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DMQ 30262



                               change    is  ineffective  or  even  detrimental.  This  validates  effective
                               improvements, which you will retain. This is enormously difficult when the

                               process is not in statistical control, because the process instability masks the
                               results, good or bad, of any changes deliberately made.



                        2.7    CAUSE AND EFFECT (ISHIKAWA) DIAGRAMS




                               Often workers spend too much time focusing improvement efforts on the
                               symptoms of problems rather than the causes. The Ishikawa cause and effect

                               or fishbone or Ishikawa diagram is a good tool to help us move to lower levels
                               of abstraction in solving problems.



                               The diagram looks like the skeleton of a fish, with the problem being the head
                               of the fish, major causes being the “ribs” of the fish and sub-causes forming

                               smaller “bones” of the ribs. A facilitator or designated team member draws the
                               diagram after questioning why certain situations occur. It has been said that
                               for each circumstance, the facilitator should ask “why?” up to five times. This

                               is sometimes referred to as the “five whys”.


                               Fishbone (cause and effect) diagrams are created during brainstorming

                               sessions with a facilitator by following these steps:



                                    i. State the problem clearly in the head of the fish.


                                   ii. Draw the backbone and ribs. Ask the participants in the brainstorming

                                      session to identify major causes of the problem labelled in the head of
                                      the diagram. If participants have trouble identifying major problem
                                      categories, it may be helpful to use materials, machines, people, and

                                      methods as possible bones.



                                   iii. Continue to fill out the fishbone diagram, asking “why” about each
                                      problem or cause of a problem until the fish is filled out. Usually it
                                      takes no more than five levels of questioning to get to root causes -

                                      hence, the “five whys.”


                                  iv. View the diagram and identify core causes.

                                   v. Set goals to address the core causes.

                 KKTM Kuantan                              26                                    DMQ 30262
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