Cause and Effect Analysis

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
What do you mean by Cause & Effect?
A PROBLEM WHICH
HAS OCCURED
A POTENTIAL
FUTURE PROBLEM
(FMEA)
CAUSE
EFFECT
CAUSE
Events/conditions Symptoms that

provide evidence
that led to
of the problem
the problem
Events/conditions
that would lead to
the problem
EFFECT
Symptoms that
would result
from the problem
Dave Wessel, An Ounce of Prevention, Quality Progress, Dec, 1998

3
Cause - Effect Relationship

A PROBLEM WHICH
HAS OCCURED
CAUSE
EFFECT
Events/conditions
that led to
the problem
Symptoms that
provide evidence
of the problem
AD
AP
TIV
Lim
E
i
E
t
pro FFE s th
e
b le
C
m o T of
a
rd
evi
atio
n
E
TIV
EC
the
RR
tes
CO
a
n
SE
mi
Eli CAU blem
ro
ap
of
ACTION
Dave Wessel, An Ounce of Prevention, Quality Progress, Dec, 1998

4
Fishbone
Diagram
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.
Materials
C/N/X
Methods
C
C
N
C
C
C
Machinery
Problem/
Desired
Improvement
Manpower
Dr Kaoru Ishikawa
Quality
control statistician
Professor in University of Tokyo
One of the pioneers of Japans 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
7
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
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????
Lets create a Fishbone Diagram using Minitab
9

Stat Quality Tools Cause-and-Effect
10

Fishbone Diagram for Surface Flaws
Measurements
Materials
Man
List specific
causes in
each category
Surface Flaws
Environment
Methods
Machines
Problem (effect)
at the head of
the fish
Major categories of causes

(or sometimes call major bones)
Why do we need to group the causes?

11

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
3. Continue
asking: Why is
this happening?
until you no
longer get useful
information.
Micrometers
Materials
Calibration Method
Calibration Interval
Precision
Accuracy
Personnel
Alloys
Lubricants
Supervisors
Suppliers
Microscopes
2. Repeat this
procedure with each
specific cause to
produce sub-causes.
Shifts
Training
Operators
Inspectors
Surface Flaws
Speed
Brake
Machine feedrate
Machine rpm
Lathes
Brand of bit
Condensation
Moisture%
Environment
Engager
Bits
Angle
Methods
Sockets
Machines
Size of bit
1. The team should ask :

What are the machine
issues affecting/causing
the problem?
When do we know we have reached the root cause ?

12
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
variables that are noise or uncontrolled variables and

cannot be cheaply/easily held constant
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
13
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.
14
Integrating Fishbone Diagram into SOPs

Example of how fishbone diagram can be used in SCAR.
Section of SCAR Procedure

Fishbone diagram can be
used here to brainstorm/
identify root causes
Received
complaint/reject
from customer, inhouse or supplier.
QA personnel verify
the defects.
Issue CAR to
production.
Purge in-house
stock
Should also
update Fishbone
diagram
1. Fishbone diagram can be used here

to brainstorm/ identify root causes.
2. To prioritize and work on most likely
causes.
15
Hold meeting with

relevant
departments (if
necessary)
Generate
report for
management
review
Follow up on
CAR
-receive CAR
reply from
production
- reply to
customer
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
16
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
Completion Date
Specific Training
needed for Task
Owner/ Date
Core Team
Member In
Charge
Internal Verified
Date
Group Phase
End Date
James
10-Dec-01
Fishbone Diagram
-15 Oct 2001
Nick
15-Dec-01
31-Dec-01
Harry
10-Dec-01
Fishbone Diagram
- 15 Oct 2001
Nick
15-Dec-01
31-Dec-01
Group 1 Tools
1
SPC
Integrate Fishbone
Diagram in the SPC
procedure/system
SCAR
Integrate Fishbone
Diagram in the SCAR
procedure/system
17
Cause & Effect

