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[[File:step3.png|right|500px]]
The Fishbone diagram is named for its resemblance to a fishbone with the investigated problem being in the place of the head and the identified root causes coming out of the spine (see picture). It is also called an Ishikawa diagram after its creator Kaoru Ishikawa or a Cause-and-Effect diagram.
Identifying the root causes of a problem makes it a valuable tool in Risk Management, as it can help the team figuring out how best to handle this with ARTA.

This article will focus on the fishbone diagram. It will consider how the diagram is appropriately used in Risk Management as well as its purpose ans limitations. It will also touch upon tools that can be used in conjunction with the diagram to strengthen a project's management of risks. The article will be based on previous literature on the subject<!-- as well as the author's personal experiences with the tool-->.


==The Purpose of the Fishbone Diagram==
The purpose of the fishbone diagram in Risk Management is to identify various root causes of a potential problem for a project or program<ref name="Carmen">Ilie, Gheorghe; CioCoiu, Carmen Nadia; ''Application of Fishbone Diagram To Determine The Risk Of An Event With Multiple Causes'', Knowledge Management Research & Practice, January 2010</ref>. It does so by having the user brainstorm over various causes for the problem and continuously going to deeper levels by finding the cause of the previous cause. Thus a cause-rib might have more subcauses, see the Illustration. The process of making new "ribs" on the fish continues until the team agrees, that the root cause has been reached. In this way the tool aims at organising the causes for the investigated problem. But the team does not have to find deeper levels for each cause they identify, only for those that they deem are "Very Likely" or "Somewhat Likely" to happen and will be "Very Easy" or "Somewhat Easy" to control or fix (see "Application" for reading more about these gradings). The reason for this is so that the team does not waste time and effort on treating a cause that is unlikely to happen or that they won't be able to do anything about anyway. If the team is hard pressed for time and have a lot of causes to look into, they can start with the ones they deem will have the highest impact or effect in causing the problem.

==Application of the Fishbone Diagram==
<!--insert image--> 
When a team is doing risk management they will often need several fishbone diagrams as each one only corresponds to one problem while several problems may arise during a project. A problem could, as suggested earlier be something like the risk of customers not buying a car. Thus the problems are the risks the team will want to manage. It is also called an effect which is how the diagram also got the name Cause-and-Effect diagram.
When using the fishbone diagram it is particularly useful to do so on a large surface -such as e.g. a whiteboard, with lots of space for categories, subcategories, and causes, since the team cannot know at the beginning of the process just how many of these will be needed. Following is a step by step guide to using the fishbone diagram<ref name="LBSpartners">Walsh, Ronan; ''Fishbone Diagram - How to Make and Use a Fishbone Diagram'', http://lbspartners.ie/fishbone-diagram/ , (August 3, 2017)</ref>:

# The investigated problem should be written in the far right side of the whiteboard and a horisontal line to the left of it. Some make it an arrow aiming at the problem <ref name="LBSpartners" /><ref name="City">''Cause and Effect Analysis using the Ishikawa Fishbone & 5 Whys'', http://www.cityprocessmanagement.com/Downloads/CPM_5Ys.pdf </ref> to illustrate that this is the effect of the causes that are to be identified. But whether it is an arrow or just a line is of no consequence to the functionality of the diagram and is so up to the personal preferences of the team. <br/>[[File:step1.png|left|600px]]<br/><br/><br/><br/><br/><br/>
# Now the categories -or causes for the problem, should be written a good distance of to each side of the line -there should also be some distance between the categories themselves. Lines ar drawn from each category to the line. Again these lines could be made into arrows<ref name="City" /> or not<ref name="Wong">Wong, Kam Cheong; Woo, Kai Zhi; Woo, Kai Hui; ''Quality Improvement in Behavioural Health'', chapter 9: ''Ishikawa Diagram'', Springer International Publishing Switzerland, (2016)</ref>. <br />[[File:step2.png|left|400px]]<br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />
# The appropriate subcategories or "sub"-causes can now be fitted into each of the categories by making horisontal lines on either side of the line connecting a category and "spine" of the fish, and writing the subcategory or cause in it. Whether subcategories are needed or not is largely up to the team and how detailed they want to do the diagram. It is entirely possible to solve the problem without a subcategory -in this case what would otherwise be the subcategory is now a cause. An example could be that for a category named "People" a cause could be "Employees not showing up for work". In this case the team could decided that this a root cause and a brainstorm on how to solve the problem could be to change the way employees are paid to depending on how much time they spend at work or put a limit on how many sick days employees are allowed. Another action could be that the team decides that "Employees not showing up for work" is a subcategory to which there is the cause "Employees bully each other". Now the team can brainstorm other ways to manage the problem, and will probably reach other conclusions than in the previous scenario. If the first scenario happens it is likely that that the work environment will worsen further and that one or more employees will leave the company. This of course creates new problems for the company as it is symptom treatment rather than doing something about the root of the problem, the root cause, which as it turns out the team had not managed to find after all. To find the root cause the team must continually ask why this happens. Why do the employees not show up for work? Why are the employees bullying each other? This approach is called "The Five Whys" as this is the approximate amount of whys a team will need to ask in order to reach the root cause<ref name="City" /><ref name=asq>''Fishbone (Ishikawa) Diagram'', Learn About Quality, http://asq.org/learn-about-quality/cause-analysis-tools/overview/fishbone.html </ref>. <br /> [[File:step3.png|left|500px]]<br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br /><br />

