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The Fishbone Diagram:

Root Cause Analysis Technique – A Deep Dive

In this article:

Introduction

In the fast-paced realm of IT service management (ITSM), complex problems often underlie seemingly simple incidents. Resolving an incident is only the first step – understanding why it happened is crucial to prevent recurrence. The Fishbone Diagram, also known as the Ishikawa diagram or cause-and-effect diagram, is a proven technique for structured root cause analysis. Originally developed for quality control in manufacturing, this visual tool has been adopted in ITIL-based Problem Management to systematically dissect problems and expose all potential causes. By organizing hypotheses into logical categories (e.g., Methods, Machines, People, Materials, Measurement, Environment), a Fishbone Diagram helps IT professionals look beyond immediate symptoms and explore multiple contributing factors. The result is a “fishbone” sketch of possible causes branching off the “spine” of a defined problem, enabling teams to focus their investigations on likely root causes rather than superficial fixes (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

In this comprehensive article, we delve into the Fishbone Diagram’s structure, history, and practical application within ITIL Problem Management. We will illustrate how this technique fits into the IT service lifecycle, from reactive post-incident analyses to proactive problem prevention. Examples from IT operations (like recurring application downtime and major incident reviews) will demonstrate real-world usage. We also draw parallels to Fishbone’s origins in manufacturing and healthcare – highlighting how this method evolved and why it remains relevant across industries. Additionally, we discuss how to facilitate a Fishbone brainstorming session, common pitfalls to avoid, and how Fishbone analysis can be integrated with other ITSM techniques such as the 5 Whys, Pareto analysis, and incident trend reviews. A comparison with other Root Cause Analysis (RCA) approaches will underscore the Fishbone Diagram’s strengths and limitations. Finally, recognizing the modern enterprise environment, we provide guidance on digital tools and templates (Lucidchart, Miro, ServiceNow integrations, etc.) that support collaborative Fishbone analysis in distributed teams (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

This article is part of a deep-dive series on RCA techniques for IT Problem Management, aligning in tone and depth with our prior installment, “The 5 Whys: Root Cause Analysis Technique – A Deep Dive.” Just as that piece explored iterative questioning to find causes, here we focus on mapping cause categories visually. Senior ITSM practitioners, service managers, infrastructure engineers, and cybersecurity leaders will find the discussion relevant and actionable. The goal is to equip you with a thorough understanding of the Fishbone Diagram technique and how to leverage it to drive continuous improvement in IT services. We cite academic research, industry best practices, and standards (ITIL, ISO, NIST) throughout to reinforce key points. Let’s begin by exploring where the Fishbone Diagram comes from and why it has stood the test of time as a go-to problem-solving tool.

Origins and Evolution of the Fishbone Diagram

The Fishbone Diagram was conceived in the 1960s by Dr. Kaoru Ishikawa, a professor and quality management pioneer at the University of Tokyo. Ishikawa introduced this diagram as part of the seven basic quality tools in industrial manufacturing, aiming to improve product quality by systematically analyzing cause-and-effect relationships. The diagram earned its “fishbone” nickname because a completed analysis chart resembles the skeleton of a fish, with a head representing the problem and bones delineating categories of causes. Ishikawa initially applied the method in the context of shipbuilding and automotive processes, helping engineers and workers identify root causes of defects or process variances (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

Ishikawa’s philosophy emphasized cross-functional teamwork and breaking down silos in problem-solving. He believed quality improvement should involve employees at all levels, not just managers or specialists. The Fishbone Diagram was deliberately designed to be simple yet powerful, so that frontline workers could participate in cause analysis without needing advanced statistical training. Over time, the technique became a cornerstone of the Total Quality Management (TQM) movement and the broader continuous improvement culture in Japan and beyond. By the 1980s, it was widely taught as a fundamental tool in Six Sigma and quality improvement courses internationally. Today, it remains one of the most widely used quality tools, recommended in standards like ISO 9001 for corrective action and problem-solving (ASQ, n.d.; CMS, 2018; International Organization for Standardization [ISO], 2015; Kumah et al., 2023).

While the Fishbone Diagram’s origins lie in manufacturing, its use quickly spread to other domains. In healthcare, for example, fishbone diagrams are routinely employed in patient safety and quality improvement initiatives to uncover causes of medical errors or adverse events. A recent study by Kumah et al. (2023) showcased how a hospital in Ghana used a fishbone diagram to analyze the causes of frequent needlestick injuries among staff. Causes were grouped into categories like training (People), hospital procedures (Methods), equipment design (Machines), and work environment. By addressing those root causes, the hospital cut needlestick incidents from 11 cases in 2018 to just 2 cases in 2021 – a clear testament to the technique’s effectiveness in healthcare quality management (Kumah et al., 2023).

Similarly, in finance and banking, risk management teams use Fishbone Diagrams to identify underlying causes of service outages or process failures (e.g., ATM network downtime causes might be traced to categories such as Software bugs, Hardware faults, Human error, Vendors, etc.). The approach is equally valued in aviation and energy industries, where rigorous root cause analysis is mandated for safety and reliability. In fact, the National Institutes of Health (NIH) and other agencies publish guidance encouraging the use of fishbone diagrams as part of comprehensive RCA in various fields.

Crucially for IT professionals, the Fishbone Diagram has been formally recognized in ITIL and other ITSM frameworks as a useful problem-solving tool. As early as ITIL v2 and v3, Ishikawa diagrams were referenced in the context of Problem Management for determining root causes of incidents. ITIL v4 continues this guidance by listing cause-and-effect diagrams among recommended RCA techniques (Axelos, 2019). The ISO/IEC 20000-1:2018 standard for IT service management (which aligns closely with ITIL practices) likewise endorses structured RCA. A template for corrective action aligned to ISO 20000 suggests methods like the “5 Whys” or “Fishbone Diagram” for investigating root causes. Even in information security standards (e.g., ISO/IEC 27001:2022, Annex A.16, or NIST SP 800-61 Rev. 2 on incident handling), performing a root cause analysis post-incident is considered best practice, with fishbone diagrams being one of the techniques available to analysts (ASQ, n.d.; Axelos, 2019; CMS, 2018; ISO/IEC, 2018; ISO/IEC, 2022; Kumah et al., 2023; NIST, 2012).

Over the decades, practitioners have also developed variations and enhancements of the basic fishbone concept. Ishikawa’s original model described the “6 M’s” (Materials, Machinery, Methods, Manpower, Measurements, Mother Nature) as generic cause categories for manufacturing. In service industries, categories have been adapted to the “4 S’s” (Surroundings, Suppliers, Systems, Skills) or other mnemonics to suit different contexts. There are also offshoots like the reverse fishbone (starting from potential causes to explore possible effects) and the CEDAC (Cause-and-Effect Diagram with Addition of Cards), which incorporates an idea generation aspect. Regardless of variant, the core principle remains: systematically brainstorm and organize all possible causes of a problem, then drill down to find the root cause(s) (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

In summary, what began as a simple quality control diagram in 1960s Japan has evolved into a versatile, cross-industry problem analysis tool. The Fishbone Diagram’s longevity and broad adoption stem from its ease of use, ability to foster collaborative discussion, and visual clarity in linking causes to effects. For IT organizations dealing with complex systems and interconnected services, these attributes make the Ishikawa diagram especially valuable. Next, we will examine the structure of a Fishbone Diagram in detail – understanding its anatomy is key to applying it effectively in an ITIL Problem Management context (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

Structure of a Fishbone Diagram

At its core, a Fishbone Diagram is a visual brainstorming tool that organizes possible causes of a problem into a structured format. The diagram’s layout resembles a fish skeleton: a horizontal arrow pointing to the right acts as the fish’s spine and points to the “head,” which contains the problem statement or effect. Diagonal lines (the “bones”) branch off from the spine, each representing a major category of causes. Further sub-branches can be drawn off each bone to capture more specific contributing factors (these are the smaller bones or ribs). This hierarchical arrangement visually maps relationships between a problem (effect) and its potential causes.

Figure 1: Generic structure of a Fishbone (Ishikawa) Diagram (Lucidchart, n.d.).

 

Figure 1 shows a sample Fishbone disgram. In the example, the “head” on the right contains the problem statement (effect) - Low website traffic. Main cause categories branch off the central spine as the primary “bones.” Causes and sub-causes are listed along these bones, forming smaller branches. This example shows categories (People, Promotion, Positioning, Packaging, Price, Production, Place), with a hypothetical problem at the head. We will discuss these components of the fishbone diagram in the next sections.

The Head (Problem Statement)

The head of the fishbone diagram is a box or shape that contains a clear, concise description of the problem or effect under investigation. In IT terms, this could be an incident symptom (“Frequent website downtime on e-commerce portal”) or a broader problem description (“High failure rate in nightly data backups”). It’s crucial to define the problem precisely; a poorly defined problem leads to a confusing analysis. Best practices suggest specifying what the issue is, where/when it occurs, and its impact. For example, instead of “Database is slow,” a better head statement might be “Database response time >5 seconds during peak 2-4 PM, affecting order processing transactions.” A well-defined problem anchors the Fishbone Diagram and ensures the team’s brainstorming stays on target.

The Spine

A straight line runs from the head to the left, forming the backbone of the fish. This line represents the connection between the effect and its potential causes. It is usually drawn horizontally. The spine itself is not labeled, but it provides a timeline-like or relationship axis onto which causes will be attached. Think of it as pointing from cause (left) toward effect (right).

Primary Cause Categories (Main Bones)

Off the spine, several major branches are drawn at approximately 45-degree angles, like ribs. These are the main cause categories under which specific causes will be listed. In traditional diagrams for manufacturing and production, the six classic categories – often called the “6 M’s” – are:

  • Materials,
  • Machines,
  • Methods,
  • Manpower,
  • Measurements,
  • Mother Nature (Environment).

Ishikawa proposed these as a starting point, but importantly, he encouraged practitioners to adapt category names to fit their context. In an IT setting, the categories are typically adjusted to reflect IT service components. A common approach (suggested by ITIL4’s guiding principles) is to use the four dimensions of service management, for example: (ASQ, n.d.; CMS, 2018; Kumah et al., 2023)

  • People,
  • Processes,
  • Technology, and
  • Partners/Suppliers.

Some IT teams expand this to six categories, such as:

  • People
    • e.g., skills gaps, human errors, lack of training.
  • Process
    • e.g., missing or outdated procedures, unclear roles, bottlenecks.
  • Technology (Systems)
    • e.g., software bugs, hardware failures, capacity issues.
  • Environment
    • e.g., power, cooling, physical environment, or network conditions.
  • Tools
    • e.g., monitoring or CI/CD tools misconfigurations, inadequate tooling.
  • Management
    • e.g., policy issues, governance, lack of oversight or resources.

These are just examples – the facilitator can choose any category labels that make sense for the problem domain. The key is that categories should be broad classes of causes, not specific causes themselves. For instance, “Software” could be a category, whereas “memory leak in module X” would be a specific cause to list under that category. Using appropriate categories helps ensure that brainstorming covers multiple perspectives of the problem (e.g., considering both technical and human factors). It also organizes the brainstorming output, which makes analysis easier.

