Cause and Effect

Analysis:
1. Fishbone Diagram
2. Cause and Effect Matrix

1
 Cause and Effect Analysis

Learning Objectives
 Define the relationship between Cause and
Effect
 Explain use and construction of:
 Fishbone Diagram
 Guidelines for Brainstorming
 Cause and Effect Matrix
 Learn how to integrate Fishbone Diagram and
Cause & Effect Matrix into your Company
SOPs

2
 Cause and Effect Analysis

What do you mean by “ Cause & Effect”?

A PROBLEM WHICH A POTENTIAL

HAS OCCURED FUTURE PROBLEM

(FMEA)

CAUSE EFFECT CAUSE EFFECT

Events/conditions Symptoms that Events/conditions Symptoms that
that led to provide evidence that would lead to would result
the problem of the problem the problem from the problem

Dave Wessel, “An Ounce of Prevention”, Quality Progress, Dec, 1998

3
 Cause and Effect Analysis

Cause - Effect Relationship

A PROBLEM WHICH
HAS OCCURED

CAUSE EFFECT
Events/conditions Symptoms that
that led to provide evidence
the problem of the problem

ACTION
Dave Wessel, “An Ounce of Prevention”, Quality Progress, Dec, 1998
4
Fishbone
Diagram

5
 Cause and Effect Analysis

What is a Fishbone Diagram?

A visual tool used to identify, explore and
graphically display all the possible causes related
to a problem to discover root causes.

A Fishbone diagram is also known as a Cause

and Effect Diagram or Ishikawa Diagram.
C/N/X
Materials Methods

C C

N N
Problem/
Desired
Improvement
N N
N
C
C
C

Machinery Manpower

6
 Cause and Effect Analysis

Dr Kaoru Ishikawa
 Quality control statistician
 Professor in University of Tokyo
 One of the pioneers of Japan’s quality
revolution in the 1940s
 Played major role in growth of QC
circles
 Best known for formalizing use of
Cause-and-Effect Diagram
 Won the Deming Prize and Shewhart
Medal
 ASQ established the Ishikawa Medal to
recognize the human side of quality
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 Cause and Effect Analysis

Why Use Fishbone Diagrams?

 To discover the most probable causes to a
problem (or effect)
– Sometimes, the effect can be a desirable effect.
– When something desirable has happened, it is
useful to find out what caused it so that you can
make it happen again

 To visual possible relationships between causes

for a given problem under investigation

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 Cause and Effect Analysis

Constructing a Fishbone Diagram

1. Establish what the problem (effect) is
 It must be stated in clear and concise terms,
agreed by everyone.
2. Write the effect on the head of the fish
3. Decide the major categories of causes
 Brainstorming
 Use standard categories such as 5M+E
(Machines, Materials, Methods, Manpower,
Measurement & Environment)
 Use major steps in the process if the effect is
resulted from a recognizable process
• See example????

Let’s create a Fishbone Diagram using Minitab

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 Cause and Effect Analysis

Constructing a Fishbone Diagram

Stat Quality Tools Cause-and-Effect

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 Cause and Effect Analysis
Constructing a Fishbone Diagram
Fishbone Diagram for Surface Flaws

Measurements Materials Man

List specific
causes in each
category

Surface Flaws

Problem (effect)
Environment Methods Machines
at the “head of
the fish”

Major categories of causes

(or sometimes call major bones)

Why do we need to group the causes?

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 Cause and Effect Analysis

Constructing a Fishbone Diagram

4. Identify possible causes through Brainstorming
• Identify specific causes within each major category that
may be affecting the problem.

