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FN: 04-FIVE WHYS_FISHBONE v2:4-1Measure mentEvaluati on and Prioritiz ationIssue AnalysisTraining for Consultants Unit 4 Five Why’s Analysis and Fishbone DiagramsFN: 04-FIVE WHYS_FISHBONE v2:4-2Introduction to Five Why’s Analysis•The Five Why’s process is designed to flush out root causes of a particular issue or problem by asking a series of “Why” questions. •By turning the problem or issue into a “Why” question and asking “Why” to each of the answers, the root cause will eventually be discovered. Each time the question is asked, the answers will become more narrowed and focused until the question cannot be answered, indicating that a root cause has been found.•It should take a maximum of five levels of “Why” questions to reach the root causes of any particular problem or issue.FN: 04-FIVE WHYS_FISHBONE v2:4-3Steps for Conducting Five Why’s Analysis 1.To begin the process, the current issue or problem will need to changed into a “Why” Question.•Issue: Sales are down 20% from last year. •Why Question: Why are sales down 20% from last year?2.This first Question will start the process and may result in a number of reasons being discovered. Each of these reasons will then start the process again. •Why Question: Why are sales down 20% from last year? •Answer #1: We lost a key customer to a competitor. •Answer #2: We were late shipping a product at year end. •Answer #3: We cut back on the number of distributors by 5%.3.Each of the answers above will need to be turned into a Why Question and the chain continued. Take each answer individually and continue to turn the answer into subsequent “Why Questions” until the question cannot be answered or the answer is outside the control of the company. At that point you will have identified the root cause that needs to be addressed. •Why Question: Why did we lose the customer to a competitor? •Answer #1: Our competitors are offering sales promotions. •Answer #2: Our product did not meet their needs.FN: 04-FIVE WHYS_FISHBONE v2:4-4Steps for Conducting Five Why’s Analysis (cont) 4.Once all the questions are answered, compile a list of all the different root causes and categorize them into logical groups. 5.Determine which of the issues to tackle first by selecting the root causes that seem the most important (pick 10 or fewer).FN: 04-FIVE WHYS_FISHBONE v2:4-5Tips for Using Five Why’s Analysis1. You may need to ask the “Why” question up to five times before a Root Cause is identified. Many problems, however, may not need that many levels before the Root Cause is identified. 2. Make sure to keep track of the questions being asked as you work through the various levels of questions. 3. Try to follow one line of questioning through to completion, then back up and tackle questions at higher levels that have not been explored. FN: 04-FIVE WHYS_FISHBONE v2:4-6Introduction to Fishbone Diagramming•Fishbone diagrams are a tool used to sort out the relationships between the root causes and their effects that pertain to a given problem.•A fishbone diagram provides a graphic representation of the cause- effect relationships of various factors.•A fishbone diagram allows the team to consider all the factors that may lead to a particular problem before narrowing the factors down to the ones that seem the most critical or important.FN: 04-FIVE WHYS_FISHBONE v2:4-7Lack of application of safety proceduresLack of trainingLack of knowledgeLack of operating proceduresLack of awareness of trip buttonsLack of induction procedures Control of working proceduresConsistent approach to reaction to fault/ mitigation of fault Retraining of operatorsWorking ProceduresTakeover proceduresLack of diagnosticsReview interface issuesLack of involvement of maintenance/op sLack of documentationWeak control of contractors/spe c of equipmentLack of knowledgeDesign of EquipmentPower InterruptionsOperationLimits of boiler operationEquipment2nd hand equipment (QC checks)Effective commissioning procedures/acceptable testsRoot cause analysis of previous incidentsWrong control settings (review of procedures)Planned MaintenanceInspections and testingEquipment history databaseLack of consistent proceduresApproach (Planning) ProceduresProject Management Procedures (identify design problems)Fishbone Diagram ExampleFN: 04-FIVE WHYS_FISHBONE v2:4-8Steps for Creating a Fishbone DiagramTo Identify CausesStep 3: Organize the causes Once various causes have been listed (at least 15~20), apply a technique such as affinity diagramming to group them.Step 2: Explore all potential causes By brainstorming, etc, hypothesize all possible causes for the problem. Put them on post-its.Step 1: Identify the issue When seeking causes: Write the negative phenomenon in the box.IssueIssueIdentify the issueUse an arrowCausesThe 2nd thickest lineThe direction of the arrow of the small bone parallels the big boneSmall boneGrand child bone Medium boneSmall boneGrand childbon。