It’s worth noting that different industries have developed their own standard categories: manufacturing uses the 6M’s; service industry might use 4P’s (Policies, Procedures, People, Plant/Place) or 5S’s; marketing might use 8P’s (Price, Promotion, People, Processes, etc.); project management might use categories like Cost, Time, Scope, Resources. In IT Problem Management, common category sets include the ones mentioned above. The ManageEngine ITSM guide recommends starting with People, Process, Technology, and Partners (the suppliers/third-parties) and adding others as needed (ManageEngine, 2023; ManageEngine, n.d.). The bottom line is: select categories that will best prompt the team to think of all relevant causes. You can even start with more categories and consolidate later (or start with a few and split if a category becomes too crowded).

Secondary and Tertiary Causes (Sub-bones)

Once the main categories (primary bones) are established, the team brainstorms specific potential causes within each category. These are drawn as smaller lines branching off the appropriate category “rib.” For each cause identified, the question “Why does this happen?” can be asked to drill down further, adding another layer of sub-causes if needed. This iterative probing is similar to applying the 5 Whys technique but in a divergent, graphical way for each branch. For example, if “Inadequate Testing” is listed under the Process category as a cause of software failures, a sub-branch might be:

  • “Why? → No formal QA process”
    • which could further branch into
  • “Why? → Lack of QA staff or tools.”

This cascading structure can continue until the team reaches root causes that are actionable or cannot be further broken down. Typically, three or so levels deep is sufficient to reach an actionable root cause, but complex problems might require four or five levels of branching.

It’s important to write each cause or factor as clearly and specifically as possible. Avoid vague terms. For instance, writing “Human Error” on a branch is not very helpful by itself (it’s too general and could fit anywhere); instead, specify “Server patch applied to wrong environment” or “Typing mistake in firewall rule” as a cause under a relevant category (Process or People). Each entry should describe a distinct contributing factor that could plausibly lead to the problem at the head.

Relationships and Causal Chains

The fishbone is fundamentally a cause-and-effect diagram. The structure implies that items on the smaller branches contribute to the item they attach to. For example, a branch might read as:

  • “Process → Change Management process not followed → Emergency change made without testing → System crash in production.”

Here, the chain indicates that not following the change process (cause) led to an untested change (sub-cause), which led to the crash (effect). The diagram visualizes these relationships all in one view. It is essentially a mind map of causes, but drawn in a standardized format.

By the end of a brainstorming session, a fishbone diagram might have dozens of entries across its various branches. This can look a bit overwhelming, but it provides a holistic view of all possible causes the team has thought of. One advantage of the fishbone’s structure is that it naturally groups related ideas together, which can help in discussing and analyzing them. For example, you may notice a cluster of causes under “People” and few under “Technology,” indicating human factors might be more dominant for this problem (or maybe that the team had more insight into people issues). Patterns like these become visually apparent.

Standard Categories: The 6 Ms and beyond

As mentioned, the 6M framework is one classic set of categories. Let’s briefly explain each, as they are still instructive even for non-manufacturing scenarios:

  • Materials:
    • All physical (or in IT, digital) inputs to the process – in IT this could mean data inputs, configurations, documents, etc. In manufacturing, it’s raw materials or components. In a software context, “materials” might be source code, requirements documentation, or third-party libraries.
  • Machines:
    • Tools, technology, equipment used – in IT, this covers servers, network devices, computers, as well as software systems and applications. Any hardware or software resource that could fail or behave incorrectly fits here.
  • Methods:
    • The processes, procedures, or methodologies in place for how work is done. For IT, this could be deployment procedures, development lifecycle processes, ITIL processes, etc. Often, process deficiencies or lack of process (ad hoc approach) end up on this branch.
  • Manpower (People):
    • Human aspects – staff skills, training, human errors, communication issues, staffing levels. Anything related to the people involved in the process or system.
  • Measurement:
    • How performance is measured or data collected. In manufacturing, this might involve calibration of measuring instruments or metrics. In IT, it could relate to monitoring systems, KPIs, or error logging. Poor monitoring or inaccurate data can lead to problems or hide the true issues.
  • Mother Nature (Environment):
    • The physical environment and external conditions. In factories, this might mean temperature, humidity, dust – any environmental factor. In IT, “environment” can be interpreted as both the physical environment (power supply, cooling, weather impacting data centers, etc.) and the broader context, like regulatory environment or external threats (e.g., a branch for “External” causes such as vendor problems or cyber-attacks) (Marquis, 2009).

Some modern adaptations add a seventh “M: Money”, to explicitly consider budget and financial constraints as a cause category. While not always included, it’s a reminder that sometimes the root cause of a technical issue might be funding-related (e.g., delayed upgrades due to budget cuts).

Again, in practice, you would tailor these categories. In an IT incident review, it’s not uncommon to simply label categories in plain language like “Software, Hardware, Network, User, Process, External”. For instance, a Fishbone for a “Website Slow Response” might use categories: Frontend, Backend, Network, User Behavior, Processes, 3rd Parties. As long as the categories comprehensively cover the space of potential causes and are meaningful to participants, the choice is flexible.

Completing the Diagram

A fishbone diagram is usually considered complete when the team has exhausted their ideas – when no new causes are being suggested in any category. At that point, the diagram is a repository of hypotheses. The next step is analyzing and prioritizing these causes to find which are the root cause(s). We will discuss facilitation and analysis in upcoming sections, but structurally it’s common to highlight or circle those causes on the fishbone that are believed to be the most significant contributors, once identified. Sometimes teams will use “multi-voting” or dot-voting on the fishbone (each member places a few dot stickers on the causes they feel are most likely) to gauge consensus on where to investigate first. This can be an effective way to narrow down from a broad list of possible causes to a critical few that are likely root causes.

Fishbone Diagram Structure Summary

In summary, the Fishbone Diagram’s structure—head, spine, category bones, and sub-branches—provides a logical and visual way to break down a problem. It encourages teams to think in terms of cause categories and relationships rather than jumping to a single assumed root cause. This structure makes it a powerful tool for root cause analysis, ensuring that investigation remains systematic and exhaustive. According to Kumah et al. (2023), the fishbone diagram “narrows the scope of an investigation to be more manageable or actionable and generates possible causes that teams can act on, visualizing relationships between all possible causes for a focused problem and establishing a shared understanding of the possible causes and solutions.” The American Society for Quality similarly notes that the fishbone diagram “helps users identify the many possible causes for a problem by sorting ideas into useful categories” (ASQ, n.d.). Together, these perspectives highlight the diagram’s dual strength in fostering both analytical depth and collaborative insight. In the next section, we will focus specifically on how the Fishbone Diagram is applied within ITIL Problem Management, tying this structure into the IT service lifecycle and Problem Management workflow.

Fishbone Diagram in ITIL Problem Management

ITIL (Information Technology Infrastructure Library) defines Problem Management as the process responsible for managing the life cycle of problems – where a “problem” is the underlying cause of one or more incidents. A core objective of Problem Management is to identify root causes of incidents and ensure permanent fixes or workarounds are implemented to prevent recurrence. In essence, Problem Management is preventative (stop incidents from happening again), whereas Incident Management is reactive (restore service when an incident occurs). The Fishbone Diagram, with its structured root cause mapping, is an ideal tool in the Problem Manager’s arsenal for performing Root Cause Analysis (RCA) within the ITIL framework (ITIL, 2019).

Role of RCA in ITIL

ITIL emphasizes that effective Problem Management requires systematic RCA. The ITIL 4: Problem Management Practice Guide (Axelos, 2020) explains that organizations employ several analytical approaches when investigating problems. It specifically notes that “root cause analysis techniques, such as 5 Whys, Kepner and Fourie, and fault tree analysis” are commonly used to identify underlying causes (Axelos, 2020, p. 14). While Ishikawa (fishbone) diagrams are not named in that excerpt, they are widely recognized in ITSM literature as a popular method for structured brainstorming of causes. Many ITSM practitioners consider Ishikawa diagrams a de facto component of Problem Management. Hank Marquis (2009) notes that “anyone with ITIL certification has heard of Ishikawa or fishbone diagrams, usually in the context of Problem Management,” even if they haven’t used them in practice. The IT Infrastructure Library assigns Problem Management the responsibility for finding root causes of events or faults, and fishbone diagrams are a natural fit for organizing and visualizing those causes (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

In ITIL’s life cycle, after a major incident is resolved by Incident Management, a Problem record is often raised to investigate why it happened. This is where a Fishbone Diagram might be employed by the Problem Manager and their team. Reactive Problem Management (investigating after incidents) uses fishbones to dissect what went wrong, while Proactive Problem Management (identifying weaknesses before incidents occur) might use fishbones to analyze incident trend data or known error data for potential future issues. The goal in both cases is the same: find root causes so they can be eliminated, or at least mitigated, ensuring higher service availability and quality.

Using Fishbone during Problem Analysis

Let’s walk through how a Fishbone Diagram might be integrated into the ITIL Problem Management workflow:

  • Problem Identification:
    1. A problem is logged (either reactively, after incidents, or proactively via trend analysis or risk assessment). For instance, suppose there have been five similar incidents of an e-commerce website freezing under load. A problem record “WebStore freezes during high traffic” is created. The Problem Manager defines the problem statement clearly (this becomes the “head” of the fishbone). As per ITIL guidance, this should include what the service impact is, when/where it occurs, etc., so that it’s well scoped. For example: “WebStore application unresponsive for 2-3 minutes during peak 7-9pm traffic, affecting checkout transactions, observed 5 times in last month.”
  • Assembling a Team:
    1. Problem analysis in ITIL is collaborative. The Problem Manager will involve relevant subject matter experts – e.g., the WebStore development lead, a database admin, a network engineer, the service desk lead who handled incidents, etc. This cross-functional team brings diverse perspectives (technology, process, user experience, etc.). They schedule a problem analysis meeting (or series of meetings). One popular approach is to conduct a blameless post-mortem meeting after a major incident, which often includes root cause brainstorming using a fishbone or similar diagram.
  • Brainstorming Causes (Fishbone Session):
    1. During the analysis phase, the team uses the Fishbone Diagram to structure their brainstorming. A facilitator (often the Problem Manager or an experienced analyst) will draw the fishbone layout – either physically on a whiteboard/flipchart or using a digital tool (more on tools later). The problem statement is written in the head. Then, the facilitator adds a few initial categories as main branches. In an ITIL context, typical categories might be aligned with ITIL’s four dimensions or known areas of failure: e.g., (1) Application, Database, Server/Infrastructure, Network, User/Customer, Process/Policy, External (some of these are technical, some process/people). The ManageEngine ITIL guide suggests starting with People, Processes, Technology, Partners as a baseline, and indeed many IT fishbones begin with similar broad buckets (ManageEngine, 2023; ManageEngine, n.d.).

The team then brainstorms causes for each category. Often, each participant is encouraged to contribute ideas – a useful technique mentioned in quality literature is to have everyone write their ideas on sticky notes first, then place them on the diagram under the relevant category. This encourages quieter members to contribute and yields a lot of input quickly. In our WebStore example, under Application category, the dev lead might say “Possibility of a memory leak in the checkout module” – that goes as a branch. Under Infrastructure, the ops engineer might add “Insufficient CPU capacity on web servers.” Under Process, maybe “No load testing done before releases.” Under User, perhaps “Unusual user behavior or traffic spikes (bots?)” is noted. The facilitator ensures the group goes around systematically for each category, asking “What could cause this effect?”.