Fishbone Diagram for Surface Flaws

Measurements Materials Personnel

3. Continue Micrometers
Calibration Method
2. Repeat this
Alloys Shifts
asking: „Why is Calibration Interval procedure with each
Precision
this happening?‟ Accuracy Lubricants Supervisors specific cause to
until you no produce sub-causes.
Microscopes Suppliers Training
longer get useful
information. Inspectors Operators

Surface Flaws
Machine feedrate
Speed
Machine rpm

Brake Lathes
Brand of bit
Condensation Engager Bits
Size of bit
1. The team should ask :
Moisture% Angle Sockets
„What are the machine
Environment Methods Machines issues affecting/causing
the problem?‟

When do we know we have reached the root cause ?

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 Cause and Effect Analysis

Analyzing a Fishbone Diagram

5. When brainstorming session is completed, every
cause should be labeled as either a “C”, “N” or “X”.

C variables that must be held as constant as possible

and require standard operating procedures to insure
consistency

N variables that are noise or uncontrolled variables and

cannot be cheaply/easily held constant

X variables considered to be KPIVs and need to be

experimented to determine what influence each has
on the output and what their optimal settings should
be to achieve customer-desired performance

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 Cause and Effect Analysis

Analyzing a Fishbone Diagram

6. The team should analyze and zoom in those
“most likely causes”.

Helpful Hint
Look out for causes that appear in more than one
category. They may be the “most likely causes”.

7. The most likely causes should be prioritized

for further investigation.

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 Cause and Effect Analysis
Integrating Fishbone Diagram into SOPs
Example of how fishbone diagram can be used in SCAR.
Section of SCAR Procedure
Received Generate
complaint/reject report for
Fishbone diagram can be from customer, in- management
used here to brainstorm/ house or supplier. review
identify root causes
QA personnel verify
the defects. Follow up on
CAR

Issue CAR to
production. -receive CAR
reply from
production
- reply to
customer
Purge in-house
stock

Hold meeting with

relevant
1. Fishbone diagram can be used here to departments (if
Should also brainstorm/ identify root causes. necessary)
update Fishbone 2. To prioritize and work on most likely
diagram causes.
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 Cause and Effect Analysis
Integrating Fishbone Diagram into SOPs
Example of how fishbone diagram can be used in SPC control

Section of SPC Control Procedure

5.4.2.4 It is the responsibility of the EA of CMM section to set-up the trend-tests for
out-of-control in the "SPC" software.
5.4.2.5 The E.A/Supervisor of the 'CMM' section shall monitor the X-R Charts on the
computer and look-out for out-of-control situation. When out-of-control is detected,
he shall analyse the subgroup data, the histogram and the prevailing Cpk value,
based on these he shall decide the action to take. When the situation necessitates,
a "PCAR" shall be issued to the Production E.A/Supervisor.
5.4.2.6 The Production Supervisor/E.A shall analyze the problem and take corrective
actions on the process concerned, after which, new samples shall be submitted
for measurement. When the problem has been rectified, Production Supervisor/EA
shall write in the "PCAR" form, the corrective actions taken and return the form to
the E.A or Supervisor of "CMM" section.

Fishbone diagram can be used here to

brainstorm/ identify root causes

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 Cause and Effect Analysis
Link Tools Integration Tasks to Work
Breakdown Structure
The effort to integrate Fishbone Diagram into
SPC and SCAR procedures should be translated
into specific tasks in the Work Breakdown
Structure.
S/N Tasks Task Owner Target Specific Training Core Team Internal Verified Group Phase
Completion Date needed for Task Member In Date End Date
Owner/ Date Charge

Group 1 Tools
1 SPC
Integrate Fishbone James 10-Dec-01 Fishbone Diagram Nick 15-Dec-01 31-Dec-01
Diagram in the SPC -15 Oct 2001
procedure/system
2 SCAR
Integrate Fishbone Harry 10-Dec-01 Fishbone Diagram Nick 15-Dec-01 31-Dec-01
Diagram in the SCAR - 15 Oct 2001
procedure/system

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Cause & Effect
Matrix

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 Cause and Effect Analysis

Cause and Effect Matrix

Cause and Effect
Matrix
Rating of
Importance to
Customer
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement

