Pakistan Institute of Incident InvestigationLahore · Karachi · Islamabad · International Insights Cases Q&A About WhatsApp
P3i — Pakistan Institute of Incident Investigation

Home / RCA Methods / Cause & Effect / Fishbone

CAUSE METHODS · 05 / 12

Cause & Effect / Fishbone

Every possible cause on the table. Only the proven ones stay.

A fishbone gets every possible cause out of people’s heads and onto one page, across six categories, without anyone having to defend a position. Then the evidence decides which bones stay.

PEOPLEMATERIALMETHODMEASUREMENTMACHINEENVIRONMENTEFFECTcolour out oftolerance

Six categories, every possible cause on a rib, one effect at the head.

Challenge each bone

One carton in twenty prints off-colour. Apply the evidence.

Tap a category to see the suggested causes, then apply the evidence to see which survive. Illustrative example.

8 suggested causes across 6 categories

Anilox roller worn

SUGGESTED

Apply the evidence to test this cause.

Dryer temperature drifting

SUGGESTED

Apply the evidence to test this cause.

Printing line in a packaging plant

Since the 1990s

30

years investigating

250+

investigations closed, incl. HiPOs

15

countries served

20+

countries of lead seminars

100+

nationalities trained

Fishbone diagram drawn on a whiteboard by a quality team
Six bones, one effect, every idea written down.

Why teams like it

It ends the argument between departments.

1

Production, quality and maintenance all put their ideas on the same page, without blame.

2

Each idea is then tested against evidence, so seniority does not decide the cause.

3

Ruled-out causes are recorded, so the same argument does not return next month.

Use it for

Quality and process problems with many possible causes

Customer complaints and 8D responses

Getting a cross-functional team aligned

On its own it cannot

Show the sequence of events

Prove a cause without data behind it

So we pair it with

5 Whys / Why Tree →8D / CAPA →Quality / Nonconformance →

Method names are given for reference. Several are proprietary or trademarked; P3i selects the approach that suits each case and does not claim licensed certification in proprietary methods.

Quality team building a cause-and-effect diagram
Every idea on the board, no one defending a position.
Print roller inspected during root cause analysis
The worn roller the evidence confirmed.
Test results checked against each suggested cause
Each bone tested, not voted on.

A quality problem with too many possible causes? A first call costs nothing, and we will tell you how to narrow it down.

Talk to an investigator WhatsApp

The P3i approach

How we investigate with a cause-and-effect map. Fact-finding, not fault-finding.

Every P3i investigation is led by a senior investigator and supported by internationally qualified process specialists. You will not receive a list of people to blame, or a long list of generic actions. You will receive the facts, the proven causes, and a short plan that closes the gaps, in this case and across your system.

Independent

No products, repairs or contracts to sell you afterwards.

Senior-led

Thirty years of investigation, from the first call to the final briefing.

Beyond the event

Process specialists find the other cracks before they fail.

Ready to present

Written for boards, buyers, insurers and regulators.

How P3i does it for you

  1. 01

    Frame the problem sharply

    One effect, stated precisely.

  2. 02

    Map every category

    People, methods, machines, materials, environment, management.

  3. 03

    Challenge each bone

    With data, not seniority in the room.

  4. 04

    Keep the ones that are proven

    The rest are parked, not argued about.

  5. 05

    Act on the real causes

    Owned, dated, tested.

What you receive

Fishbone mapEvidence for each causeProven causesParked hypothesesAction planBriefing

Call us when

A quality problem with many possible causesMeetings end in blame between departmentsA customer wants a structured RCAYou need the whole team aligned

Free 30-minute case assessment.

Tell us what happened. In confidence, we will tell you what the investigation should cover, how long it will take and what to preserve today.

Questions

What quality heads ask about fishbones.

What are the six categories?

Commonly people, methods, machines, materials, measurement and environment. We adapt them to services, hospitals and offices where needed.

Is a fishbone enough on its own?

It is excellent for generating possible causes. Each one must then be tested with data, which is where most internal fishbones stop short.

Why do you cross out causes?

Because proving what did not cause the problem stops the same theory being raised again, and protects people from unfair blame.

Can we use it for an 8D?

Yes. It fits the root cause step of an 8D and most customer CAPA formats.

Every idea on the board. Only proven causes in the report.

Discuss a caseTrain your team in RCA
Investigator sampling cartons on a packing line
Sampling good and bad cartons side by side.
Colour measurement taken with a spectrometer
Measuring the effect precisely first.