This session should be a judgment-free brainstorming – all ideas are welcome, and they are just hypotheses at this stage. ITIL promotes a culture of collaboration rather than blame, which is essential in these discussions. The fishbone diagram serves as a focal point that externalizes the problem – it’s not about who caused what, but what factors caused the outage. It’s also a visual knowledge capture; Marquis (2009) observes that “just getting all the ideas of a group organized into a diagram dramatically speeds problem diagnosis and resolution” in IT troubleshooting.

  • Analyzing and Identifying Root Cause(s):
    1. Once the fishbone is populated with many possible causes, the team moves into analysis. They discuss which causes seem most likely or had evidence during the incidents. They may mark some causes as confirmed or refuted based on data (for example, logs might show that CPU hit 100% at the times of freeze – supporting the “Insufficient capacity” cause). They might also perform deeper analysis on certain branches: e.g., taking one cause and doing a quick 5 Why on it to see if there’s a deeper reason (if not already captured). The fishbone diagram is a guide here – the group can systematically go through each main branch and evaluate the items. This is where other techniques can complement fishbone: for instance, the Pareto analysis could be applied if there’s historical data about incidents – focusing on which cause appears most frequently. Or a fault tree analysis might be constructed for the technically complex branch to logically verify how a combination of causes could lead to the effect.

In ITIL Problem Management, typically one or a few “root causes” are identified and documented in the problem record (along with a Known Error record if applicable, and a workaround or permanent fix). The fishbone diagram often helps surface these root causes. For example, the team might conclude that the primary root cause of the WebStore freezes was “Application memory leak due to improper session handling under high load” – which falls under Application (with a sub-cause that developers didn’t catch it due to lack of load testing, linking to a Process cause). Another contributing root cause could be “No failover mechanism on the app server cluster” (Infrastructure gap). These would be recorded, and then Problem Management moves to the resolution phase – initiating changes to fix the code and add redundancy.

It’s not uncommon that multiple root causes or contributing causes are identified (hence sometimes the term “Cause and Effect diagram is more apt than singular “root cause”). ITIL teaches that complex problems may have more than one root cause and might need multiple corrective actions. In such cases, the fishbone can help organize which causes have been addressed by which actions. Some teams annotate the fishbone with notes like “FIXED” or dates when a solution was implemented next to certain branches, to track that each cause was handled.

  • Documentation and Knowledge Management:
    1. After the session, the fishbone diagram (if on a physical board) is transcribed into an electronic format – many teams take a photo of the whiteboard or recreate the diagram in a tool like Visio, Lucidchart, or even an Excel template. The Problem record in the ITSM system (e.g., ServiceNow, JIRA Service Management, etc.) will include the root cause description and likely an attachment or reference to the RCA analysis like the fishbone diagram. This becomes part of the organization’s knowledge base (KEDB – Known Error Database, in ITIL terms). Should a similar incident occur in the future, this documentation helps response teams quickly find the historical causes and fixes.

Using a fishbone diagram in ITIL Problem Management provides several benefits:

  • It brings a structured approach to what can be a messy analytical process. IT problems often have technical, organizational, and external facets; the fishbone ensures each gets examined systematically.
  • It encourages collaboration and shared understanding. People from different teams contribute their insights, which builds a more complete picture and avoids siloed thinking. This aligns with Ishikawa’s original intent of cross-functional quality improvement. (ASQ, n.d.; CMS, 2018; Kumah et al., 2023)
  • It helps separate symptoms from causes. By explicitly writing things out, the team can question: is this a root cause or just a symptom? (One of the facilitator’s tasks is to challenge vague entries – e.g., if someone put “Outdated technology” as a cause, you’d probe “What about it? Is it causing performance issues or unsupported? Let’s be specific.”). ITIL problem management stresses focusing on the real cause, not just what happened.
  • It integrates well with other ITIL practices. For example, Continual Service Improvement (CSI) can use fishbone diagrams to analyze why a KPI is not meeting targets (like why the SLA compliance dropped, using categories like People, Process, Tools, etc.). In Change Management, a fishbone might be used to analyze failed changes. In Information Security Incident Management (which often dovetails with Problem Management for root causes of breaches), fishbone diagrams can map out how/why an intrusion succeeded (with categories like People, Process, Technology, as often multiple breakdowns lead to a breach).

It is important to realize that while fishbone diagrams aid in finding root causes, they do not automatically tell you the root cause – human judgment and often further data analysis are needed to validate which of the many identified causes is truly responsible. ITIL Problem Management typically requires evidence or at least logical verification of a root cause (sometimes using techniques like replication of the problem in a test environment, or linking to diagnostic data). The fishbone provides the hypotheses to test; the problem analyst must then drill down and confirm the actual cause(s). An advantage noted by one source is that a fishbone diagram “documents which causes are targeted for data collection or have already been verified with data,” serving as a checklist of what to investigate next (Kumah et al., 2023, para. 18).

In summary, the Fishbone Diagram is a natural fit for ITIL Problem Management, supporting the process of RCA that is at the heart of preventing future incidents. It transforms the often overwhelming task of diagnosing complex IT problems into a more approachable, team-oriented exercise. Visualizing possible causes helps ITIL practitioners ensure that no stone is left unturned in the hunt for the true root cause. Next, we will provide guidance on how to effectively facilitate a Fishbone Diagram session in practice, which will be useful for Problem Managers or anyone leading a root cause analysis meeting.

How to Facilitate a Fishbone Analysis Session

Conducting a Fishbone Diagram session requires both methodological discipline and good facilitation skills. Whether it’s a quick 30-minute brainstorm or a multi-day RCA workshop for a major outage, following a structured approach will maximize the diagram’s effectiveness. Below are steps and tips for facilitating a productive fishbone analysis, tailored to an IT environment:

1. Preparation

Before the session, do your homework. Ensure the problem statement is well-defined and agreed upon. If possible, gather some initial data about the incident or problem (logs, error messages, user reports) and share a summary with participants. Determine which people should be in the room (or call) – include those with relevant technical knowledge, and also someone who can speak to processes or user impacts if applicable. Aim for a cross-functional group but keep it to a manageable size (perhaps 5-10 people) so that discussion remains focused. Also, decide on the medium: will you use a physical whiteboard with sticky notes or a digital collaboration tool? In today’s dispersed teams, tools like Miro or Lucidchart can serve as a virtual whiteboard where everyone can add notes in real time. If using a tool, set up the fishbone template in advance with the problem at the head and some likely categories drawn to save time.

2. Set the Stage (Intro to Session)

As the session begins, clearly state the purpose: “We are here to identify all potential causes of [Problem X] in order to determine its root cause(s) and prevent recurrence.” Emphasize that this is a blameless analysis – the goal is not to assign fault to individuals, but to understand what in the system or process allowed the problem to occur. Establish ground rules: encourage creative thinking, allow all voices to be heard, and defer judgement of ideas. It may help to briefly explain the fishbone method if participants are not familiar, perhaps showing a quick example. If time permits, you could note categories you plan to use (and that they can be adjusted as needed).

3. Draw the Skeleton

Draw the fishbone diagram with the problem statement in the “head” (right side) and a long horizontal line for the spine. Confirm everyone agrees on the wording of the problem. Sometimes spending an extra few minutes refining the problem statement pays off by aligning everyone’s understanding. For example, clarify scope: are we analyzing one specific incident occurrence, or a pattern over time? Once the head is finalized, add the main category “bones” branching off. You can start with a standard set (like People, Process, Technology, Environment, etc.) or ask the group what categories might make sense for this problem. If using a standard set, mention that these are a starting point and we can add or change categories if needed. The ManageEngine guidance suggests it’s easy to start with known broad categories, then tailor – for instance, if during brainstorming a category gets overloaded, you might split it; or if one stays empty, you might decide to drop or merge it (ManageEngine, 2023; ManageEngine, n.d.).

4. Brainstorm Causes

Now, facilitate the brainstorming of causes for each category. One effective technique is round-robin brainstorming: go category by category, asking each participant in turn for one idea at a time. For example, “Let’s start with People – what are some potential people-related reasons for this issue? Alice?” If Alice gives one, then ask Bob, and so on. Write each cause as a short phrase on a branch off that category. Continue around, possibly multiple rounds, until ideas are exhausted for that category, then move to the next category. Another technique is silent brainstorming with sticky notes: give everyone 5 minutes to write down causes on sticky notes (real or virtual) and then place them under the categories they think fit. The facilitator can then read them aloud and cluster duplicates. This method is good for generating a lot of ideas quickly and involving introverted people. Encourage specificity. If someone suggests a vague cause, ask clarifying questions: “What do you mean by ‘configuration issues’? Can you elaborate or give a specific example?” Then refine it to something like “Configuration drift – servers not consistently patched.”

As facilitator, manage the pace: keep the conversation moving, but also ensure people have time to think. You might encounter lulls; try prompting with different angles: “Think about recent changes – could any change have introduced this issue (under Process)?” or “Could any external factors be at play (under Environment)?” Use the categories as prompts themselves. Also watch for people fixating on one branch – if the team goes deep down one rabbit hole (say they keep talking about a database issue), gently park detailed debate on that (maybe note it as a sub-cause to explore later) and redirect to gather causes in other categories. This ensures a broad exploration rather than a premature deep dive on one idea.

Keep an eye out for cause-and-effect confusion: sometimes, a participant might mention what is actually an effect or symptom rather than a cause. For example, “High CPU usage” might be raised as a cause of slow performance, but high CPU is itself an effect likely caused by something else. In such cases, ask “why do we have high CPU?” and turn it into a cause like “Insufficient capacity” or “Inefficient code causing high CPU”. It’s fine to note the observed symptom as a starting point, but the diagram should drive toward underlying causes.

Allow some creative speculation too – sometimes the cause might not be obvious. In one major incident review, someone proposed, “Could it have been a DDoS attack by competitors?” – even if far-fetched, recording it under Environment as “Potential DDoS attack” ensures it gets considered or ruled out with evidence later. The fishbone is a living hypothesis list, so capturing all plausible causes is helpful.

5. Dig Deeper with Why’s

If the group identifies a cause that can be further dissected, encourage them to ask “why” and add sub-branches. For instance, suppose on the Process bone someone said “Lack of code review”. You could ask, “Why do we lack code review? Is there no policy, or was it not followed?” This might produce sub-causes like “No code review policy in place” or “Developers under time pressure skip reviews”. Write those as smaller branches. This is essentially integrating 5 Whys analysis into the fishbone session. According to Kumah et al. (2023), the fishbone diagram and the five-whys technique are commonly “used together to identify the root cause of a problem”. The fishbone provides structure and breadth, while 5 Whys provides depth on any given chain of causation. Use this combination selectively – not every branch needs a 5-why drilling, just where the root cause isn’t obvious or the team has insight to go deeper.

6. Maintain Participation

As facilitator, ensure everyone participates. IT discussions can sometimes be dominated by senior engineers or outspoken individuals. To counter this, explicitly ask quieter members for their thoughts: “John, you work with this system daily, any causes you think of in the Tools category?” Or go around the virtual room systematically. Also, be mindful of hierarchy – if a manager is present, they should refrain from shooting down ideas. It may be worth reminding the group: “All ideas are valid at this stage; we will evaluate them later.” Create a safe environment for brainstorming.

7. Avoid Blame Game

If someone brings up a cause that implicates a team or person (e.g., “Operator didn’t follow procedure”), keep the language neutral and focus on process causes. You might rephrase it as “Procedure not followed” or “Process gap: no validation step” – shifting from blame to what in the system allowed the mistake. This aligns with the idea of human error as a symptom of deeper issues. It’s fine to note human errors, but pair them with reasons (training gap, fatigue, unclear documentation). This approach is common in post-incident reviews to promote learning over blaming.

