Document text
Slide 1
Fishbone Diagram
Root cause analysis: [problem] · [Team] · [Date]
Edit: write the problem in the fish head first; then fill each bone with causes.
Slide 2
State the problem, then hunt for causes
Edit: one measurable problem per diagram. Blame processes, not people.
Problem statement What: [what went wrong] Where: [line, shop, team] When: [since date / how often] How much: [number, % or cost]
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Gather the right people
Everyone who touches the process, 5–8 people, 45 minutes.
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Brainstorm by category
Go bone by bone. Write every cause as a fact you could check.
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Ask why until it stops
Take the likeliest causes to the 5 Whys slide.
4
Check with data
Confirm the root cause with numbers before you fix anything.
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Slide 3
Fishbone diagram: 6M categories
Edit: 6M = People, Methods, Machines, Materials, Measurement, Environment. Rename bones that do not fit.
[Problem: what, where, how much]
People
[skill or training gap]
[workload, handover]
Methods
[unclear procedure]
[step skipped]
Machines
[breakdown, wear]
[wrong settings]
Materials
[supplier quality]
[wrong part, late]
Measurement
[no data or late data]
[gauge not calibrated]
Environment
[heat, noise, space]
[season, demand peak]
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Slide 4
Example: orders shipped late (fictional)
Edit: an invented example — replace it with your own causes or delete the slide.
12% of orders ship after the promised date
People
one packer per shift
new staff untrained
Methods
orders picked by arrival
no cut-off time
Machines
label printer jams
scanner battery dies
Materials
boxes run out Fridays
late supplier stock
Measurement
delays seen next day
no daily late report
Environment
holiday order peaks
small packing area
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Slide 5
5 Whys: from symptom to root cause
Edit: each answer becomes the next question. Stop when the answer is something you can fix.
Problem: [the symptom you see, with a number]
Why 1? Because [answer] [evidence: data, observation]
Why 2? Because [answer] [evidence: data, observation]
Why 3? Because [answer] [evidence: data, observation]
Why 4? Because [answer] [evidence: data, observation]
Why 5? Because [answer] [evidence: data, observation]
Root cause: [the cause that, once fixed, stops the problem coming back]
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Slide 6
Corrective action plan
Edit: one action per root cause; “how we check” says which number must change, and by when.
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