Requirement
Total

Process Step Process Input

1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 0
10 0
11 0
12 0
13 0
14 0
15 0
16 0
17 0
18 0
19 0
20 0
0
0

0
Total
Lower Spec
Target
Upper Spec

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 Cause and Effect Analysis

Description: Cause and Effects Matrix

 Simple QFD (Quality Function Deployment) matrix.
 Used to relate and prioritize X’s to customer Y’s through
numerical ranking using the process map as the
primary source.
 Y’s are scored as importance to the customer
 X’s are scored as to relationship to outputs

Results
 Pareto of Key Inputs to evaluate in the FMEA and Control Plans
 Input into the Capability Study
 Input into the initial evaluation of the Process Control Plan

 This is the team’s first stab at determining Y = f(X)

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 Cause and Effect Analysis

Constructing a Cause & Effect Matrix

1. List key outputs (Y‟s)

Cause and Effect

Matrix

Rating of
Importance
to Customer
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Homogeneity

Temperature
Consistency
Cleanliness
Viscosity
Gel Time

Solids
Color

Process Inputs Total

1 0
2 0
3 0
4 0
5 0
6 0
7 0

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 Cause and Effect Analysis

Constructing a Cause & Effect Matrix

2. Rank Y‟s with respect to customer importance

Cause and Effect

Matrix

Rating of
Importance to 9 9 7 10 10 9 3 2 6
Customer
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Homogeneity

Temperature
Consistency

Digets Time
Cleanliness
Gel Time

Viscosity

Solids
Color

Process Inputs Total

1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
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 Cause and Effect Analysis

Constructing a Cause & Effect Matrix

3. List key inputs (X‟s)
Rating of
Importance to 9 9 7 10 10 9 3 2 6
Customer
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Homogeneity
Input

Temperature
Consistency

Digets Time
Cleanliness
Gel Time

Viscosity
Variables

Solids
Color
Process Inputs Total

Scales
1 0
Accuracy
Preheating
2 0
DICY TK
DMF Load
3 0
Accuracy
DMF
4 0
Cleanliness
DMF Raw
5 0
Materials
DICY Load
6 0
Accuracy
DICY Envir.
7 0
Factors
DICY Raw
8 0
Materials
DICY Mixer
9 0
Speecd

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 Cause and Effect Analysis

Constructing a Cause & Effect Matrix

 You are ready to correlate customer
requirements to the process input variables

 Avoid confusion and inconsistency by

establishing scoring criteria:
0 = no correlation
1 = the process effect only remotely affects the
customer requirement
4 = The input variable has a moderate effect on
the customer requirement
9 = The input variable has a direct and strong
effect on the customer requirements
Note: Not recommended to use more than 5 different criteria.
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 Cause and Effect Analysis

Constructing a Cause & Effect Matrix

4. Relate X‟s to Y‟s
Rating of
Importance to 9 9 9 10 10 9 2 2 6
Customer
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Homogeneity

Temperature
Consistency

Digets Time
Cleanliness
X‟s
Viscosity
Gel Time

Y‟s

Solids
Color
Process Inputs Total

Scales
1 9 9 3 1 1 9 1 1 9 348
Accuracy
Preheating
2 1 1 1 1 1 1 1 1 1 66
DICY TK
DMF Load
3 3 9 1 1 1 9 1 3 9 255
Accuracy
DMF
4 1 1 5 1 1 1 1 1 1 102
Cleanliness
DMF Raw
5 1 1 1 1 1 1 1 1 1 66
Materials
DICY Load
6 9 9 1 1 1 9 1 1 1 282
Accuracy
DICY Envir.
7 9 5 3 1 1 9 1 1 1 247
Factors
DICY Raw
8 8 5 1 1 1 9 1 1 2 242
Materials
DICY Mixer
9 1 1 1 1 7 1 1 1 1 126
Speecd

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 Cause and Effect Analysis

Constructing a Cause & Effect Matrix

5. Cross-multiply and add
Rating of
Importance to 9 9 9 10 10 9 2 2 6
Customer
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Homogeneity