8. Time Management

Depending on the complexity, a fishbone session can range from 15 minutes (for a simple issue) to multiple hours (for a major problem). If time is limited, focus on main categories first and identify at least a few causes in each. You can always revisit or detail out sub-causes later. It’s better to have a roughly complete fishbone than an overly detailed half-fishbone. Watch the clock per category – e.g., give ~5-10 minutes per main category initially, then loop back if needed.

9. Wrap-Up and Next Steps

When the flow of new ideas peters out (you’ll notice more pauses, or repetition of earlier points), it’s time to conclude brainstorming. Review the diagram aloud: summarize each main branch and its causes. This helps validate that everyone’s input was captured correctly and nothing obvious was missed. Ask if there are any final additions. Then discuss initial impressions: Does any cause stand out as most likely? Often the team already has hunches – maybe 3 of 5 people feel the database connection leak is a prime suspect. You can highlight those items (circle or mark them). If time permits, you might do a quick prioritization vote. For example, give each person 3 votes (dots or checkmarks) to mark the causes they think contributed the most to the problem. Causes with the most marks can be flagged for deeper investigation. This multi-voting technique is recommended in some RCA guides as a way to focus efforts on likely root causes.

Crucially, define action items: e.g., “Alice will pull memory usage logs to see if the memory leak hypothesis holds,” “Bob will verify if the patching process was skipped,” “Carol will simulate the scenario in the test environment to reproduce it.” Essentially, the fishbone’s output needs to feed into verifying and addressing causes. In ITIL Problem Management, this could mean raising change requests or tasks to implement fixes for confirmed causes, or further problem tasks to investigate uncertain causes. Make sure someone is assigned to document the fishbone (if it’s not already in a digital format). Also, plan to update the Problem record with the findings.

10. Follow-Through

After the session, as the team collects evidence and confirms which cause(s) were actual root causes, update the diagram or at least note it in the documentation. For example, if logs confirm the memory leak, you might annotate the fishbone branch “YES - confirmed by log analysis.” If another cause was investigated and ruled out, mark it “NO - not a factor (ruled out by test).” This practice ensures the RCA is thorough and also helps anyone reading the report understand which ideas were tested and eliminated (iSixSigma, n.d.). It’s frustrating when an RCA report lists a bunch of possibilities but doesn’t clarify which one was the true culprit – avoid that by clearly highlighting the root cause on the fishbone or in the summary.

Additionally, capture any lessons learned about the process. Perhaps during the session, the team found that documentation was lacking (which itself might have been a cause). That insight can be fed into Continual Improvement: e.g., “We need to update our knowledge base for handling future incidents of this type,” or “We should train operators on the new procedure.” The fishbone session might expose systemic issues beyond the immediate problem.

Facilitation Tips & Common Pitfalls

A skilled facilitator will guard against several pitfalls:

  • Pitfall: Lack of detail or too much detail.
    • If causes are noted too generally, the analysis may not be actionable (“network issue” isn’t actionable, but “DNS misconfiguration causing lookup delays” is). Conversely, writing a whole paragraph on the diagram is counterproductive – it should be succinct phrases. Strike a balance by using concise, specific terms.
  • Pitfall: Jumping to conclusions/solutions.
    • Team members might try to debate solutions in the middle of brainstorming (e.g., “If it’s the database, we should upgrade the server”). Gently refocus them: “Hold on solutions for now, let’s first agree on causes. We’ll get to fixes soon.” The fishbone is about what and why, not how to fix – that comes afterward.
  • Pitfall: Grouping errors – e.g., putting a cause in the wrong category might confuse people (“QA skipped” under Machines? That doesn’t fit).
    • As facilitator, you can reposition an item to the appropriate category if needed (or copy it to two categories if it relates to both). Some causes do intersect categories; you can cross-reference them on the diagram if that helps (or repeat them under each relevant category).
  • Pitfall: Domination and bias.
    • Avoid one person or one theory dominating too early. If the senior architect says “It must be the vendor’s fault” and everyone else goes quiet, you risk confirmation bias. Encourage exploring all categories systematically, and perhaps hold off discussion on that one pet theory until other ideas are out.
  • Pitfall: Incomplete participation or missing perspective.
    • If the fishbone is heavily filled in technical branches but nearly empty on process/people, and you know the incident had human elements, it may indicate the team lacks someone with that perspective (maybe no one from the operations team present to speak to procedural causes). Recognize that and consider following up separately with those stakeholders or scheduling another short session to fill that gap.
  • Pitfall: Not validating results.
    • One of the biggest mistakes is to treat the output of brainstorming as fact without further validation (iSixSigma, n.d.). The fishbone is a hypothesis generator; it should lead to verification steps. Ensure the team plans how to validate the likely causes (through testing, data, etc.) before implementing changes, otherwise you might fix the wrong thing.

By adhering to a structured facilitation approach and avoiding these pitfalls, a Fishbone session can be highly effective. Participants often report that just the act of diagramming the problem makes them understand it better. It “visualizes the relationships between all possible causes for a focused problem” and “establishes a shared understanding of the possible causes”. Moreover, it makes the RCA process more engaging – people feel like detectives solving a mystery together, rather than slogging through a document. In IT cultures that value firefighting heroics, introducing structured RCA techniques like fishbone sessions can shift the mindset towards proactive problem prevention (a key ITIL principle).

Having covered facilitation, let’s turn to some common pitfalls and challenges in using fishbone diagrams (beyond just facilitation missteps). Understanding these will help practitioners use the tool more effectively and be aware of its limitations.

Common Pitfalls and How to Avoid Them

While Fishbone Diagrams are straightforward to use, several common pitfalls can undermine their effectiveness. Recognizing these pitfalls and applying countermeasures will lead to more reliable root cause analysis results. Let’s explore some of these in detail next.

Poorly Defined Problem Statement

This is a foundational pitfall – if you start with the wrong or vague problem definition, the analysis will wander in the wrong direction. For example, a problem stated as “Database issue” is too broad; the team might identify causes that have nothing to do with the actual pain point. Always refine the problem statement to be specific and measurable (what system, what symptom, when, how often). In ITSM, use incident data to pinpoint what exactly needs analysis. If multiple symptoms are occurring, consider focusing on one at a time or doing separate diagrams. Avoid combining multiple issues into one fishbone – it muddles the cause-effect focus. If you suspect more than one distinct problem, create multiple diagrams or clearly delineate in the head what effect you are analyzing.

Superficial Causes (Symptoms vs. Causes)

A common mistake is listing symptoms or proximate causes, but not tracing back to underlying causes. For instance, saying “Service crashed” on a cause branch is just restating the problem. Or listing “High CPU” or “High memory usage” as causes – those describe the state that resulted, not why that state occurred. To avoid this, enforce asking “Why?” until you reach a cause that is actionable and not just descriptive. If you can’t reasonably ask “why” one more time, you might be at a root cause. Also, differentiate between contributing factors and root causes: contributing factors (like heavy user load) might exacerbate the issue, but the root cause could be a software bug that fails under load. Ensure the diagram captures both, but in analysis, highlight the root cause. A good practice: for each branch, ask, “If we eliminate this cause, would the problem have been avoided?” If not, it might not be a root cause but just a contributing factor or symptom.

Too General Categories or Causes (Lack of Detail)

If the fishbone remains at a high level and lacks detail, it won’t guide specific actions. For example, a branch “Process failure” is too vague to act on. The iSixSigma forum notes that lack of detail is a hindrance; causes written as single words like “Communication” or “Training” without context could mean anything. Remedy this by fleshing out causes: “Communication breakdown – Dev team not informed of patch schedule” is far clearer. Each cause entry should ideally include a subject and an action or condition (not just a one-word noun). On the flip side, avoid writing essays on the diagram (too much detail), which can overwhelm and make the diagram unreadable. The fishbone should be concise; you can always attach supporting data or an explanation in a report (iSixSigma, n.d.).

Analysis Paralysis (Too Much Detail)

Another side is when teams try to map every tiny nuance and draw five levels of bones with exhaustive detail. While thoroughness is good, the diagram can become unwieldy. Remember, a fishbone is a starting point to identify areas for deeper analysis – not every detail needs to be on the diagram itself. If you find a branch getting very detailed, consider summarizing parts of it or breaking it into a separate sub-diagram. For instance, you might do a separate mini-fishbone for “Causes of inadequate testing” if that itself is complex, rather than cluttering the main diagram. Keep the main fishbone focused on primary and secondary causes; use additional notes or sub-diagrams for extreme detail if needed.

Confirmation Bias and Groupthink

Teams might latch onto one cause early (especially if a strong personality suggests it) and unconsciously skew the brainstorming towards that cause, neglecting others. This bias can lead to the fishbone being filled lopsidedly – e.g., 10 causes under “Software” and nothing under “Process” because everyone assumed a software bug. To counter this, facilitators should consciously spend time on each category and perhaps brainstorm categories in a different order (not always starting with the obvious technical one). Another trick: ask members to brainstorm independently first (which reduces influence of others’ opinions) and then compile the results. Also, consider inviting an outsider or someone from a different team to the session – they may ask naive questions that challenge assumptions and reveal overlooked areas.

Not Validating Causes with Data

One risk of fishbone diagrams, as noted in a healthcare quality study, is they can generate both relevant and irrelevant potential causes, which could lead to chasing false leads if not validated. After the brainstorming, failing to validate the suspected causes is a pitfall. In IT, there’s often data available (logs, monitoring metrics) – use it to confirm or rule out causes. For example, if “Disk full” is on the diagram, check the disk usage at incident time. If “Coding error in module X” is suspected, test that module. Not validating can result in implementing fixes for problems that never existed, while the real cause remains. ITIL Problem Management recommends confirming the root cause with evidence or replication if possible, before declaring the problem resolved. Ensure the team allocates time/resources to verify causes – this might involve recreating the scenario in a staging environment or instrumenting systems for deeper monitoring.

Stopping Too Soon (One Root Cause Syndrome)

Another subtle pitfall is assuming there must be a single root cause and stopping analysis when you find one. Many problems, especially in IT, are multifactorial. For example, an outage might require a bug and a misconfiguration and a failed alert – a combination of causes. Fishbone diagrams are well-suited to capture multiple contributing causes. Be open to the possibility that more than one thing went wrong (in fact, in major incidents it’s often a cascade of failures). If the analysis only focuses on one cause, you might fix that but the next incident finds a different weak link. Use the fishbone to identify all weak points and address each. That said, beware of analysis fatigue – prioritize which causes to tackle first (Pareto principle can help here: address the 20% of causes that caused 80% of the effect).

Mixing Cause and Effect on Diagram

Sometimes teams inadvertently put an effect as a category or cause, which can confuse logic. For example, making “Downtime” a category for causes of downtime – that’s circular. Each main bone should be a category of causes, not another effect. If an effect is listed as a cause elsewhere on the diagram, it can create loops. Maintain a clear cause→effect direction from left (causes) to right (effect). If a chain is complex (like A causes B, which causes the problem), represent that with sub-branches: A → B on the diagram. If drawn correctly, reading any branch from leftmost cause to the spine should form a plausible “A leads to B leads to problem” sentence.

