This is an older presentation that I gave at an ASQ, but the topic is just as valid today as it was yesterday. To reduce Ishikwawa Diagram user variability., contact as at www.taproot.com

1. 4/14/2011
1
A Family Secret: “The Un-
balanced Ishikawa Diagram”
Christopher Vallee
TapRooT® (System Improvements, Inc.)
2011 World Conference on Quality and
Improvement
Session M08
Objectives: Learn and have fun
1. Recognize that the limitations of the Ishikawa
(Fishbone) Diagram come from its users …
by that I mean us!
2. Learn ways to overcome the limitations that
we can use today after this lecture
3. Stop solving problems before we have the
facts

2. 4/14/2011
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Agenda: Learn and have fun
1. Review the secret and a few bad examples
2. Review the general guidelines that we all
learned and identify the current gaps in our
use
3. Learn some perspectives that you can use
today to standardize the process
4. See an alternative industry best practice
5. Questions and Answers
The Secret?
• Unbalanced “Completed” Ishikawa Diagrams
• Starving bone branches visible… other bones
well fed
• Starts with a blank tool and premature
problem scope
• An incomplete problem analysis
• Teach, use it and know this but never talk
about it

3. 4/14/2011
3
A website training example…
note: same type of training I received from another company
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
A website training example…
note: same type of training I received from another company
7 13
6
3
4
20
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html

4. 4/14/2011
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Is it just a training example? No
Reducing
Process
Wire Loss
Is it just a Training Example? No
Reduce
Package
Handling
Defects

5. 4/14/2011
5
Your Example?
Let’s share a few
examples from our own
Repertoire.
Just a Training Example? No
Where did the tool go wrong?
We might say that the wrong family of P’s, M’s or
other Evolved Family Categories were selected for
the industry being analyzed.
Quiz Time (Write Down your Answers; no looking around ☺)
1. What are the 4 M’s?
2. What are the 6 M’s?
3. What are the 8 P’s?
4. What are the 4 S’s?
5. What do you normally use?

6. 4/14/2011
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Were you close? Was I close?
1. 4 M’s: Machine, Method, Material, Man Power
2. 6 M’s: Machine, Method, Material, Man Power,
Money, Milieu (Environment)
3. 8 P’s: Product, Price, Place, Promotion, People,
Process, Physical Evidence, Productivity, and
Quality
4. 4 S’s: Surroundings, Suppliers, Systems, Skills
Where did the tool go wrong?
Quiz Time (A Group Discussion)
1. What goes under the “People” Category?
2. What goes under the “Method” Category?
Now a test on something we should all agree
on…
Point North with your left finger

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Where did we go wrong?
The Fishbone Diagram does not “go
wrong”…….
It starts out as a skeleton with no assumptions
or different frames of reference.
We as the Quality Improvement Facilitators
introduce the variability!
“Path and source of the variability”
It starts with the
Motivated Broke-
Fixer… Also known
as Quality
Assurance!
After all, you have to
be motivated to do
this job or just crazy!

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Curse of the Motivated Broke-Fixer
• Motivated to fix the problem…
• Takes Charge (no one else would)…
• Often recognized as the “fire fighter”…
• Fix is sometimes never implemented, short
lived or things get worse…
• Rest of the world says Quality Improvement
tools just do not work….
• Many Bosses yell at you….
• No more motivation to broke-fix or fix
anything!
“Path and source of the variability”
note: same type of training I received from another company
1. When to Use a Fishbone Diagram
• When identifying possible causes for a
problem
• Especially when a team’s thinking tends to
fall into ruts.
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html

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2. How to do make a Fishbone Diagram
• Agree on a problem statement (effect).
• Write it at the center right of the flipchart
or whiteboard.
• Draw a box around it and draw a
horizontal arrow running to it.
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
“Path and source of the variability”
note: same type of training I received from another company
3. Brainstorm the major categories of
causes of the problem.
• If this is difficult use generic headings:
–Methods, Machines (equipment), People
(manpower), Materials, Measurement,
Environment
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
“Path and source of the variability”
note: same type of training I received from another company

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4. As each idea is given, the facilitator
writes it as a branch from the
appropriate category.
• Again ask “why does this happen?” about each
cause.
• Write sub-causes branching off the causes.
Continue to ask “Why?” and generate deeper
levels of causes. Layers of branches indicate
causal relationships.
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
“Path and source of the variability”
note: same type of training I received from another company
Starting to see the Variability Source?
note: same type of training I received from another company
“Why does this happen?”
STOP… STOP... STOP… STOP… STOP… STOP
It is not how many Why’s you ask, but what you ask.

