Root Cause Analysis

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two pages should be prepared and included in the report to meet the
above stated purpose.

Transparency Tools


The following tools may be most effective for events that have many problems
and potentially many solutions.

Cause & Effect Analysis (Ishikawa or fishbone diagram)


Figure 14 : Cause and Effect Analysis Quick Facts

This basic tool displays the relationship between various factors that
contribute to a specific event. These factors are typically Methods, Materials,
Manpower and Machinery (but may also include Measurements and
Environment). Its applications include safety, quality systems, environmental,
product design, troubleshooting events. For the majority of problem solving
and troubleshooting events, this tool is too basic and not an efficient method
to get to the cause(s). It can help as pre-work, as a brainstorming tool to
develop causes for the fault or logic tree analysis methods.
An example of this tool is shown on Figure 15:

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