Overlooking Human and Process Factors

Technical teams may be biased toward technical causes, ignoring that many outages involve process failures or human errors as part of the chain. This is why categories like People and Process are important. A common pitfall is to conclude “root cause = software bug” and ignore that maybe why the bug hit production was a lack of code review or testing (process cause). Or if an ops team misconfigured something, ask why the training or documentation didn’t prevent that (people cause). Always examine not just the direct technical fault, but also any organizational factors that allowed it. Often, addressing those makes the organization more resilient. Many post-incident reports in IT (like Google’s SRE postmortems) highlight process improvements as outcomes, not just technical fixes.

Lack of Collaboration/One-Person RCA

A fishbone done solo or with little input will be limited by that person’s perspective. Sometimes a single engineer will draw a fishbone and declare they’ve found the root cause. This risks missing knowledge that others have. ITIL Problem Management is clear that RCA should be a team exercise for significant problems. One person can start the diagram, but always review it with a broader team. The pitfall here is thinking you know the answer without consulting all stakeholders, which can lead to bias or incomplete cause analysis. As the saying goes, “None of us is as smart as all of us.” The fishbone is a tool to harness that collective insight.

No Follow-up (Analysis done, no action)

Sometimes teams create a great fishbone analysis, identify causes, but then fail to implement corrective actions or track them. This is a serious pitfall because the entire exercise yields no actual improvement. Ensure that for each root cause identified, there is an owner and a plan for resolution (be it a code fix, adding monitoring, updating a process, training staff, etc.). Also, update documentation and feed into knowledge bases as appropriate (e.g., Known Error entries for the causes). In ITIL, Problem Management should ensure a Request for Change (RFC) is raised for the permanent fix, or that the risk is formally accepted if no fix is possible. A fishbone without follow-through is just art on the wall – valuable only if it drives change.

Over-reliance on the Tool

Finally, it’s possible to misuse fishbone diagrams by expecting them to do more than they can. A fishbone won’t rank or quantify causes; it doesn’t replace data analysis or technical debugging. It is a facilitation and visualization aid. Some critics, such as system engineers in high-reliability fields, note that fishbones lack the logical rigor of methods like Fault Tree Analysis (FTA). Fishbones don’t show the interactions between causes (they are mostly a simple list under categories). For extremely complex problems where combinations of factors matter, tools like FTA or causal factor charting might be better. The pitfall would be to stick solely to fishbone if the situation calls for a different approach. Solution: Use fishbone as part of a toolkit. For instance, after brainstorming with fishbone, you might model part of it as a fault tree to evaluate logical AND/OR relationships (like multiple failures needed to cause the outage). Or use fishbone to identify candidates, then use statistical analysis or experimentation to validate them.

Summary of Common Pitfalls and How to Avoid Them

In summary, avoid these pitfalls by being thorough but focused, evidence-driven, and collaborative in your fishbone analyses. When well executed, a fishbone diagram session will identify not only the technical fault line but also organizational issues that contributed. It provides a comprehensive view so fixes can be comprehensive as well – addressing both the immediate problem and its systemic causes. A well-known quality proverb is, “Every defect is a treasure, if the company can learn from it.” Fishbone diagrams help ensure that each incident or problem yields treasure in the form of lessons and improvements, rather than being dismissed as one-off flukes.

Next, to complement our discussion of pitfalls and best practices, we will look at how the Fishbone Diagram can be integrated with other problem-solving techniques commonly used in ITSM – specifically the 5 Whys technique, Pareto analysis, and leveraging incident trend data. Each of these has its role, and combined with fishbone analysis, they form a powerful toolkit for Problem Management.

Integrating Fishbone with Other ITSM Techniques

Fishbone and the 5 Whys

These two techniques are often used hand-in-hand to ensure depth and breadth in analysis. As noted earlier, the fishbone diagram lays out multiple potential cause pathways, while 5 Whys is a method to dig deeply into a single pathway by repeatedly asking “Why?”. In practice, an IT problem manager might first facilitate a fishbone session to identify numerous possible causes across categories, then apply the 5 Whys to the most plausible cause or causes to find the underlying root. For example, on a fishbone for “Recurring server outages,” one cause listed might be "Inadequate patch testing.” To fully understand that, you’d do a 5 Whys:

  • Why inadequate testing? → Because the testing process is ad hoc.
  • Why? → Because there’s no formal QA environment.
  • Why? → Because the budget was not allocated, etc.

By the fifth why, you uncover something actionable like "Lack of a QA environment due to budget constraints and no policy" – that’s a root cause to address.

These techniques complement each other. The Freshworks ITIL guide in its FAQ articulates it well: “The 5 Whys technique helps drill down to root causes by repeatedly asking 'why'… The Fishbone Diagram complements this by visually organizing potential causes into categories... making it easier to identify all contributing factors and their relationships in complex problems.”. So, the fishbone ensures you’re not fixated on one line of reasoning (a limitation if you only do 5 Whys without considering other angles), and the 5 Whys ensures that for any given branch on the fishbone, you push down to a fundamental cause rather than stopping at a symptom (Freshworks, n.d.).

In facilitating RCA, one could, for instance, mark a few branches of the fishbone with a star and assign small groups to do a 5 Why on each of those, then bring it back to the table. This merges brainstorming with deep analysis. A caution from ITIL: use 5 Whys for relatively straightforward or moderately complex issues, but for very complex ones with many causal streams, a fishbone or other method is needed since 5 Whys alone might make you miss parallel causes. On the flip side, 5 Whys helps fishbone by preventing a shallow analysis. Together, they exemplify the principle of “systematic interrogation” of a problem both horizontally and vertically.

Fishbone and Pareto Analysis

Pareto analysis (based on the 80/20 principle) is a technique to prioritize issues or causes by their frequency or impact. In IT Problem Management, Pareto analysis is often applied to incident data to identify the most common causes of incidents or the systems that generate the most downtime.

Integrating this with fishbone can happen in two ways:

  1. Up-front integration:
    1. Use Pareto to identify which problem to tackle with a fishbone. For example, by plotting incidents by category, you might find that 60% of your incidents are due to email service failures. That indicates a problem area worth analyzing with a fishbone to find root causes. ITIL proactive problem management often uses incident trend data (which is essentially Pareto analysis) to drive which problems get attention first.
  2. Post-brainstorm integration:
    1. After populating a fishbone with many causes, Pareto thinking can help decide which causes to address first. If you have data on how often each cause has occurred or contributed to incidents, you could tabulate that. For example, on the fishbone for service outages, perhaps the “Power failure” cause happened only once (rare), but “Memory leak in app” happened 5 times. You might create a Pareto chart of cause frequency. This analysis might show that a small number of causes account for the majority of incidents. Focus your resources on those causes to get the biggest bang for your buck in preventing future incidents.

In practice, a service manager might use the fishbone diagram from one major incident review to implement fixes for that specific incident. But to decide which broad problem areas to invest in, they use Pareto across all incidents in a quarter. For instance, if “User error” is a top cause category by frequency, one might launch a training program (addressing multiple user-related issues at once). Pareto also complements fishbone by injecting a data-driven perspective – it prevents teams from fixating on a dramatic cause that happened once, instead highlighting the mundane cause that happens often and thus deserves priority.

The ManageEngine resource states: “Pareto analysis complements the Ishikawa and K-T methods by providing a way to prioritize the category of problems, while the other methods analyze the root cause.” (ManageEngine, 2023, para. 8). Essentially, Pareto helps you decide which fishbone to do first (if you have multiple problem areas), and after a fishbone, it helps decide which causes to tackle first. A concrete example: you may have a fishbone for “application downtime” with causes ranging from network issues, DB issues, to code bugs. If your incident stats show 40% of downtime incidents were due to code bugs, 30% network, 20% DB, etc., you might prioritize code-related fixes first (maybe allocate development time to code review and refactoring) since that will reduce the largest chunk of downtime. Pareto charts (like those of problem frequency or impact) can even be used in presentations to management to justify investments (e.g., “80% of our disruptions come from these two causes, so we propose addressing those with x and y changes”) (ASQ, n.d.; CMS, 2018; Kumah et al., 2023; ManageEngine, 2023; ManageEngine, n.d.).

Fishbone and Incident Trend Analysis

This is closely related to Pareto, but trend analysis might look at patterns over time, seasonality, and emerging issues. Integrating this with fishbone means using trending data to inform the categories or causes. For example, if weekly incident reviews show an increasing trend of incidents after deployments, that trend itself could be the “effect” you analyze with a fishbone: e.g., “Why do incidents spike post-deployment each month?” – categories could be Change Management, Testing, Monitoring, etc. The fishbone might reveal multiple causes like “inadequate rollback procedures,” “insufficient load testing,” “release on Fridays causing delays in response,” etc.

Alternatively, incident trend analysis could be used to feed frequency data into a fishbone: perhaps in the fishbone session, you bring a chart showing that 70% of last month’s incidents were network-related. That ensures the team doesn’t ignore network causes. It may also help quantify some causes on the diagram (like writing next to a cause “Occurred 5 times last quarter” to highlight significance).

Another integration point: after doing fishbone analysis for several recurring problems, one might discover systemic issues. For example, if three separate fishbone analyses (for three different services) all have “Lack of monitoring alert” as a cause, the trend is that monitoring gaps are a common theme. That insight should trigger a higher-level CSI initiative to improve monitoring overall, rather than treating each case in isolation. Thus, fishbone results themselves can be aggregated. Some organizations maintain a log of common causes identified across many problems – essentially building their own Pareto of root causes. That’s a powerful approach to long-term improvement, aligning with frameworks like ITIL Continual Service Improvement (CSI) and ISO/IEC 20000-1:2018, which require demonstrating continual reduction of problems by addressing root causes (Axelos, 2019; ISO/IEC, 2018).

Fishbone and Other RCA Methods

Beyond 5 Whys and Pareto, fishbone diagrams can integrate or be compared with methods like:

  • Fault Tree Analysis (FTA):
    • Fault trees use a top-down deductive logic approach, often with Boolean logic gates, to model how multiple failures combine to cause an incident. An advantage of FTA is that it can handle complex interactions (e.g., an incident happens only if A and B fail, etc.) and can incorporate probabilities. Fishbone is simpler – it doesn’t show combinations explicitly, each cause is listed somewhat independently. In some cases, an RCA might start with a fishbone to gather possible causes, then formalize some of that into a fault tree for deeper analysis (particularly in safety-critical or highly complex scenarios). ITIL 4 explicitly mentions fault tree analysis as a technique for problem management (Axelos, 2019). So, an ITSM practitioner might choose: initial brainstorm via fishbone, then hand off to a reliability engineer to do an FTA for the critical parts. Or vice versa: use fishbone for the human and process factors and FTA for the technical logic, then combine findings.
  • Kepner-Tregoe (KT) Analysis:
    • KT is a systematic troubleshooting approach that asks a series of questions to narrow down causes by distinguishing what an issue is and is not, in terms of dimensions like “what, where, when, extent”. KT’s Problem Analysis step results in a list of possible causes which are then tested against the observed pattern of facts to find the true cause. One could use fishbone as a visual way to capture and discuss the list of possible causes in a KT analysis step. Some practitioners might find KT too narrative and use fishbone to visualize what KT is logically deducing. Both are complementary: KT ensures you leverage evidence to eliminate unlikely causes, while fishbone ensures you’ve thought of causes in all categories. The ManageEngine article places fishbone and KT both as valuable, suggesting they can be used alongside each other. Indeed, one might do a fishbone then apply KT verification on each major cause to see if it fits the “is/is-not” profile of the problem (ManageEngine, 2023; ManageEngine, n.d.).
  • Brainstorming & Affinity Mapping:
    • Fishbone itself is essentially a structured brainstorming tool. Some teams might prefer free-form brainstorming then grouping ideas into categories (affinity mapping). That is actually very similar to fishbone, but done in a more bottom-up way. If a team did affinity grouping of causes, those groupings often correspond to what would be fishbone categories. Thus, fishbone can be seen as a form of affinity diagram specifically tailored for cause-effect. They integrate in that brainstorming could be initially unstructured (everyone throws out causes), then the facilitator organizes them onto a fishbone diagram with category labels after the fact. This approach might be useful if participants are not initially comfortable with the category structure – let the ideas flow first, then categorize.
  • Timeline Analysis:
    • For incidents and problems where the sequence of events is critical (like a chain reaction failure), a timeline (chronological) analysis is useful. Sometimes, timeline and fishbone go hand-in-hand: the timeline reveals when and in what order things failed, and the fishbone explores why each failure occurred. For example, a timeline might show: "2:00 AM patch deployed, 2:05 AM server crash, 2:10 AM failover failed, 2:15 AM users impacted". Then, a fishbone diagram can analyze causes of "patch caused crash" (under Application category perhaps) and causes of "failover failed" (under Infrastructure or Process category). Combining insights, you see not only individual causes but also how multiple causes aligned in time to cause a major incident.

