1. Root Cause AnalysisRoot Cause AnalysisRoot Cause AnalysisRoot Cause Analysis
in Project Management
and Software Development
Addressing Common Problems
ASEE
February 20, 2016
Barbara DeVries
2. Table of ContentsTable of ContentsTable of ContentsTable of Contents
• Definition
• Six Sigma Measure Phase
• BABOK
• Approach — How To
• Examples
• Communication
• Shortcomings
• Supplemental Information
• Instructions
• Templates: Visio, PowerPoint, Excel
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3. DefinitionDefinitionDefinitionDefinition
https://en.wikipedia.org/wiki/Ishikawa_diagram
Ishikawa diagrams (also called fishbone diagrams and cause-and-effect diagrams) are
causal diagrams created by Kaoru Ishikawa (1968) that show the causes of a specific event.
Common uses of the Ishikawa diagram are product design and quality defect prevention, to
identify potential factors causing an overall effect. Each cause or reason for imperfection is
a source of variation. Causes are usually grouped into major categories to identify these
sources of variation. The categories typically include:
• People: Anyone involved with the process
• Methods: How the process is performed and the specific requirements for doing it, such
as policies, procedures, rules, regulations and laws
• Machines: Any equipment, computers, tools, etc. required to accomplish the job
• Materials: Raw materials, parts, pens, paper, etc. used to produce the final product
Measurements: Data generated from the process that are used to evaluate its quality
• Environment: The conditions, such as location, time, temperature, and culture in which
the process operates
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4. Six SigmaSix SigmaSix SigmaSix Sigma ---- Ishikawa, Cause and Effect, Root Cause AnalysisIshikawa, Cause and Effect, Root Cause AnalysisIshikawa, Cause and Effect, Root Cause AnalysisIshikawa, Cause and Effect, Root Cause Analysis
ProcessProcessProcessProcess Mapping and Potential Vital FewMapping and Potential Vital FewMapping and Potential Vital FewMapping and Potential Vital Few InputsInputsInputsInputs
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5. Six SigmaSix SigmaSix SigmaSix Sigma ---- Ishikawa, Cause and Effect, Root Cause AnalysisIshikawa, Cause and Effect, Root Cause AnalysisIshikawa, Cause and Effect, Root Cause AnalysisIshikawa, Cause and Effect, Root Cause Analysis
Process Mapping and Potential Vital FewProcess Mapping and Potential Vital FewProcess Mapping and Potential Vital FewProcess Mapping and Potential Vital Few InputsInputsInputsInputs
The C&E diagram:The C&E diagram:The C&E diagram:The C&E diagram:
-Is a visual brainstorming tool to identify potential causes for your problemIs a visual brainstorming tool to identify potential causes for your problemIs a visual brainstorming tool to identify potential causes for your problemIs a visual brainstorming tool to identify potential causes for your problem
-Enables alignment of potential causes to the inputs identified in process mapEnables alignment of potential causes to the inputs identified in process mapEnables alignment of potential causes to the inputs identified in process mapEnables alignment of potential causes to the inputs identified in process map
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6. BABOKBABOKBABOKBABOK ----A Guide to theA Guide to theA Guide to theA Guide to the Business Analysis Body of Knowledge®Business Analysis Body of Knowledge®Business Analysis Body of Knowledge®Business Analysis Body of Knowledge®
Version 2.0 Section 9.25 pageVersion 2.0 Section 9.25 pageVersion 2.0 Section 9.25 pageVersion 2.0 Section 9.25 page 202202202202
• A fishbone diagram (also known as an Ishikawa or cause-and-effect diagram) is used to
identify and organize the possible causes of a problem. This tool helps to focus on the
cause of the problem versus the solution and organizes ideas for further analysis. The
diagram serves as a map depicting possible cause-and-effect relationships.
• Steps to develop a cause-and-effect diagram include:
• Capture the issue or problem under discussion in a box at the top of the diagram.
• Draw a line from the box across the paper or white board (forming the spine of the
fishbone).
• Draw diagonal lines from the spine to represent categories of potential causes of the
problem. The categories may include people, process, tools, and policies.
• Draw smaller lines to represent deeper causes.
• Brainstorm categories and potential causes of the problem and capture them under the
appropriate category
• Analyze the results. Remember that the group has identified only potential causes of the
problem. Further analysis is needed to validate the actual cause, ideally with data.
• Brainstorm potential solutions once the actual cause has been identified.
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8. ApproachApproachApproachApproach ———— When would I want to create a fishboneWhen would I want to create a fishboneWhen would I want to create a fishboneWhen would I want to create a fishbone?
• You are in Production support. Some problems, issues, defects recur
which seem to be related.
• You are reviewing the procedures for a line of business that you
support. Some of the procedures are repeatable steps to address a
step in the "unhappy" path of operations.
• You are reviewing the quality control process for a line of business
• A new issue has emerged in production that is somewhat
mysterious and the reasons are not fully known
• You are analyzing a process which has interrelated properties.
For example: the triple constraint in project management — time,
quality, and cost.
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9. How do I select the branches and organize theHow do I select the branches and organize theHow do I select the branches and organize theHow do I select the branches and organize the fishbonesfishbonesfishbonesfishbones????
Brainstorm Approach
• Ask your team to contribute their thoughts on what is
causing the problem.
• If they are stumped, ask them to list things which MIGHT
impact the outcome
• Ask who is involved and what they contribute
• Ask who provides the initial information
• Ask who uses the resulting information
• Ask where the information comes from
• Ask how long the process takes. Is there a delay? Is
anything impacting the delay?
