4 Examples of a Fishbone Diagram

John Spacey, March 05, 2018

A fishbone diagram is a visualization of the causes of a problem. As the term suggests, the diagram looks like a fishbone with each bone representing a category of root cause. This discourages the common tendency to assign a single root cause to problems that may have deeper causes such as a human error that could have been prevented with controls. The following are illustrative examples of a fishbone diagram.

Operations Outage

A production line goes down for three shifts due to a failed machine. A root cause analysis determines that the machine had multiple design issues. Such problems weren't detected or mitigated by maintenance processes. When the machine needed to be replaced, several issues complicated the process making the outage longer.

Service Outage

A software service experienced an outage after a bug that was missed in testing was launched to production. The procedures required to fix the problem did not go smoothly as backout procedures failed and developers had trouble accessing environments due to issues with security keys.

Quality Failure

A customer finds a problem with a product that had passed quality control. A quality assurance investigation reveals that a machine error caused the defect. Quality control tests and processes failed to detect the problem.

Security Incident

A worker loses a laptop filled with company data at a bar. The incident investigation discovers a lack of policy and procedure to prevent such problems. Root cause analysis also reveals technical shortcomings such as weak encryption, a poor password policy and lack of an audit trail for data.

Overview: Fishbone Diagram
Type	Problem Analysis
Definition	A visualization of the causes of a problem.
Also Known As	Ishikawa Diagram
Invented By	Kaoru Ishikawa
Related Concepts	Problem Analysis » Root Cause » Human Error » Internal Controls » Production Line » Root Cause Analysis »