In applying a comprehensive RCA, ITIL encourages using the right technique for the right situation (ManageEngine, n.d.). The Freshworks guide explicitly advises not to rely on a single method but to “Match the technique to the problem type”, giving examples: “5 Whys: straightforward issues... Fishbone Diagram: ideal when multiple contributing factors are suspected... Fault Tree Analysis: for complex system failures... Pareto Analysis: for prioritizing problems to tackle first” (Freshworks, n.d.). This is sound advice. For an ITSM leader, having a toolbox of RCA approaches and knowing how to combine them is key. Fishbone diagrams are arguably the most accessible of these – they work for many situations and can be a starting point before deeper methods. They might not provide the analytical depth of an FTA or the evidentiary rigor of KT, but they ensure no major avenue is overlooked in the early analysis (ManageEngine, 2023).

To sum up integration:

  • Use 5 Whys within fishbone branches to identify root causes for each major causal chain.
  • Use Pareto and trend analysis to decide which problems/causes are most significant, thereby focusing fishbone efforts where it matters most.
  • Combine fishbone with formal methods like FTA or KT for thoroughness in complex environments – fishbone for brainstorming and categorization, other methods for validation and logical analysis.
  • In all cases, maintain a holistic view: technical, human, and process factors, short-term triggers, and long-term systemic issues – a fishbone diagram can capture all these facets in one picture, which is why it’s often called a “Cause-and-Effect” analysis rather than just root cause, acknowledging multiple causes and effects may be involved.

With an understanding of how Fishbone Diagrams fit with other techniques, let’s now explore some real-world ITSM scenarios where Fishbone Diagrams prove useful. We will walk through example cases like recurring downtime, a major incident post-mortem, and a configuration drift issue to illustrate practical usage and outcomes of the fishbone approach.

Real-World ITSM Scenarios Illustrating Fishbone Usage

To make the discussion concrete, let’s consider a few scenarios that IT service management professionals might face, and how applying a Fishbone Diagram could help drive root cause analysis and solutions. Each scenario will show the problem context, how the fishbone is constructed, and what insights or outcomes it yields.

Scenario 1: Recurring Application Downtime

Context: A customer-facing web application has been experiencing frequent downtime, roughly once a week. The incidents have common symptoms: the app becomes unresponsive and requires a server restart to recover. This is impacting customers and causing SLA breaches. An IT Problem Manager has opened a Problem record to investigate the recurring issue after several incidents in the past month.

Fishbone Application: The problem statement (effect) at the head of the fishbone is defined as: “WebApp X experiences unplanned downtime ~weekly (app unresponsive, requires reboot) – likely causes to identify.” The team assembled includes the application developers, a database admin, a system admin, and the service owner. They choose initial categories: Application/Code, Database, Infrastructure/Server, Network, Process, People (covering the spectrum of technical components and operational factors).

  • Under Application/Code:
    • The developers suggest causes like “Memory leak in application code,” “Uncaught exception causing thread hang,” and “Inadequate connection pooling”. They note one observation: heap memory usage was very high before one crash, indicating a possible leak. They also suspect a recent new feature (e.g., a file upload module) might be related.
  • Under Database:
    • The DBA adds “Long-running query locks table,” “Connection pool exhaustion at DB,” “Intermittent DB deadlock”. One incident correlated with heavy DB usage, and log files showed some lock wait timeouts.
  • Under Infrastructure/Server:
    • The sysadmin contributes causes: “Insufficient CPU/memory on app server (resource exhaustion),” “OS-level issue or memory fragmentation,” “Background job spike (e.g., backup or antivirus scan) choking the server.” It’s noted that these servers run other scheduled tasks at midnight, which is when one outage occurred – perhaps backups consumed I/O.
  • Under Network:
    • They list “Network latency or drop causing cascading failures,” “Load balancer misrouting traffic,” “DNS resolution issues for API calls.” One anecdote: during one downtime, an external API that the app calls was unreachable – if the app waits too long on that, it might hang.
  • Under Process:
    • They consider operational processes: “Deployment process error (maybe a bad build being deployed),” “Lack of routine maintenance (not applying patches, leading to instability),” “Monitoring/Alerting gaps (issue detected late).” Indeed, they realized that the alert for high memory wasn’t set properly, so they only discovered the leak when it crashed.
  • Under People:
    • They add things like “Developers not fully trained on concurrency issues,” “Turnover in team leading to knowledge gaps in maintaining legacy code,” “Human error misconfiguration – e.g., an ops engineer might have misconfigured the load balancer session stickiness.” In fact, one cause that came up: a new hire was managing server configs and might have missed a critical setting.

Now, with the fishbone fully populated, the team analyzes it. They notice two branches are particularly crowded: Application/Code and Infrastructure. That suggests these areas likely hold the root cause. Using 5 Whys on “Memory leak in code” might go:

  • Why memory leak? → Possibly not closing file streams in new upload module.
  • Why not closing? → Developer oversight, no code review caught it.
  • Why no code review? → Code review process is informal.
  • (So root cause chain might be: a coding defect due to process gap.)

They also do a quick 5 Why on “Resource exhaustion”:

  • Why exhausted? → Only 2 app servers handling all traffic, spikes exceed capacity.
  • Why only 2 servers? → Originally sufficient, but traffic grew 30% this quarter.
  • Why not scale? → No auto-scaling in place, and capacity planning was missed.
  • Why missed? → No monitoring alerts on high CPU, and no one tasked with review.

This indicates another root cause: insufficient capacity due to lack of proactive capacity management (a process/management issue).

Thus, from the fishbone, two primary root causes emerge:

  1. an application memory leak bug and
  2. inadequate infrastructure capacity/monitoring.

The Problem Manager verifies the memory leak by having the developers do a stress test – indeed memory usage grows without release. Meanwhile, analyzing server metrics confirms CPU was maxed out during peak usage.

Outcome: The team implements fixes for both aspects: developers fix the memory leak in code and improve code review practices (preventing that class of bug in future), and the operations team adds another server to the cluster and sets up auto-scaling plus better monitoring alerts for resource saturation. The recurring downtime stops. Additionally, they documented a Known Error in their KEDB about this issue and wrote a knowledge article for the NOC explaining symptoms of memory leak vs. capacity issues for quicker diagnosis if it ever recurs.

This scenario highlights how a fishbone helped separate multiple contributing causes in a recurring downtime scenario. Without it, the team might have kept rebooting servers (treating symptoms) or only fixed one cause (e.g., just adding servers, but the memory leak would have eventually taken those down too). By visualizing all possibilities, they addressed both the technical bug and the process shortcomings (monitoring, code review).

Scenario 2: Major Incident Post-Mortem (Email Service Outage)

Context: A major incident occurred: the corporate email service was down for an entire organization for 4 hours on a Monday morning. This was a severe, P1 incident affecting productivity. A post-mortem Problem Management analysis is convened after service restoration to find the root cause and corrective actions.

Fishbone Application: The problem (effect) is “Corporate email outage for 4 hours on 2025-08-01 – all users unable to send/receive.” The team includes email system admins, network engineers, vendor support (as the email system is partly third-party), and an incident manager. Categories might be: Email Application, Server/OS, Network, Security, Process, External/Vendor.

  • Email Application:
    • Causes discussed: “Email service software bug triggered by specific email content,” “Corrupted email database/index,” “SMTP queue overflow.” They recall error logs complaining about database corruption in mailbox store.
  • Server/OS:
    • “Server ran out of disk space,” “OS patch caused service to crash,” “Memory spike/garbage collection freeze.” They discovered the drive hosting email databases was indeed 95% full; possibly an automated maintenance, like backup, failed due to low space.
  • Network:
    • “Network segmentation issue – email servers couldn’t contact each other or internet,” “DNS failure for email domain,” “Firewall blocked email traffic inadvertently.” There was a network change that weekend – network team wonders if a firewall change at midnight (a routine update) might have impacted the email port.
  • Security:
    • “Security software (antivirus/antispam) quarantined critical email process,” “Expired certificate for TLS causing connections to fail,” “DDoS attack overwhelmed the service.” The security officer notes the TLS certificate for the email gateway was set to expire in a week – could there be an issue around certificate renewal? Also, they saw unusual inbound traffic but not clearly a DDoS.
  • Process:
    • “Change management – an unauthorized change broke something (was there a change?),” “Backups/Restore processes not working (since restoration took 4 hours, maybe recovery processes were slow),” “Monitoring – alerts not seen promptly.” Indeed, the incident was discovered by users, not monitoring; monitoring did not catch that email flow stopped (lack of an end-to-end synthetic transaction perhaps).
  • External/Vendor:
    • “Vendor cloud dependency outage (e.g., if using a cloud spam filter, was it down?),” “Email client update from vendor causing clients to overload server,” “Telco ISP issue – maybe company’s internet link was down.” One clue: other internet services were up, so internet was fine. The vendor had released a patch two days ago – perhaps related?

Through analysis, multiple potential root causes emerged:

  • Disk space was critically low, likely contributing. Why low? Logs show email database maintenance hadn’t run for a month (it was disabled inadvertently). So old logs and defrag not purged.
  • The weekend firewall update did include a rule change for email filtering. On review, it inadvertently blocked a port needed for internal email replication traffic. That explains why primary and secondary email servers got out of sync, causing a failover confusion.
  • The email service crash itself: turns out it crashed when it tried to failover to secondary and found the databases inconsistent (due to blocked replication and possibly corruption from no maintenance). So software bug or limitation that it couldn't handle that scenario gracefully.
  • Process issues: Monitoring was insufficient (no alert on replication backlog, no alert on low disk until it was too late).

Change management issue: the firewall change was not properly tested for impact on email, so a change caused the incident – a classic case of a Change causing Incident leading to Problem.

They apply 5 Whys on the firewall cause:

  • Why outage? → Email server failover failed.
  • Why failover failed? → Primary couldn’t replicate to secondary (inconsistent data).
  • Why no replication? → Network port blocked.
  • Why blocked? → Firewall change on Sunday closed needed port.
  • Why was change implemented without testing? → Change process gap (email team wasn’t aware of the firewall change, no cross-team review).