Temperature
Consistency

Digets Time
Cleanliness
Viscosity
Gel Time

Solids
Color
Process Inputs Total

Scales
1 9 9 3 1 1 9 1 1 9 348
Accuracy
Preheating
2 1 1 1 1 1 1 1 1 1 66
DICY TK
DMF Load
3 3 9 1 1 1 9 1 3 9 255
Accuracy Key inputs are now
DMF
4
Cleanliness
1 1 5 1 1 1 1 1 ranked
1 in importance 102

5
DMF Raw
1 1 1 1 1 1 1 1 with
1 respect to the 66
Materials
6
DICY Load
9 9 1 1 1 9 1 1
key
1
outputs 282
Accuracy
DICY Envir.
7

8
Factors
DICY Raw
Materials
9

8
5

5
3

1
1

1
1

1
9

9
1

1
1

1
1

2
So?? 247

242

DICY Mixer
9 1 1 1 1 7 1 1 1 1 126
Speecd

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 Cause and Effect Analysis
How Cause & Effect can Fit into Process
Improvement Activities
C&E Matrix
The Big Picture Rating of
Importance to
Customer
9

1
9

2
7

3
10

4
10

5
9

6
3

7
2

8
6

9 10 11 12 13 14 15

Homogeneity

Consistency

Temperature
Digets Time
Cleanliness
V iscosity
Gel Time

S olids
Color
Process Inputs Total

Scales
1 9 8 2 1 1 9 1 1 8 321
Accuracy
Preheating
2 1 1 1 1 1 1 1 1 1 65
DICY TK
DMF Load
3 3 8 1 1 1 8 1 3 8 255
Accuracy
DMF
4 1 1 4 2 1 2 1 1 1 105
Cleanliness
DMF Raw
5 1 1 1 1 1 2 1 1 1 74
Materials
DICY Load
6 9 7 1 1 1 9 1 1 2 269
Accuracy
DICY Envir.
7 8 5 3 1 1 8 1 1 2 247
Factors
DICY Raw
8 8 5 1 1 1 9 1 1 2 242
Materials
DICY Mixer
9 1 1 1 1 7 1 1 1 1 125
Speecd

Capability Summary Control Plan Summary

Operational Excellence
Control Plan
Key Process Output Variable

FMEA
Product: Core Team: Date (Orig):
Key Contact:
Capability Status Sheet Phone: Date (Rev):

Upper Lower Process

Measurement %R&R Sample Sample Control
Customer Requirement Measurement %R&R or P/T Sample Process Process Step Input Output Specification (LSL, Cpk /Date Reaction Plan
Spec Target Spec Cp Cpk Date Actions Technique P/T Size Frequency Method
(Output Variable) Technique Ratio Size USL, Target)
Limit Limit
Gel Time DICY Turn Steam on Scales
Viscosity Accuracy

Cleanliness Process/Product DMF Load DMF DMF Load

Color Failure Modes and Effects Analysis Accuracy
Homogeneity DMF Load DMF DMF
Consistency (FMEA) Cleanliness
Digets Time DICY Envir.
DICY Load DICY
Temperature Factors
Solids Process or DICY Load
Prepared by: DICY Load DICY
Product Name: Accuracy

DICY Load DICY DICY Raw

Responsible: FMEA Date (Orig) ______________ (Rev) _____________ Materials

DICY Load DICY DICY Mixer

Speecd

DMF Load DMF DMF Raw

The Key Outputs are

Materials
Process S O D R
Step/Part E C E P DICY Turn Steam on Preheating
Number Potential Failure Mode Potential Failure Effects Potential Causes Current Controls DICY TK
V C T N
Spin Draw Fiber Breakouts Undersized package, High SD Dirty Spinneret Visual Detection of Wraps and
Process panel-hours lost 2 8 broken Filaments 9 144