It should be noted that though this is presented as a step by step guide it might be that the team e.g. fills out a category before making the next or once having filled out all the categories realise that some of the causes from several of the categories are connected and is better treated in a new category made just for them. It is possible to go back in the steps to alter the output of it. It means that team didn't know all they thought they did at the beginning and is figuring out something new about the project. If the team used any tools or methods to find the categories or causes, the team might need to go through those again to make sure they have all relevant categories or causes, if this is the case.

After having used the Fishbone diagram to identify the root causes for a problem the team can grade them in regards to how easy to fix or control they are and how likely they are to happen. This will help the team prioritising which causes to treat and how to manage their time and effort. This step is important in order for the team to get to use the knowledge they had just gathered from the Fishbone diagram. A way of grading this could be, "Very Easy", "Somewhat Easy", "Not Easy" and "Very Likely", "Somewhat Likely", "Not Likely". The causes the team should focus on have the combinations "Very Easy-Very Likely", "Very Easy-Somewhat Likely", and "Somewhat Easy-Very Likely"<ref name="Wikipedia">''Ishikawa diagram'', https://en.wikipedia.org/wiki/Ishikawa_diagram </ref><ref name="LBSpartners" />.


===The Team===
The fishbone diagram facilitates communication in the team as it requires the team members to discuss the likelihood and effect each of the identified causes might have on the project. As in how likely each cause is to cause the problem. This allows the team to treat the problem as according to ARTA<ref name="How">Geraldi, Joana; Thuesen, Christian; Oehmen, Josef; ''How to DO Projects'' Version 0.5 BETA VERSION, (July 27, 2016)</ref> by handling the root causes of the problem. 
When using the diagram a diverse team can be an advantage as the team is likely to identify more causes, but it is also very important to have a common ground on which to grade the likelihood and effect of each root cause, which can be difficult for a too diverse team as each member will tend to focus on the categories they are the expert in. As such they may not be able to relate the likelihood and effect of the root causes of their own categories to those of the other categories. This can potentially lead to some root causes being underestimated while others are overestimated, so that some root causes will not get the attention and contingency plans they deserve and need because it is given to other root causes. Thus the problem might happen anyway without an effective contingency plan. This goes to show, that proper communication and a common ground or standard on which to grade the effect and likelihood of a cause is very important when using the fishbone diagram.

A less diverse team might have an  easier time finding this common ground or standard, but in return it is likely that they find all the relevant root causes or will have the knowledge to make the appropriate contingency plans.

Here a diverse team means that that the members have different strengths in the form of a category for the diagram. 
As an example think of a team from a start-up company making a new car. The team might be discussing something as open as why the car is not selling well. There might be someone in the team who is the expert on the car as a product, and someone who is the expert on the market wants and needs, etc. But without an expert on the sales channels the team might overlook that all of the car distributors have agreements or contracts with other and bigger car fabricants that means they are either not interested in or allowed to do business with the start-up company.
Here expert simply means that this person is in charge of that specific aspect of making or selling the car and in the light of this naturally will have more knowledge about this category than the other team members.

When a team creates a Fishbone diagram it is important that they have an in-depth understanding of the problem<ref name="LBSpartners" /> in order to reach the right root causes. Thus it is important that the team consists of those who are closest to the problem or that those closest to the problem at the very least are involved in the brainstorming to make it.

===Common ways it is used===
<!--References from City process, wikipedia, wong, Harvey-Maylor-->
In Project Management the Fishbone Diagram is usually used in '''Manufacturing''', '''Services''', or '''Product Marketing'''. It can also be used in other context than what would traditionally be considered Project Management, such as e.g. for medical purposes<ref name="Wong" /><!--possibly change sentence a little-->.
Because of the frequent use in the first three mentioned contexts several standard first level causes exists for them. Of course if a team should need to, they can add or subtract any course they may need. These standards exist as guidelines to help teams think of and consider various causes for the problem they are treating and can be a good starting point.

