Case Study: Understanding Why-Why Analysis and Fishbone Analysis for Root

Cause Problem Solving

Root cause analysis (RCA) is a foundational tool in quality management and

troubleshooting, aimed at identifying the true cause of problems rather than just
treating symptoms. Among the many RCA methods, Why-Why Analysis (often referred
to simply as the “5 Whys”) and Fishbone Analysis (also called Ishikawa or Cause-and-
Effect diagrams) stand out for their effectiveness and simplicity. This case study
explores these two powerful techniques—how they work, their applications, and
examples illustrating their impact in solving complex issues.

Why-Why Analysis: A Deep Dive into “Asking Why” Multiple Times

Why-Why Analysis, pioneered by Toyota in the 1930s as part of the Toyota Production
System, is a question-based method used to peel back layers of symptoms and identify
a problem’s root cause by repeatedly asking "why" — typically five times. The
technique’s power lies in its focus on process and avoidance of quick fixes, drilling
down from surface-level problems to fundamental system flaws.

How It Works:

1. Define the Problem: Start with a clear problem statement. For example, “The
production line stopped unexpectedly.”

2. Ask Why?: Question why the problem happened. For example, "Why did the
production line stop?" Answer: “Because the circuit overloaded.”

3. Ask Why Again: Take each answer and ask why it happened. This iterative
process continues until the root cause is discovered (or it becomes clear the
answers are no longer useful).

Each answer reveals another layer of causality, such as poor maintenance, inadequate
training, supply chain failures, or faulty equipment design.

Example in Manufacturing:

A factory faced recurring breakdowns in a welding robot. Applying Why-Why Analysis:

• Why did the robot stop? Because a fuse blew.

• Why did the fuse blow? Because the circuit was overloaded.

• Why was the circuit overloaded? Because the robot’s arm was stuck.

• Why was the arm stuck? Because its lubricant was insufficient.
 • Why was lubricant insufficient? Because maintenance checks were not
performed on schedule.

This examination revealed the maintenance schedule as the root cause rather than the
fuse or robot malfunction itself, enabling a lasting fix.

Fishbone Analysis: Visualizing Cause and Effect

Fishbone Analysis, named for its resemblance to a fish skeleton, organizes potential
causes of a problem into categories to visually explore all possibilities. Developed by
Kaoru Ishikawa, it is particularly useful for group brainstorming and complex problems
where multiple factors may interact.

Structure of Fishbone Diagram:

• Head represents the problem statement.

• Spine is the main arrow pointing to the problem.

• Bones branching from the spine represent broad cause categories, often
including:

• People (Human factors)

• Methods (Processes)

• Machines (Equipment)

• Materials (Inputs)

• Environment (External factors)

• Measurement (Data precision or issues)

Each category is further dissected into specific causes, creating a comprehensive map
visualizing all factors contributing to a problem.

Example in Healthcare:

A hospital experienced an increase in medication errors. Using a Fishbone Diagram,

causes were grouped under:

• People: Inadequate training, communication lapses between staff.

• Methods: Absence of standardized procedures.

• Machines: Faulty labeling machines.

• Materials: Similar packaging leading to confusion.

 • Environment: High workload, distractions in pharmacy.

• Measurement: Poor incident reporting mechanisms.

This helped the hospital identify multiple improvement points rather than focusing on a
single cause, leading to protocol standardization and staff retraining that reduced
errors.

Combining Both Tools for Robust Analysis

Many organizations use Why-Why Analysis in combination with Fishbone Diagrams for
comprehensive problem solving. Fishbone provides breadth — a wide-angle view of all
possible causes—while Why-Why drills down on the most promising or critical issues to
find root causes.

Key Benefits and Lessons Learned

• Thoroughness: Both tools promote in-depth inquiry beyond surface complaints.

• Visual Clarity: Fishbone diagrams convert complex, multifactor problems into

manageable visuals.

• Simplicity and Accessibility: Easy to apply without sophisticated tools or

extensive training.

• Cross-Functional Engagement: Both processes encourage team participation,

creating shared understanding.

• Rooted Solutions: Focus on process or system improvements, reducing

recurrence of issues.

Conclusion

Why-Why Analysis and Fishbone Analysis remain cornerstone techniques in root cause
problem-solving, ideal for industries ranging from manufacturing to healthcare and
service sectors. Their practical application leads to objective problem identification,
aids in designing permanent solutions, and fosters continuous improvement cultures.
Organizations that embrace these methods gain a strategic advantage by systematically
breaking down issues to their core and fostering collaborative problem solving.

By applying these methods judiciously, companies can save time and costs, avoid
recurrence, and improve their operational robustness and customer satisfaction.