When the fish rots from the head down

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Root Cause Analysis (RCA) is a systematic process of identifying, defining, and understanding a problem. There are numerous Root Cause Analysis tools, such as, 5 Whys, Pareto Analysis, Fault Tree Analysis, Fishbone Diagram, Event mapping, etc.

Fishbone diagrams is most widely used tool and simple to develop. The method is often called a cause and effect diagram or Ishikawa diagram. It is used to identify potential root causes of a problem. The Japanese Professor for Quality Management Kaoru Ishikawa developed beginning of the 40s of the last century. The fishbone diagram is a graphical presentation of cause and effect relationship in the form of a diagram that resembles fishbone.

Because of its simplicity, the fishbone diagram has been used across various industries over the last decades. Companies are using the diagram in its various forms from defining the user requirements for a project to general risk assessment. With its simplicity, the diagram comes with limitations, which often the users are not fully aware of. For example, one of the key limitations of a fishbone diagram is that its inability to single out the root cause of a problem. It is difficult to pinpoint the exact cause of a problem, thereby making all causes equally important.

Most importantly, the fishbone diagram captures and provides a snapshot of a particular situation, but is not used to identify immediate measures nor helps to measure the impact of a measure taken. Another limitation is that the process of developing a fishbone diagram is opinion based rather than evidence based. Many users find that the tool easily results in complex charts, wasting time and resources on aspects which are are less important.

An alternative to the fishbone diagram is called Event Map. It is a powerful tool used to analyse the cause and effect relationship and to create the focus needed. Event Map is used across various industries to assess and visualise a critical situation and to set clear priorities.

Event Map is an integral part of the RATIO toolbox. It is used during the first stage „Reflect the Issue“.

The tools is developed by stating the event or key issue, considering the effects and their impact and then mapping our a cause/effect chain by repeatedly asking “why” in order to gain insight into the problems. Facts are separated from assumptions. The causes, contributing circumstances and breached barriers are identified and visualised.

The Event Map is not just used to provide a single snapshot, it documents all subsequent measures and actions taken to resolve the issue and helps to observe and evaluate the effectiveness of the solution.

In decades of real-life application in critical situations, CoThink has further developed the tool to its actual stage. It provides a causal chain which includes effects, to give insight to the (potential) threats and a comprehensive overview of the problem’s gravity. It helps to find the right entry point for a problem analysis. Event Map emphasises on facts and does not include assumptions. The tools visualises contributing circumstances and breeched barriers.

The ability to visualise the development of a situation over time is one of the key reasons why Event Map is way ahead of fishbone diagram. Using an Event Map, the organisation can immediately identify new measures to effectively avoid reoccurrence of the problem or/and identify new barriers. Contact us to learn more about RATIO model and Event Map.

Download the Event Map App for your tablet from the App Store or Google Play.

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