Matrix
18
Lower Spec
Lower Spec
Target
Target
Upper Spec
Upper Spec
19
0
R e q u ire m e n t
R e q u ire m e n t
R e q u ire m e n t
R e q u ire m e n t
14
14
R e q u ire m e n t
R e q u ire m e n t
13
13
R e q u ire m e n t
R e q u ire m e n t
12
12
R e q u ire m e n t
R e q u ire m e n t
11
11
R e q u ire m e n t
R e q u ire m e n t
10
10
R e q u ire m e n t
R e q u ire m e n t
9
9
R e q u ire m e n t
R e q u ire m e n t
8
8
R e q u ire m e n t
R e q u ire m e n t
7
7
R e q u ire m e n t
R e q u ire m e n t
6
6
R e q u ire m e n t
R e q u ire m e n t
5
5
R e q u ire m e n t
R e q u ire m e n t
4
4
R e q u ire m e n t
R e q u ire m e n t
3
3
2
2
R e q u ire m e n t
R e q u ire m e n t
1
1
R e q u ire m e n t
R e q u ire m e n t
Rating of
Rating of
Importance to
Importance to
Customer
Customer
Total
Total
Cause and Effect Matrix

Cause
Causeand
andEffect
Effect
Matrix
Matrix
15
15
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
Total
Total
Process Step Proce ss Input

Process Step Process Input
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Description: Cause and Effects Matrix
Simple QFD (Quality Function Deployment) matrix.

Used to relate and prioritize Xs to customer Ys through
numerical ranking using the process map as the primary source.
Ys are scored as importance to the customer
Xs 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
This
is the teams first stab at determining Y = f(X)
Input into the initial evaluation of the Process Control Plan
20
Constructing a Cause & Effect Matrix

1. List key outputs (Ys)
21

2. Rank Ys with respect to customer importance
10
10
Cleanliness
Color
Homogeneity
Consistency
Digets Time
Temperature
Solids
Process Inputs
Viscosity
Rating of
Importance to
Customer
Gel Time
Cause and Effect

Matrix
1
2
3
4
5
6
7
8
10
11
12
13
14
15
Total
0
0
0
0
0
0
0
0
22
1
2
3
4
5
6
7
8
9
10
10
C o n s is te n c y
D ig e ts Tim e
Tem p e ra tu re
S o lid s
H o m o g e n e ity
C o lo r
Process Inputs
C le a n lin e s s
Input
Variables
V is c o s ity
Rating of
Importance to
Customer
G e l Tim e
3. List key inputs (Xs)
Scales
Accuracy
Preheating
DICY TK
DMF Load
Accuracy
DMF
Cleanliness
DMF Raw
Materials
DICY Load
Accuracy
DICY Envir.
Factors
DICY Raw
Materials
DICY Mixer
Speecd
10
11
12
13
14
15
Total
0
0
0
0
0
0
0
0
0
23

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.

24

4. Relate Xs to Ys
7
8
9
10
11
12
13
14
15
S olids
Tem perature
D igets Tim e
C ons is tenc y
10
H om ogeneity
Scales
Accuracy
Preheating
DICY TK
DMF Load
Accuracy
DMF
Cleanliness
DMF Raw
Materials
DICY Load
Accuracy
DICY Envir.
Factors
DICY Raw
Materials
DICY Mixer
Speecd
10
C olor
C leanlines s
Process Inputs
V is c os ity
Xs
G el Tim e
Rating of
Importance to
Customer
348
66
255
102
66
282
247
242
126
25
Ys
Total

5. Cross-multiply and add
8
9
10
11
12
13
14
15
S olids
Tem perature
D igets Tim e
C ons is tenc y
10
H om ogeneity
10
C olor
Scales
Accuracy
Preheating
DICY TK
DMF Load
Accuracy
DMF
Cleanliness
DMF Raw
Materials
DICY Load
Accuracy
DICY Envir.
Factors
DICY Raw
Materials
DICY Mixer
Speecd
C leanlines s
V is c os ity
Process Inputs
G el Tim e
Rating of
Importance to
Customer
348
66
255
247
242
126
26
Total
Key inputs are now