For '''Manufacturing''' two such standards exist:
# The first originates from lean manufacturing and the ''Toyota Production System'', it is ''The 5 Ms''<ref name="Wikipedia" /><br />
#*Machine (which covers the equipment and technology)
#*Method
#*Material (which cover both raw material, consumables and knowledge)
#*Man (which cover both physical and knowledge work)
#*Measurement (which cover inspection and environment)
#:<!--Insert picture-->
#:Sometimes it is relevant to include three extra Ms, these are:
#*Mission (which covers the purpose and the environment)
#*Management
#*Maintenance           
#:<!--Insert picture-->
# The second one considers these causes<ref name="City" />
#*People
#*Material
#*Equipment/Machinery
#*Methods
#*Environment
#*Measurement
#:<!--Insert picture-->

For '''Services''' another two standards exist:
#The first considers these causes<ref name="City" />:
#*People
#*Policies
#*Procedures
#*Location (this usually includes equipment and machinery)
#*Measurement
#:<!--Insert picture-->
#The second one is called ''The 4 Ss''<ref name="Wikipedia" /> and considers these causes
#*Surroundings
#*Suppliers
#*Systems
#*Skills
#:<!--Insert picture-->

For '''Product Marketing''' this standard exists
#''The 8 Ps''<ref name="Wikipedia" />
#*Product (would be service for '''Service Marketing''')
#*People
#*Price
#*Promotion
#*Process
#*Physical evidence
#*Performance
#*Place
#:<!--Insert picture-->

==Limitations of the Fishbone Diagram==
<!--References from Wong et al.; conclusion from Carmen Ciocoiu; conclusion from Journal of Medical Case reports; and ... could also be something like: it is emphasised that the tool is used in teams (ref) to better identify all causes this means that ...; -->

As with any other tool the Fishbone Diagram has limitations and one of them is the people it is used by. People sometimes won't think of everything that might be relevant to put on the diagram, that is why the above mentioned guidelines exist. However it might also be that the team members just do not know enough about certain aspects of the project to identify all the relevant causes for the problem. It is also possible that the team misjudges the likelihood for one or more of the causes or ease with which they might be controlled or fixed. This could happen e.g. because the team members do not know enough about the subjects that they are not the expert of themselves and the team does not have a common standard by which to decide in what category of likelihood and ease of controlling or fixing, that a specific root cause fits into. <!--check explanation to see why this standard is important, is it explained properly?? --> The outcome of all of this could be that the team focusses on the wrong root causes.

===What the tool will not achieve===
The tool is meant to identify and organise the root causes to a specific problem <ref name="Carmen" /><ref name="Wikipedia" />. Thus the tool itself will not help the team in finding solutions for the problem, it merely provides a more concrete context or specification for the solution.
The diagram also does not translate the identified solutions into actions, that is up to the team, and it cannot help the team find the best way to execute the necessary actions or even to identify the actions necessary to execute the solution.
The diagram itself does not constitute Risk Management or even Risk Analysis<ref name="Carmen" />, more tools and methods are needed to do either those properly and some suggestions for them are mentioned in the following section. 
To put it shortly, the Fishbone diagram will help organise a team's knowledge about a problem, but it will not help the team quantify the problem or decide what the appropriate response should be. If the team only does the Fishbone diagram they might be aware of certain problems or risk they might encounter, but they will have no plan for how to manage them or otherwise do any form of damage control.

===Tools the Fishbone diagram is often used in conjunction with to achieve the end goal===
The Fishbone diagram was created by Ishikawa as a tool in ''The Seven Basic Tools of Quality''<ref name="asq2">''7 Basic Quality Tools For Process Improvement'', http://asq.org/learn-about-quality/seven-basic-quality-tools/overview/overview.html</ref>. Other tools from this basic toolset includes the Pareto Chart, which has given way to the Pareto Analysis or Method<ref name="Carmen" /><ref name="Harvey">Taylor, Harvey, ''Project Management'', Pearson (2010)</ref>. A basic 80/20 rule of this analysis  says that about 80% of the teams problems will be from the same 20% of their causes. To uses this in conjunction with the Fishbone diagram means that the team will find out which 20% of their causes will cause 80% of their problems and focus their efforts on them.
<!--Another of these tools is the ... Stratification->flowchart-->
Another good tool to use in conjunction with the Fishbone diagram was presented in '''step 3''' of the '''Application'''. It is of course ''The Five Whys''. This method will heighten the quality of the output of the Fishbone diagram as it helps the team dig deeper until they reach the root cause of the problem. 
Another tool that -like ''The Five Whys'' will always be used to some extent in conjunction with the Fishbone diagram is ''Brainstorm''. This is in order to identify the problem that is to be treated with the diagram as well as for identifying the relevant causes and root causes. To get started on identifying the problem the Fishbone diagram can be used in conjunction with a ''Potential Problem Analysis''<ref name="PPA">''Potential Problem Analysis'', https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/potential-problem-analysis </ref>. The ''Potential Problem Analysis'' identifies potential problems for a product or service by breaking it up into the required steps for providing the product or service. Then it identifies potential problems for the steps and rates them according to the likelihood of it happening and the impact it might have. This will help identify what problems it might be relevant to treat with the Fishbone diagram. Once an overview of these risks has been created the team can take preventive measures and make contingency plans. These might be kept in a register to make it easier and quicker for the team to act once they encounter one the problems.

It should be noted that these tools are only suggestions on how to take better advantage of the Fishbone diagram to reach the goal of doing proper ''Risk Management'' that would be the reason why a team would use the diagram in the first place. It should also be noted that this list is in no way exhaustive.

==Suggested literature not covered by the DTU License==
<!-- Ishikawa original works; ...-->
==References==
<references />