In this Episode of Safeti School, we follow from the previous show with another method of problem-solving, the Fishbone Diagram. This is another way to get your team together to use your combined knowledge of your business and it processes, to find the root causes of an event.
As mentioned in the last episode, the Fishbone Diagram, otherwise known as Cause and Effect Analysis or the Ishikawa Diagram, can be used as a bolt-on to the 5 Whys method. It can help you identify specific areas of focus that are relevant to your business, enabling you to find the root causes of an accident or incident.
Want to read? Please scroll down for the transcript version of this podcast if you’d prefer to read today or just use it as a reference when listening to the audio!
Additional ResourcesFishbone Diagram Example: download this simple example below to help you understand the Fishbone investigation process.
Similar Episodes: 5 Whys to the Root Cause, Hierarchy of Control – 5 key pillars to manage risk, What is Risk Assessment?
Safeti School: for more free, educational HSE content visit the Safeti School podcast page
How to do a Fishbone Diagram - TranscriptWelcome to Safeti school where we crunch down health safety and environment learning into simple bite-size snippets that you can use for your business or your career. Helping you improve your knowledge, boost your performance and maybe even providing some inspiration.Let's get started. In this episode of Safeti School.
We're going to take a look at another method that’s used for root cause analysis following on from a previous episode on the five ways tool.We're going to take a look at the fishbone diagram method. Otherwise known as cause and effect, Ishikawa or sometimes known as the 6m methodology.
So as I was saying in the five whys episode, this tool can actually be used if you're finding that there's not enough detail in the five whys method. You can use this tool as a bit of a bolt on and actually to add on top of the five whys to give you more structure around trying to find that root cause and to help you instigate ideas within your team as to what alternatives for causation there might be.
How to Structure a Fishbone DiagramYou'll see as we talk through it and put I’ll put a resource in the links for you to look at just as a visual representation as to how this thing is structured. Or how you can structure it can be done in slight variations.
It sort of follows the same set of rules as you're using it.It's more structured maybe than the five whys process would be in helping you identify underlying factors or causes of an adverse event or a near-miss if you want to investigate those as well. Understanding the contributing factors or the causes of the failure.
As I said in the last episode of five whys, helps you develop the actions that sustain an ongoing, improvement or correction to risk within your business.
It can be really useful and this cause and effect or fishbone diagram can really help with you brainstorming to identify the possible causes of the problem. Sometimes more so than the 5 whys method might as I was saying before regarding the 5 whys you really need to know that the people that are doing it understand the processes and the procedures and they activities in depth. So they can really pull out the relevant data.
The fishbone diagram is useful for this because it gives you a visual way to look at the potential causes and it's a structured approach that the 5 why tool doesn't really have and as you'll see in the diagram that I've used as an example the main problem or the problem statement or what we would class as the effect here in this analysis is actually at the head or mouth of the fish on the diagram.
Leading on from the head of the fish then you have various cause categories which you determine to be,you know,whatever suitable for your investigation relevant to your organization or the part of the business that you're looking at.
There's plenty of examples of typical categories that people would use to make up the rest of the body of the fish to give you those triggers to look into the issues in more detail, a good example as the one I've shown is to use half of it for the material elements and the other half for the human related elements and you can split those up as I've done on the diagram example. And that gives you good categorisations that you can then work from get your mind thinking about what particular elements of the problem or the accident or incident that relate to each of those specific areas.
From those main categories, then you would put in the smaller bones of the fish which are really acting like the branches on the five whys diagram and that is just digging deeper into each of those categories that have chosen and following and the links of information and facts that are related to the issue or problem that we're discussing.
Steps to Complete Fishbone DiagramOkay. So let's walk through those steps down in terms of actually filling out the information on a fish bone diagram.
So first of all, as I was saying you agree your problem statement make sure everybody's in agreement with it and put it at the mouth of the fish as you see in the example that we given this could be otherwise known as the effect and be as clear and specific as you can about that problem and make sure everybody is in agreement with it. It should be really a statement of fact or you know the outcome of whatever it is you're investigating.
Then of course as I said earlier, you must agree on the major categories of the causes within your particular context and these will form the the bones of the main bones of your fish branching off from the main body.
Examples of those as I've already discussed can be things like machinery and equipment, environmental factors, management methods, your people and your staff as I was saying,it's good to sometimes split.these are between materials and human factors to make things easier when you're when you're looking in the health and safety context. Certainly that makes it a bit easier to distinguish what exactly you're dealing with.
Then after you have got to that point.you want to start brainstorming around all the causes that are coming from each of the categories.
So asking as you would in a 5y investigation,why did/does this happen as each idea is given or received from the group. Then whoever is facilitating the conversation will put the causal factors on to the appropriate branch or bone. And from that there you can dig deeper and just really use as you would with the five why, a series of questions to dig deeper in to the data, the facts and the information that are relative to the case.
You’ll want to just continue that same process over and over again for each of your categories getting into all the details necessary for each element and getting all of your group involved. As you can imagine you end up with quite a lot of information in many circumstances when you're using this strategy.
And as I was saying previously, if you're using a five whys tool and you find that you're not getting to the root causes or you're not able to get the correct or relevant detail out of your investigation.Then the fishbone diagrams are really great way of helping you channel into the areas that you need to look at and then you can use a data from it to carry out of five why in the correct direction and get to that root cause.
Some Things to RememberA few more things to remember there is firstly just to ensure that your team is focusing on the causes of the problem rather than the symptoms and you can use imagery or drawing your fish on a flip chart. Somewhere everyone can see it and it's nice and visible to create discussion.
The flip chart or a large white board can be good to give you lots of space to make sure you're going deep in detail for each element and getting as much information as you can.
When you are brainstorming the causes you might want to consider having your team members just writing each of the causes on sticky notes and going around asking each person for a cause and getting everyone to contribute for each of the categories until all the ideas from the group are provided.
Just ensure that everybody is getting their turn and you're not missing any critical information.
It is really about participation when it comes to this activity and going back to what we said about the five ways to before, it's really important to tap into that knowledge and competence within your organization.
Make sure that the right people are voicing their opinions where possible. Finally, once you have all your information depicted on your diagram,you're going to want to identify what your main root causes might be.
So you may want to consider doing some sort of a voting technique amongst your team's totry and get the opinions of all those involved as to what your top three root causes may be regarding your particular incident. You'll want to ask each team member to feed into that process and then from that you'll be able to identify where your priority lies in terms of action.
Just remember that the root causes of your event are the underlying process and systemic issues that ultimately, over time,culminate and contribute to a harmful event and using these strategies and investigation practices is a great way to get it to the depth of detail that you needto get to, to make sustainable improvements going forward.
That's it for the Fishbone Diagram summary!That's it for this episode of Safeti School.We hope this was helpful.If so,please remember to rate, review and subscribe to this podcast on iTunes, Google podcasts or Spotify and remember for more health safety and environment help, you can visit us at safeti.com. Until next time, take care.
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