1
ranked
in importance
with
respect to the
1
key
outputs
1
So??
102
66
282
How Cause & Effect can Fit into Process

Improvement Activities
C&E Matrix
6
7
8
9
10
11
12
13
14
15
Solids
Temperature
Digets Time
10
Consistency
10
Homogeneity
Scales
Accuracy
Preheating
DICY TK
DMF Load
Accuracy
DMF
Cleanliness
DMF Raw
Materials
DICY Load
Accuracy
DICY Envir.
Factors
DICY Raw
Materials
DICY Mixer
Speecd
Color
Process Inputs
Cleanliness
s
t
u
tp
Viscosity
Rating of
Importance to
Customer
Gel Time
The Big Picture
321
65
255
105
74
269
247
242
125
Total
In
p
%R&R or P/T
Ratio
Upper
Spec
Limit
Target
Lower
Spec
Limit
Operational Excellence
Control Plan
FMEA
Key Process Output Variable

Capability Status Sheet
Measurement
Technique
Cp
Cpk
Sample
Size
Date
Product:
Key Contact:
Phone:
Process
Actions
Gel Time
Viscosity
Cleanliness
Color
Homogeneity
Consistency
Digets Time
Temperature
Solids
DICY
Process/Product
Failure Modes and Effects Analysis
(FMEA)
The Key Outputs are

evaluated ability to meet
customer spec.
Control Plan Summary
Capability Summary
Customer Requirement
(Output Variable)
ut
Process or
Product Name:
Prepared by:
Responsible:
FMEA Date (Orig) ______________ (Rev) _____________
Process
Step/Part
Number
Spin Draw
Process
Potential Failure Mode

Fiber Breakouts
Potential Failure Effects

Undersized package, High SD
panel-hours lost
S
E
V
Potential Causes
Dirty Spinneret
O
C
C
8
Filament motion
Current Controls
Visual Detection of Wraps and
broken Filaments
D
E
T
R
P
N
144
Visual Sight-glass
Core Team:
Date (Rev):
Process Step
Input
Output
Process
Specification (LSL,
USL, Target)
Cpk /Date
Measurement
Technique
%R&R
P/T
Sample
Size
Sample
Frequency
Control
Method
Reaction Plan
Turn Steam on Scales

Accuracy
DMF
Load DMF
DMF Load
Accuracy
DMF
Load DMF
DMF
Cleanliness
DICY
Load DICY
DICY Envir.
Factors
DICY
Load DICY
DICY Load
Accuracy
DICY
Load DICY
DICY Raw
Materials
DICY
Load DICY
DICY Mixer
Speecd
DMF
Load DMF
DMF Raw
Materials
DICY
Date (Orig):
Turn Steam on Preheating

DICY TK
The Key Inputs are

evaluated for process
control
Key Inputs are explored while evaluating
process for potential failure
5
Polymer defects
80
144
Fuzzball Light
27
Integrating Cause & Effect Matrix into SOPs

Example of how Cause and Effect Matrix can be used in SCAR.
Section of SCAR Procedure

Cause and Effect Matrix can be
used in conjunction with
fishbone diagram to identify, rank
and prioritize the key causes.
Received
complaint/reject
from customer, inhouse or supplier.
QA personnel verify
the defects.
Issue CAR to
production.
Purge in-house
stock