evaluated ability to meet 5

Filament motion
2
Visual Sight-glass
8 80

The Key Inputs are Polymer defects Fuzzball Light

customer spec.
8 2 9 144

evaluated for process

0

Key Inputs are explored while evaluating control

process for potential failure

27
 Cause and Effect Analysis
Integrating Cause & Effect Matrix into SOPs
Example of how Cause and Effect Matrix can be used in SCAR.
Section of SCAR Procedure Received Generate
complaint/reject report for
Cause and Effect Matrix can be
from customer, in- management
used in conjunction with fishbone
house or supplier. review
diagram to identify, rank and
prioritize the key causes.
QA personnel verify
the defects. Follow up on
CAR

Issue CAR to
-receive CAR
production.
reply from
production
- reply to
Purge in-house customer
stock

Hold meeting with

Cause and Effect Matrix can be relevant
used in conjunction with fishbone departments (if
diagram to identify, rank and necessary)
prioritize the key causes.
28
 Cause and Effect Analysis
Integrating Cause & Effect Matrix into SOPs
Example of how Cause & Effect Matrix can be used in SPC control

Section of SPC Control Procedure

5.4.2.4 It is the responsibility of the EA of CMM section to set-up the trend-tests for
out-of-control in the "SPC" software.
5.4.2.5 The E.A/Supervisor of the 'CMM' section shall monitor the X-R Charts on the
computer and look-out for out-of-control situation. When out-of-control is detected,
he shall analyse the subgroup data, the histogram and the prevailing Cpk value,
based on these he shall decide the action to take. When the situation necessitates,
a "PCAR" shall be issued to the Production E.A/Supervisor.
5.4.2.6 The Production Supervisor/E.A shall analyze the problem and take corrective
actions on the process concerned, after which, new samples shall be submitted
for measurement. When the problem has been rectified, Production Supervisor/EA
shall write in the "PCAR" form, the corrective actions taken and return the form to
the E.A or Supervisor of "CMM" section.

Cause and Effect Matrix can be

used in conjunction with fishbone
diagram to identify, rank and
prioritize the key causes.

29
 Cause and Effect Analysis

Link Tools Integration Tasks to Work

Breakdown Structure
The effort to integrate Cause & Effect Matrix into
SPC and SCAR procedures should be translated
into specific tasks in the Work Breakdown
Structure.
S/N Tasks Task Owner Target Specific Training Core Team Internal Verified Group Phase
Completion Date needed for Task Member In Date End Date
Owner/ Date Charge

Group 1 Tools
1 SPC
Integrate Cause and Dick 10-Dec-01 Fishbone Diagram Nick 15-Dec-01 31-Dec-01
Effect Matrix in the -15 Oct 2001
SPC procedure/ system Cause & Effect
Matrix
-15 Oct 2001
2 SCAR
Integrate Cause and Mary 10-Dec-01 Fishbone Diagram Nick 15-Dec-01 31-Dec-01
Effect Matrix in the -15 Oct 2001
SCAR procedure/ Cause & Effect
system Matrix
-15 Oct 2001

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 Cause and Effect Analysis

End of Topic
Any question?

31
 Cause and Effect Analysis
Product/Manufacturing Example

Measurement Machine Material

Ÿ Slurry Type (C)

Ÿ Settling of Slurry Ÿ Program used (N)
Ÿ Substrate (C)
Particles (C) Ÿ Skew (N)
Ÿ Tape Type (C)
Ÿ Slurry Flow Rate (C) Ÿ PU Pad (C)
Ÿ Surfactant Type (C)
Ÿ Ra (C) Ÿ Sonic power (C)
Ÿ PU Pad (C)
Ÿ Line Density (C) Ÿ Texture
Ÿ Texture Temperature (C)
Temperature (C) Ÿ Calibration (N)

