s)
List the major causes that underlie the problems above.
Depending on your situation there may be one or more root causes.
List all the root causes you consider viable as a basis for discussion with your clients
Section 4. Summary of Potential Solutions
List all potential solutions to the root cause, problems you identified in Section 3.
Will you be replacing a manual system with an automated system?
Will you create a new system?
Will you up-grade an existing system?
Section 5a.Your System Solution 1
For each potential solution listed in Section 4 make a bulleted list of the associated general objectives and
performance criteria. Whether you include constraints for each of your solutions, as shown belowor a
single final section on constraints depends on your situation. If the constraints apply to all of your
suggested solutions, the single section on constraints makes more sense than repeating the same constraints
for every single solution.
Objectives for Solution 1
Xxxxxxx
Xxxxxxxx
Xxxxxxxx
Etc.
Measurable Performance Criteria for Solution 1
Xxxxxxx
Xxxxxxxx
Xxxxxxxx
Etc.
Constraints for Solution 1
Xxxxxxx
Xxxxxxxx
Xxxxxxxx
Etc.
NOTE: Collaborate with your team to develop this list. Doing so should lead to a clear consensus about
the project scope. This will enable a clear understanding of the time and skill constraints associated with
your project.
Section 5b.Your System Solution 2 (if you suggest more than 1)
For your 2nd
potential solution, listed in Section 4, make a bulleted list of the objectives and measurable
performance criteria.
Objectives for Solution 2
Xxxxxxx
Xxxxxxxx
Etc.
Measurable Performance Criteria for Solution 2
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Xxxxxxx
Xxxxxxxx
Etc.
Constraints for Solution 2
Xxxxxxx
Xxxxxxxx
Etc.
NOTE: Again, collaborate with your team to develop this list.
Section 6. Constraints
Constraints will limit your scope. If they are different for each potential solution, then include your
constraints in each of the 5x sections. If they are the same for all solutions, list them here, rather than repeat
the same constraints in the above format.
Constraints for all Solutions
Xxxxxxx
Xxxxxxxx
Etc.
NOTE: Collaborating early and often with your team enables informed decision-making and sets
reasonable project expectations.
REFERENCES
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[2]. Scheinkopf, L. J. (1999). Thinking For A Change: Putting The TOC Thinking Processes to Use. Boca Raton, FL:St. Lucie press.
[3]. Sproull, B. (2001). Process Problem Solving: A Guide for Maintenance and Operations Teams. Portland: Productivity Press.
[4]. Wilson, P. F., Dell, L. D., & Anderson, G. F. (1993). Root Cause Analysis: A Tool for Total Quality Management. Milwaukee:
ASQC Quality Press.
[5]. Pasquarella, M., Mitchell, B., & Suerken, K. (1997). A Comparison on Thinking Processes and Total Quality Management
Tools. In 1997 APICS Constraints Management Proceedings: Make Common Sense: A Common Practice. Denver, CO: Falls
Church, VA: APICS, 59-65.