28
Hold meeting with

relevant
departments (if
necessary)
Generate
report for
management
review
Follow up on
CAR
-receive CAR
reply from
production
- reply to
customer
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.
29
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
Completion Date
Specific Training
needed for Task
Owner/ Date
Core Team
Member In
Charge
Internal Verified
Date
Group Phase
End Date
Dick
10-Dec-01
Fishbone Diagram
-15 Oct 2001
Cause & Effect
Matrix
-15 Oct 2001
Nick
15-Dec-01
31-Dec-01
Mary
10-Dec-01
Fishbone Diagram
-15 Oct 2001
Cause & Effect
Matrix
-15 Oct 2001
Nick
15-Dec-01
31-Dec-01
Group 1 Tools
1
SPC
Integrate Cause and
Effect Matrix in the
SPC procedure/ system
SCAR
Integrate Cause and
Effect Matrix in the
SCAR procedure/
system
30
End of Topic
Any question?
31
Product/Manufacturing Example
M e a s u re m e n t
M a c h in e
S e t tlin g o f S lu r r y
P a r tic le s ( C )
S lu r r y F lo w R a t e ( C )
R a (C )
L in e D e n s ity ( C )
T e x tu re
T e m p e r a tu re (C )
M a te r ia l
P ro g ra m u s e d (N )
S k e w (N )
P U P a d (C )
S o n ic p o w e r ( C )
T e x tu re
T e m p e ra tu re (C )
C a lib r a tio n ( N )
S lu r r y T y p e ( C )
S u b s tra te (C )
T a p e T y p e (C )
S u rfa c ta n t T y p e (C )
P U P a d (C )
NLA
M e th o d
S e t t l i n g o f P a r t ic le s ( C )
S lu r r y S tir r in g P r o c e d u r e s ( C )
P ro g ra m u s e d (N )
S p e e d A d ju s t m e n t ( C )
U lt r a s o n i c o n / o f f ( C )
S o a k T im e ( C )
S ta g g in g T im e ( N )
T r a n s f e r T im e ( C )
T e x tu r e T e m p e r a tu r e ( C )
C o n c e n tr a t io n o f C h e m ic a ( C )
T a p e S p e e d (C )
S l u r r y F lo w R a t e ( C )
T e x tu r e P re s s u r e (C )
M an
32
S lu r r y S t ir r in g P r o c e d u r e ( C )
S o a k T im e ( C )
S t a g g i n g T im e ( N )
T r a n s fe r T im e ( C )
C o m p lia n c e to P r o c e d u r e s ( C )
Transactional Example
Estimated Ship Date Change - CAUSE & EFFECT / FISHBONE
MDC
PRACTICES
SCHEDULE
CHANGES
ORDER
CANCELLATION
- Firm
- Planned
MDC
CAPACITY
- B.O.. Consol.
- SC late
WCSC
PRACTICES
- Receiving
- Picking
- PC delays
- Off shift support
- Unrealistic
Del. Req
Dates
- Customer Order
Priority Changes
Estimated
Ship Date
Changes
- Bad IT days
- Table Maint.
IN
TRANSIT
TIMES
- Availability
Overrides
- No Stocks
INVENTORY
ACCURACY
APPOINTMENT
CUSTOMER
- Waiting for
Delivery Appt.
PLANNED
SHIP DATE
ALGORITHM
- Late PT print
- Late EDI data
LDSS
33
- No Delivery Constraints
After initial PSD
- Back Ord. Release Logic
- Cust Priority vs. availability
-Future orders at AP
ESD
ALGORITHM
ANOMALIES
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 individuals
Input for other C&E tools
Active participation
34
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
Leaders 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
35
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
Its 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
the break if
I stop here?
WHY? No standard process for supplier leak test

36
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
have a high degree of control over
parts or functions, virtually complete
authority to change anything
SPHERE OF INFLUENCE
(Influence or persuasion only)
Sphere of Influence - areas where we

can influence things to varying
degrees but dont have direct control.
SPAN OF CONTROL
(Full authority)
Outside Environment - where we

have neither control nor influence
OUTSIDE, UNCONTROLLED
ENVIRONMENT
37
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 Cs, the better we can control the
effect and improve its performance measure.
38

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Cause and Effect

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