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Robust Root Causes/ Absent Best Practices
(Assumptions and “Best Guesses Need Not Apply)
• Who are the best problem solvers in the world?
• As problem solvers get more experience they
filter out what type of evidence to get to the true
problem?
• What happens when we brainstorm based on our
experience and frame of reference only?
What we have essentially done at this point
is fill in the blanks with our own frames of
reference…….
Sort of like giving everyone a blank ruler and
saying, “fill in your own notches and
numbers.”
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
“Path and source of the variability”
note: same type of training I received from another company

12. 4/14/2011
12
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
Reduce
Package
Handling
“Path and source of the variability”
note: same type of training I received from another company
http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html
Reduce
Package
Handling
We would not pass a
Measurement System Analysis
with our own tools.
“Path and source of the variability”
note: same type of training I received from another company

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1. Understand what really happened the day the
incident or defect occurred. (can not be done in
a Brainstorming Session).
2. Note: The original Fishbone Guidelines stated
to go investigate areas that we were not familiar
with, not ignore them.
3. Standardize the Fishbone Tool with set
definitions.
4. Force Improvement Facilitators to use more
than just their experience to troubleshoot the
defect.
There is still hope! How?
Observe and Map out the task or
process that needs to be analyzed
(Reactively or better yet, Proactively
before an Incident or Defect.)
Before you even start a Fishbone
Step 1: GOAL – Go Out And Look
(Brainstorming not allowed)

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Good, bad or ugly certain behaviors have to come
together to allow an Incident/Defect to occur or to
increase the probability of one to occur….
These ARE NOT ROOT CAUSES!
Before you even start a Fishbone
Step 2: Identify Equipment, People or
Process Behaviors (Brainstorming not
allowed)
Before you even start a Fishbone
Step 3: Determine a Standardized Set of
Fishbone Categories that can be used for all
industries and process (some suggestions
below)
Procedures Training
Work Direction Communications
Quality Control Human Engineering
Management Systems

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Starting a Fishbone
Step 4: Start your Fishbone Analysis looking
at only one behavior in question at a time.
NOT the larger defect!
For Example:
Lathe Operator used the incorrect
speed setting which caused the part
to overheat
Starting a Fishbone
Step 5: Have your expert for each category
ask detailed questions about the behavior in
question.
Procedures Training
Work Direction Communications
Quality Control Human Engineering
Management Systems

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Show of Hands in this Room
Who is an expert in each of the specific
categories?
Procedures Training
Work Direction Communications
Quality Control Human Engineering
Management Systems
Nobody raised their hand for all
categories; what now?
At this point, what have we accomplished?
1. Identified our limitations in the current use
of the Fishbone Diagram.
2. Started an analysis process based on
facts not assumptions or brainstorming
using GOAL.
3. Set Standardized Fishbone Category list
that can fit any process or industry.
Just these items alone can improve your
process immensely.

17. 4/14/2011
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Taking the Fishbone to the next level
…. A look at a multi-industry investigative
analysis tool that I integrate with my
previous quality training today.
Action 1 Action 3Action 2 IncidentError
You must clearly understand the sequence
of events that lead to an incident or defect.
TapRooT® Root Cause Analysis
What Happened? (The same as GOAL)

18. 4/14/2011
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What is a
Root Cause?
TapRooT® Root Cause Analysis
How an Error Causes an Incident or Defect
Hazard Target
Failed Safeguard
Error (Causal Factor)
Specific Root Causes
Generic Root Causes
TapRooT® Root Cause Analysis
Implementing good practices can stop or reduce error:
Good Procedures Good Training
Good Work Direction Good Communications
Good QC Good Human Engineering
Good Management Systems
The absence of best practices/EXPERTS leads to
human, equipment or process error.
Let’s look at the
TapRooT® model
for Procedures

19. 4/14/2011
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TapRooT® Root Cause Analysis
Definition of "Root Cause"
A Root Cause is the absence of best
practices or the failure to apply
knowledge that would have prevented
the problem.
TapRooT® Root Cause Analysis
Should Guide the Investigator just like any
other examining/measuring tool…
Successfully tested ideas:
1.Tree "Branching" Format…
2.Expert System to Guide Analysis…
3.Definitions in Dictionary…

20. 4/14/2011
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TapRooT® Root Cause Analysis
Result - A Root Cause Expert System
TapRooT® Root Cause Tree®
TapRooT® Root Cause Analysis
Result - A Root Cause Expert System
Question and Answers Session

21. 4/14/2011
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Take Home and Action Plan
No more Quality Family Secrets…
1. Share our lessons learned
2. Go Out And Look (GOAL) before we
troubleshoot
3. Dig into areas where there are fish bones
with nothing on them
4. Invite the missing experts to the table
when performing root cause analysis