So, root cause #1: an unauthorized or uncoordinated change by network team affecting email (process failure).

On disk space:

  • Why low? → Maintenance off.
  • Why off? → Admin disabled it to troubleshoot something last month, forgot to re-enable.
  • Why forgot? → No change control for that action, no reminder system.

This is a People/Process cause (human error due to lack of process oversight).

Thus, the fishbone helped isolate that multiple factors combined: a network firewall misconfiguration and low disk leading to database issues and a software failover bug (which the vendor will need to patch). All were root causes in their own way:

  • Primary root cause: misconfigured firewall (human/process issue).
  • Contributing root causes: maintenance lapse (human/process issue), software not handling full disk and split brain condition (technical issue).

Outcome:

The company implements several actions:

  1. Revise the change management process: firewall changes must be communicated to app owners for impact analysis. They add a step in change tickets to list dependent systems and notify them.
  2. Configure monitoring to alert on low disk space at 80% threshold and on replication status. Also enabled synthetic email test alerts.
  3. Conduct training with admins to follow up on temporary changes (like disabling maintenance) and properly document them so they aren’t forgotten. Perhaps implement an automated health check that flags if maintenance hasn’t run.
  4. Work with the email vendor to get a patch for the failover bug; in the interim, adjust procedures so if failover is triggered, techs will check replication consistency to avoid a crash.
  5. A Major Problem Review is done and documented, sharing these lessons with all IT teams to learn the importance of cross-team communication (since network and application teams were siloed in this incident).

This scenario shows how a fishbone diagram in a major incident post-mortem uncovers often a chain of causes (the so-called “perfect storm” of multiple failures). Visualizing them ensures none of those causes are ignored. It also underscores how human factors (change processes) frequently appear in root cause analysis for outages – technology often works until a human error or oversight intervenes. The fishbone helped categorize issues into technical vs. process, so improvements could be made in both areas.

Scenario 3: Configuration Drift and Instability

Context: A company’s server infrastructure is suffering from “configuration drift” – over time, servers in a cluster become inconsistent in their configurations (different patch levels, different settings), leading to incidents where one server behaves differently or fails. For example, during a failover, the backup server didn’t work because a config setting wasn’t the same as primary. The IT operations team identifies configuration drift as a problem to solve via Problem Management.

Fishbone Application: Problem statement: “Frequent configuration drift in Server Cluster Y causing inconsistent behavior and failures – causes?” The team (DevOps engineers, config management tool admin, security compliance officer) brainstorms categories: People, Process, Tools, Change Management, Environment, Compliance (since config drift often spans process and tooling).

  • People:
    • “Manual changes done by admins out-of-band,” “Lack of discipline in following config procedures,” “Poor training on using config management tool.” The compliance officer notes that during on-call, admins sometimes directly tweak servers to fix issues and don’t always roll those changes back or document them – a big source of drift.
  • Process:
    • “No formal configuration management process or audits,” “CMDB not updated,” “No clear ownership of configuration baseline.” Indeed, they lack a robust Configuration Management Database (CMDB) or a baseline definition of “desired state” for these servers.
  • Tools:
    • “Not using automation (Infrastructure as Code) consistently,” “Configuration management tool (e.g., Ansible/Puppet) not fully implemented or has gaps,” “No drift detection tool in place.” The tool admin admits they have Puppet in use, but only applied to some settings, and many others are left to manual configuration.
  • Change Management:
    • “Changes not going through Change Control, leading to ad hoc differences,” “Emergency changes circumvent normal processes,” “Change reviews don’t verify config consistency post-change.” They recall a specific incident where an urgent patch was applied to one server to fix a vuln but not to others until later – that period caused differences.
  • Environment:
    • “Different environments (test vs prod) not aligned, causing mistakes migrating configs,” “Server hardware differences (one has different NIC so requires different driver config),” “Network segmentation causing some config pushes to fail on some servers.” E.g., maybe some servers didn’t get group policy updates because they’re on a different VLAN occasionally disconnected.
  • Compliance:
    • “No periodic audits or drift reports,” “Security team not enforcing baseline hardening uniformly,” “Policies exist on paper but not enforced.” Possibly internal policy says “servers must have X setting,” but no one checks after deployment, so drift happens over time.

From the fishbone, the theme is clear: this is largely a process and tool maturity issue rather than a one-off technical bug. They identify root cause contributors:

  • Lack of a standardized configuration baseline and enforcement mechanism (process/tools).
  • Human interventions outside the automation (people not following process).
  • Gaps in automation coverage (tool not managing everything).
  • Inadequate change control (emergency changes and exceptions not tracked).

Using 5 Whys on “manual changes”:

  • Why manual? → Because automated deployment couldn’t fix issue in time.
  • Why automation not used? → Team not fully confident or it doesn’t cover that scenario.
  • Why not cover? → We never scripted that config because it was set manually originally.
  • Why manual originally? → Legacy practice, never updated.

So, root cause: Legacy manual practices due to incomplete automation adoption.

On “no audits”:

  • Why no audits? → Not prioritized, assumed config mgmt tool covers it.
  • Why assumed? → Over-reliance on tool without verification.
  • Why not verify? → No process owner assigned to config audit.

Solution: assign config manager role.

Outcome:

The problem manager and team propose a set of improvements:

  1. Implement a formal Configuration Management process (aligning with ITIL’s Configuration Management practice). This includes defining a “golden configuration” for the cluster and tracking it in a CMDB or as code.
  2. Expand usage of the config management tool (Puppet) to manage all critical settings and regularly enforce state (perhaps run agent every hour to correct drift).
  3. Introduce a Configuration Drift Report monthly – comparing actual server configs to baseline and flag differences.
  4. Train all admins on using automation and create a policy: no manual config changes unless through the automation tool (or if done, must be captured and fed back into baseline). Essentially, infrastructure as code practice to be mandated.
  5. Strengthen change management: even emergency changes must be retroactively reviewed. They add a step in the incident post-mortem checklist: “Were any temporary config changes made? If so, reconcile them within 24 hours.”
  6. Possibly evaluate a drift detection product or extend monitoring to catch drift (some tools can alert if a config file checksum changes unexpectedly).
  7. Management support: ensure leadership communicates that config consistency is critical and provide resources to fully implement these measures.

This scenario did not involve a one-time incident but a chronic problem undermining reliability. The fishbone approach helped unify the team’s understanding of why drift was happening from multiple angles – cultural (people just doing quick fixes), procedural (no audits), and technical (lack of full automation). It leads to solutions that are also multi-faceted: technical (use the tool), procedural (introduce audits), and people (training and policy enforcement). In effect, it moves the organization closer to DevOps best practices (treating configuration as code and ensuring consistency), showing how root cause analysis can drive process improvement beyond just fixing immediate incidents.

Real-World Scenario Summary

These scenarios demonstrate the versatility of the Fishbone Diagram in IT contexts:

  • It can be used after major incidents to identify both the immediate technical fault and the latent organizational issues that allowed it.
  • It can tackle recurring issues, helping break the cycle by addressing all contributing factors. - It can address process-oriented problems (like config drift) by uncovering the reasons behind human behaviors and system gaps, thus guiding process change.

In each case, the fishbone provided a framework for discussion that surfaces insights which might be missed if one jumps straight to a presumed cause or if analysis is done in silos. The visual nature also helps when communicating findings to stakeholders; for example, one can include the fishbone diagram (cleaned up) in a post-incident report to illustrate the thoroughness of analysis and justify the recommended actions. (In sensitive cases, one might remove or anonymize "People" factors to focus on process changes, to maintain a blameless tone.)

Next, we will step back and compare the Fishbone Diagram with other RCA techniques in terms of strengths and limitations, many of which have been hinted at in our discussion but will be summarized for clarity. This will help readers choose the appropriate method for their needs or understand when fishbone is most beneficial.

Comparing Fishbone with Other Root Cause Analysis Techniques

No single root cause analysis method is best for all situations. The Fishbone Diagram has particular strengths, especially in ITSM scenarios, but it also has limitations when compared to other RCA techniques. Here we contrast it with a few commonly used methods:

Fishbone vs. 5 Whys

  • Strengths of Fishbone:
    • Handles multiple causes and complex problems where several factors might contribute. Encourages exploring different categories (people, process, tech, etc.), ensuring a broad view. It’s visual and collaborative, good for group brainstorming, and creates a quick snapshot of all hypotheses.
  • Strengths of 5 Whys:
    • Simplicity and depth on a single cause-and-effect chain, useful for straightforward problems or drilling down a known issue quickly. Easy to do on the fly or by an individual, no special diagram needed.
  • Limitations of Fishbone:
    • It can end up identifying many possible causes, some of which may be irrelevant, thus requiring effort to validate and narrow down. It doesn’t inherently prioritize which cause is most likely (the team must do that). If used without enough critical thinking, one might list superficial causes and think the job is done. Also, fishbone alone might not trace a specific chain deeply – it might stop one level shy of root cause if not combined with “why” questioning.
  • Limitations of 5 Whys:
    • As noted, 5 Whys tends to follow a single thread – it may miss parallel causes. If the problem is multifaceted, 5 Whys might identify one root cause but not others. It also can suffer from the knowledge and bias of the person doing it; ask “why” five times to different people and you might get different answers. It’s less structured for group input.
  • When to use:
    • Fishbone is ideal when a problem is complex or unexplained and you need a group to consider all angles – e.g., a widespread service outage or chronic issue with many potential causes. 5 Whys is great when the cause is suspected to be in a specific area and just needs confirming, or for simpler issues (e.g., a single configuration error causing a problem – you can peel that onion alone). In practice, as we’ve shown, they’re complementary: use fishbone to map the territory, 5 Whys to dig the mine at promising spots.

Fishbone vs. Fault Tree Analysis (FTA)

  • Strengths of Fishbone:
    • Much easier to construct in a brainstorming session; doesn’t require knowledge of Boolean logic or formal training. It shines in early stages of problem-solving to enumerate possibilities without needing precise data. It’s qualitative and intuitive.
  • Strengths of FTA:
    • More analytical rigor. Fault trees illustrate how multiple lower-level failures combine (AND/OR relationships) to cause higher-level failures. You can quantify probabilities and identify the weakest links by calculating which basic events most increase top event probability. FTA is common in reliability engineering for mission-critical systems (e.g., aerospace, IT infrastructure reliability).
  • Limitations of Fishbone:
    • It shows causes in parallel branches, but doesn’t show relationships between causes (other than hierarchy of cause vs sub-cause). It cannot represent “cause A and B together result in effect” clearly, nor “either A or B could result in effect” logically – it just lists A and B separately. In a fishbone, if multiple things had to go wrong together, you might list each, but the diagram won’t depict the necessity of their combination.
  • Limitations of FTA:
    • Requires thorough knowledge and often more time to build correctly. It’s typically done by an analyst after initial info is gathered, not so much as a group brainstorming tool. It can be overkill for everyday IT problems. Also, FTA primarily focuses on failure events and conditions, potentially missing human/organizational factors unless incorporated as events.
  • When to use:
    • If you have a complex system failure and need to understand all the combinations of faults that could cause it (and maybe get a measure of reliability), FTA is superior. For instance, analyzing how a data center outage could happen by simultaneous failures of power and cooling, a fault tree is apt. In ITSM, fault tree might be used for high-availability systems analysis or to comply with something like a risk assessment. But for day-to-day problem solving of incidents, fishbone’s ease and collaborative nature make it more practical. One might start with fishbone, then task someone to create an FTA if needed for deeper analysis on the critical branches.

