Issue link: https://www.e-digitaleditions.com/i/1472963
July/August/September 2022 I 61 FIGURE 2: The Fishbone Diagram, courtesy of QualityInspection.org The advantage with this methodology is identifying a rapid cause and solution. What is known is that the human did not flip the switch, and technically a human also did not include that step in the manual. It is a copout just to blame human error without some remedy. What is missing in this approach is the brainstorming and group participation that could provide additional insights. As the investigation expands, perhaps it is learned that a procedure is missing or has changed with a recent update. Furthermore, it is learned that if the fuel tank is empty, the generator automatically switches to manual mode in an override capacity. It is important to understand that this exercise is working toward identifying the "root" of the problem. The Five Whys is a great tool, but only one tool. This tool can also be completely ineffective if it leads to a knee-jerk reaction or blame game. The Fishbone Diagram The Fishbone Diagram does a great job of looking at a more in-depth problem analysis, such as a more complex problem occurring in a smart building environment. While there is no need to draw the fish literally, it is a great illustration and a sort of blueprint. By breaking down any process or issue into a sum of all parts, the primary spines for the Fish Diagram are developed. The spines represent the inputs to the problem. If it is assumed that this is a manufacturing problem, the layout becomes clear. This examination covers the machines, methods, materials, environment, and people, while also peeking into their measure- ments, such as the cost of materials in a network downtime scenario, as all inputs contribute to the problem at hand. For other investigations, the prominent spines may be different. The spines could be labeled facilities, IT, and networking or warehouse, procurement, and processing. The combination will depend on the inputs being evaluated to solve the problem. There is no need to add additional inputs just to have them. Keep only things pertinent to this exact step in the RCA exercise. It is important to note that this exercise could easily spin off additional RCAs as the brainstorming process begins (Figure 2).