• Is this related to a particular time or season? Is it only at
night? Is it spring, fall, winter or on a holiday? Is it during
the week or the weekend?
• Does the size vary?
• Does the content vary?
Structured Approach
• Label the branches: people, process, environment
(physical),materials (inputs)
• Label the branches with the steps in the process to
perform QC
• Label the branches with the steps in the procedures
• After you work with the diagram, please feel free to
rename the branches, move the fishbones and reorganize
the diagram.
• There is no right or wrong answer. This is an analysis
technique. There are no Ishikawa police.
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15. Communication: One Size Does Not Fit All
• Interpretation Differs
• Visual, Spoken, Felt (Emoted), Kinetic
• Different Types of Diagrams
• Process Maps, Process Flows, Swim Lanes
• UML
• Venn Diagrams
• Context Diagrams – Business, System, Groups – Input, Output
• Different Expressions
• Business Requirements, System Requirements
• Use Cases
• User Stories
• Design Specifications
• Test Plans, Test Cases, Test Scripts, Test Results
• And Then….. The Code and The Executables
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16. Shortcomings in Our Industry
• Total Cost of Ownership
• Cost on a Project Basis
• Maintenance, Operations, Business as Usual Separate from Enhancements and New
Functions
• Replace Cost and Value
• Unused or Obsolete Functions
• Requirements Management
• Requirements on a Project Basis
• No Documentation outside of Project
• Few Training Materials or Job Aids
• No User Help
• Business Procedures
• Replace a System – Reinvent
• Evolution
• New Business, New Functions,
• Expansion or Replacement – Little Sharing
• Non-Functional Requirements – Maintenance, Performance, Scalability
• No Reuse, Only Reinvention – Parts Not Compatible
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19. Translation, Reuse, Rosetta Stone
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Machine Language, Binary
Language 1
Language 2
Language 3
Requirements and Specifications (Embedded)
Future Language
21. BiographyBiographyBiographyBiography
https://www.linkedin.com/in/bdevries
Barbara DeVries has over 20 years of experience in software
development and technology implementations, with vertical expertise
in banking and finance. She has held positions ranging from software
developer and system analyst to Vice-President of Software and Data
Architecture, managing initiatives, programs, projects and teams. She
holds multiple Bachelor and Master’s degrees, as well as certifications
in project management, network engineering, scrum master and Scaled
Agile Framework. She has worked with companies from startup to
Fortune 500, banks on the east coast and west coast, software
development and consulting companies as well as investment
firms. She holds standards in high esteem, but people and
relationships in higher esteem.
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22. Supplemental Information
• Templates
• How to Create a Diagram
• Examples of Other Diagrams
• Process Maps, Process Flows, Swim Lanes
• UML
• Venn Diagrams
• Context Diagrams – Business, System, Groups – Input, Output
• Requirements Tracking
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25. Create a cause and effectCreate a cause and effectCreate a cause and effectCreate a cause and effect diagramdiagramdiagramdiagram
Microsoft OfficeMicrosoft OfficeMicrosoft OfficeMicrosoft Office----ExcelExcelExcelExcel
Cause and effect diagrams document all the factors that contribute to or affect a given situation: all the causes,
that is, that lead to a certain effect. They are also called Ishikawa, fishbone, or characteristic diagrams.
The Cause and Effect Diagram template opens a drawing page that already contains a spine shape (effect) and
four category boxes (causes) to help start your drawing. This template also provides a variety of shapes
representing primary and secondary causes that can be used to add even greater detail
• On the File menu, point to New, point to Business, and then click Cause and Effect Diagram.
• Select the spine (the horizontal arrow) on the drawing page, and then type text that describes the effect, problem, or objective.
• Determine the number of cause categories that contribute to the effect, and then do one of the following:
• To add a category, drag a Category 1 or Category 2 shape onto the drawing page and position it so that the arrowhead is touching
the spine.
• To delete a category, select the shape and then press the DELETE key.
• For each category shape on the drawing page, select the shape, and then type the name of the cause category.
• To represent major causes contributing to the categories, drag Primary cause shapes onto the drawing page and snap the
arrowheads to category lines.
• To represent secondary causes contributing to primary causes, drag Secondary cause shapes onto the drawing page and snap the
arrowheads to primary cause lines.
• NOTES
• To label a primary or secondary cause shape, select the shape and then type.
• To change the direction of a secondary cause arrow, use the Rotate or Flip commands on the Shape menu.
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26. Examples of Diagrams
• Process Maps, Process Flows, Swim Lanes
• UML
• Venn Diagrams
• Context Diagrams – Input, Output
• Business, System, Groups
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29. Example Venn Diagram: Security Design
User Profiles & Permissions
Documents Images Access
Role Based Department/Loan Based
Manager/Administrator
all documents
Document
Supervisor
Document
Image User
Loan Access
by Type
Loan
Supervisor
Manager All loan types,
including celebrity, high
net worth
30. Image Repository
Context Diagram for Image Inputs (Source)
Proposed System Perspective
Business Unit
Folders
FTP
Customer Service
Letters/Fax
User Access
Scanner –
Original and Trailing
Documents
Internal
Documents
Word Docs
RightFax
Scan, Fax
CD or
Hard Drive
Exceptions
Sweep Process
External
Corrected
Verify
Mail Room
Scanning
Format Error
PDF or TIFF
Business Unit
converts native
format
Email
Attachments
Manual
Conversion–
Rename
MIN#
to Loan#
Vendors