NLA
Ÿ Settling of Particles (C)
Ÿ Slurry Stirring Procedures (C) Ÿ Slurry Stirring Procedure (C)
Ÿ Program used (N) Ÿ Soak Time (C)
Ÿ Speed Adjustment (C) Ÿ Stagging Time (N)
Ÿ Ultrasonic on/off (C) Ÿ Transfer Time (C)
Ÿ Soak Time (C) Ÿ Compliance to Procedures (C)
Ÿ Stagging Time (N)
Ÿ Transfer Time (C)
Ÿ Texture Temperature (C)
Ÿ Concentration of Chemica (C)
Ÿ Tape Speed (C)
Method Ÿ Slurry Flow Rate (C) Man
Ÿ Texture Pressure (C)

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 Cause and Effect Analysis
Transactional Example

Estimated Ship Date Change - CAUSE & EFFECT / FISHBONE

MDC MDC WCSC
SCHEDULE
PRACTICES CAPACITY PRACTICES
CHANGES

- Unrealistic
- B.O.. Consol. Del. Req
- Firm - SC late - Receiving Dates
ORDER
- Planned - Picking - Customer Order
CANCELLATION
- PC delays Priority Changes
- Off shift support

Estimated
Ship Date
- Bad IT days Changes
- Table Maint.
- Waiting for PLANNED - No Delivery Constraints
Delivery Appt. SHIP DATE After initial PSD
- Availability ALGORITHM - Back Ord. Release Logic
IN Overrides - Cust Priority vs. availability
TRANSIT - No Stocks -Future orders at AP
TIMES - Late PT print
- Late EDI data

INVENTORY APPOINTMENT LDSS ESD

ACCURACY CUSTOMER ALGORITHM
ANOMALIES

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 Brainstorming
? ?
? A technique to
? generate a large
number of ideas or
?
possibilities in a
?
relatively short time
frame.

Why Use Brainstorming?

• A tool for the Team (not individual)
• A method to generate a lot of ideas
• Two persons’ knowledge and ideas are
always more than an individual’s
• Input for other C&E tools
• Active participation
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 Cause and Effect Analysis
How to Conduct a Brainstorming Session
Team Makeup
 Experts
 “Semi” experts
 Implementers
 Analysts
 Technical staff who will run the experiment
 Operators
Discussion Rules
 Suspend judgement
 Strive for quantity
 Generate wild ideas
 Build on the ideas of others

Leader‟s rules for Brainstorming

 Be enthusiastic
 Capture all the ideas
 Make sure you have a good skills mix
 Push for quantity
 Strictly enforce the rules
 Keep intensity high
 Get participation from everybody
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 Cause and Effect Analysis

Root Cause
How do we know when we have reached
ROOT CAUSE ?
Root Cause is the lowest cause in a chain of cause and
effect at which we have some capability to cause the
break
 It‟s within our capability to unilaterally control, or to influence,
changes to the cause

Products are failing for contamination

WHY? Base castings leak at mounting screw hole
WHY? Suppliers leak test may not detect porosity leak
WHY? Suppliers have different leak test processes
Can I cause WHY? No standard process for supplier leak test
the break if
I stop here?
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 Cause and Effect Analysis
Span of Control / Sphere of Influence
Before we begin, we must establish the context in which the
Cause-Effect will be used.

Span of Control - areas where we SPHERE OF INFLUENCE

have a high degree of control over (Influence or persuasion only)
parts or functions, virtually complete
authority to change anything

Sphere of Influence - areas where

we can influence things to varying SPAN OF CONTROL
degrees but don’t have direct control. (Full authority)

Outside Environment - where we

have neither control nor influence

OUTSIDE, UNCONTROLLED
ENVIRONMENT
37
 Cause and Effect Analysis

Points to Note for Fishbone Diagram

 Treat the cause-and-effect diagram as a living
document
 As new variables are discovered, update the
cause-and-effect diagram
 After your experimental investigations, when
you have optimized the “X” factors, and
implemented control, update them to “C”.
 Therefore, ideally, when the fishbone diagram
has more “C”s, the better we can control the
effect and improve its performance measure.

38