Fishbone vs. Pareto Analysis

These serve different purposes; one can’t directly replace the other. Pareto is quantitative, and fishbone is qualitative.

  • Strength of Fishbone:
    • Captures cause-effect thinking and underlying reasons, which Pareto doesn’t (Pareto just tells you frequencies or sizes).
  • Strength of Pareto:
    • Cuts through noise by focusing on what occurs most often or has the biggest impact. It’s data-driven and thus persuasive for resource allocation (e.g., telling management “these 2 issues cause 80% of our incidents”).
  • Limitation of Fishbone:
    • Without Pareto, a fishbone might tackle a less significant problem or spend time on rare causes, as it doesn’t inherently weight them. It needs external data for that perspective.
  • Limitation of Pareto:
    • It tells you “what” to look at, not “why” it’s happening. It might identify “Network issues” as 40% of incidents, but you still need RCA (like a fishbone) to find out why network issues are so common.
  • When to use:
    • Use Pareto to inform and prioritize fishbone efforts (as discussed). For example, monthly incident review – do Pareto to find top offenders, then conduct fishbone analysis on the top one or two problems. They’re complementary tools in an ITIL Continual Improvement context.

Fishbone vs. Kepner-Tregoe (KT) Analysis

  • Strengths of Fishbone:
    • More free-form brainstorming, which can generate creative hypotheses beyond the immediate evidence. It’s collaborative and can involve the whole team easily.
  • Strengths of KT:
    • Very structured and evidence-driven. KT’s Problem Analysis asks: what is the problem, what it is not, what distinguishes the is vs. is-not (in terms of time, location, etc.), thereby eliminating causes that don’t fit the pattern. It helps avoid pet theories that don’t actually align with the facts. It can be more methodical in narrowing down, reducing false leads.
  • Limitations of Fishbone:
    • Can include causes that don’t match the evidence (unless team actively cross-checks with known incident data). It might not explicitly highlight which facts disqualify which causes.
  • Limitations of KT:
    • Can be time-consuming to gather detailed information and go through the matrix. It requires training to do well, and some find it a bit rigid. It might be less engaging for group brainstorming, as it’s more questionnaire-like. Also, KT focuses on one problem at a time; it doesn’t explicitly encourage exploring categories of causes – though it does in a way by asking “what could cause those distinctions.”
  • When to use:
    • For tricky problems where initial analysis was inconclusive, KT can be very helpful to systematically rule things out. In an IT context, one might do fishbone first to throw all ideas out, then use KT logic to test each candidate cause against the problem profile (does it explain the who/what/when/where of the issue?). If some causes on the fishbone don’t align with the pattern, they might be pruned out. So fishbone generates possibilities, KT filters them. Conversely, if a team is stuck, KT might identify the odd factor (“the issue happens only on one server, not others” – that clue might spark a cause that fishbone missed). They can be sequential: KT to refine problem definition and clues, fishbone to broaden thinking, then KT again to evaluate hypotheses.

Fishbone vs. “5W1H” or Checklist methods

Some problem-solving uses checklists of questions (Who, What, When, Where, Why, How) or cause checklists (like human, technical, external categories).

  • Fishbone essentially incorporates some of this by categorization, but a checklist might be more straightforward in certain cases or for ensuring you ask every relevant question.
  • However, fishbone’s advantage is the visual map that shows how various causes branch and relate to sub-causes, which a simple checklist might not convey.

Strengths of Fishbone (Summary)

  • It fosters team collaboration and collective brainstorming.
  • It provides a holistic view – seeing all potential causes in one diagram triggers discussion on interrelations and prevents tunnel vision.
  • It’s flexible and quick – can be drawn on paper in minutes, requiring no specialized software (though tools help).
  • It is intuitive – even non-technical stakeholders can understand a fishbone chart in a report, which can be useful in communicating analysis to management or auditors, demonstrating that a structured approach was taken.

Limitations of Fishbone (Summary)

  • It relies heavily on the knowledge and experience of the participants for brainstorming – if the team misses something, the fishbone won’t automatically include it. (For example, if none of the team know about a certain obscure bug or external factor, it might never appear on the diagram.)
  • It doesn’t prioritize; additional steps are needed to weigh causes by likelihood or impact.
  • For extremely complex problems with combinatorial factors, fishbone might oversimplify (you might list each factor separately but not show that, say, two specific factors must coincide to cause the failure).
  • It can become unwieldy if overused for very large scope problems (imagine trying to fishbone “Why is our IT service not meeting customer expectations” – that could blow up into a huge diagram that might be better handled by breaking down into sub-problems).

In ITIL Problem Management practice, many organizations use a mix of methods. A survey of best practices might find that fishbone diagrams and 5 Whys are among the most popular due to ease of use, while more advanced techniques are reserved for special cases. The key is to not be dogmatic: one should select the technique that fits the problem’s complexity and the data available, and sometimes use them in tandem.

For example, one might define an RCA process: Start with documenting timeline (to collect facts), use fishbone (to brainstorm causes), use 5 Whys or KT (to drill down and test causes), use Pareto (if multiple problems to rank or if quantifying frequency), etc., and possibly use FTA if needed to verify logic or probability. The fishbone is a central part of that toolkit, often the go-to when convening a Problem Review Meeting, because it engages everyone and sets the stage for deeper analysis.

In terms of strengths vs limitations in the ITSM context:

  • Fishbone’s strength is addressing the blend of technology and process issues typical in IT incidents. It encourages inclusion of causes like “lack of training” alongside “software bug,” which purely technical tools might omit. ITIL’s ethos is that service failures often come from process and people issues as much as technology – fishbone naturally accommodates that breadth.
  • A limitation is that if an organization has a weak problem-solving culture, a fishbone session could devolve into a blame session or a superficial checkbox exercise. It requires good facilitation and culture (which Problem Managers should cultivate).

In conclusion, the Fishbone Diagram is a powerful, versatile tool for root cause analysis in IT, but it is not a panacea. It should be used as part of a broader problem management toolkit. When used appropriately, its strengths in visualization, organization, and collaboration outweigh its drawbacks, especially for the day-to-day complex problems in IT service management. Understanding its limits (like the need for verification and complementary analysis) ensures we don’t misuse it.

Now, recognizing that modern ITSM work often involves distributed teams and digital workflows, we will discuss what digital tools and templates are available to create and use Fishbone Diagrams in enterprise environments, and how these integrate with platforms like ServiceNow or collaborative suites.

Digital Tools and Templates for Fishbone Diagrams in Enterprise Environments

Creating a Fishbone Diagram can be as low-tech as drawing on a whiteboard, but in many enterprises, especially with remote teams, digital tools greatly aid in building, sharing, and preserving these diagrams. Additionally, integrating RCA outputs into ITSM systems (like ServiceNow) ensures the analysis is accessible and actionable. Below are common tools and approaches for using fishbone diagrams in a modern IT context:

1. Diagramming Software (Visio, Lucidchart, etc.)

Traditional office tools like Microsoft Visio have fishbone (Ishikawa) diagram templates, allowing you to drag and label bones easily. Visio is popular in many enterprises for all sorts of diagrams and can be saved as part of documentation. Newer cloud-based tools like Lucidchart and Creately offer collaborative editing of fishbone diagrams. Multiple team members can add ideas simultaneously, akin to a virtual whiteboard. Lucidchart, for example, has built-in templates for fishbone diagrams, and its interface is easy for non-artists to use (just type cause labels into shapes). These diagrams can then be exported to images or embedded in documents (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

Using a diagramming tool is particularly useful for post-session documentation: after a brainstorming meeting on a physical board, one can recreate it in Lucidchart or Visio for a cleaner version to attach to the problem record or incident report. Some tools (Lucidchart, Miro) also allow direct importing into documentation platforms (Confluence, SharePoint) or integration with Slack, etc., making collaboration smoother.

2. Online Whiteboard & Mind Mapping Tools (Miro, Mural, XMind)

Miro is a popular online whiteboard platform that many agile and DevOps teams use for collaborative sessions. It doesn’t have a specific Ishikawa template by default, but one can quickly draw a central line and use sticky note objects for causes. In fact, Miro is great for the brainstorming part, where participants can each add sticky notes on the board under category headings (which can be drawn as branches). After the session, the facilitator can tidy up the arrangement. The advantage is real-time collaboration: it simulates the in-room experience for distributed teams. Mural is similar in capabilities (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

There are also dedicated mind mapping tools like MindMeister, which can be adapted for cause-and-effect (mind maps generally start from a central idea and branch out, which is a bit different, but one could map from right to left to mimic a fishbone). Some might prefer mind maps for less structured cause brainstorming; however, a fishbone’s distinctive structure might be easier to interpret for RCA specifically.

3. Templates in ITSM Systems (ServiceNow, Jira, etc.)

Many ITSM platforms do not have an out-of-the-box fishbone diagramming capability built-in, but there are ways to integrate:

  • ServiceNow: By default, ServiceNow’s Problem record might have a text field for root cause analysis, but nothing visual. Some organizations attach the fishbone diagram image to the problem ticket. There has been interest in whether ServiceNow provides any RCA visualization. A community Q&A shows people asking “Is there any facility in ServiceNow to represent RCA in a fishbone diagram?”. The answer often is: not natively, but one can embed images or links. One approach is to use the ServiceNow knowledge base or a Visual Task Board. Alternatively, ServiceNow can integrate with third-party tools via iframes or custom UI pages – for example, embedding a Lucidchart diagram into a form. Some ServiceNow customers create a custom module for RCA, where they might capture cause categories and sub-causes as data (though not as visual as a fishbone image).
  • For Jira Service Management (Atlassian), one might attach a Confluence page that contains the fishbone diagram (Confluence has draw.io integration for diagrams).
    • Some specialized ITSM add-ons might offer RCA tracking forms that mimic fishbone logic (e.g., fields for listing causes by category). But often the simplest integration is to include a picture or PDF of the fishbone diagram as part of the Problem record’s work notes or resolution notes.

Given that a fishbone diagram is typically used as a problem-solving intermediary artifact, teams often use whatever tool is easiest during analysis (whiteboard or Miro), then store the result in the ITSM system after the fact. It might not be as interactive once stored, but it serves as documentation.

4. Enterprise Collaboration Suites

If your company uses Office 365 or Google Workspace, you might utilize tools like Excel or PowerPoint to make fishbones (there are fishbone SmartArt graphics in PowerPoint, for example). Some teams share these over SharePoint or Teams. PowerPoint is surprisingly a common tool to illustrate RCA findings in post-incident review meetings (with a slide showing a fishbone diagram summarizing causes). There are also fishbone templates for Google Slides/Drawings for those using Google.

5. Dedicated RCA Software

There are products aimed at RCA and CAPA (Corrective Action/Preventive Action) tracking – e.g., Sologic’s RCA software, Apollo RCA software, etc. These often include fishbone diagramming capabilities as part of an RCA report workflow. They allow users to build cause trees or fishbones and link evidence. However, these might be overkill for many IT departments unless part of a larger quality or safety program.

Some companies have internal templates – e.g., an RCA Word template that includes a section for a fishbone diagram (which one would paste in as an image) and narrative sections for 5 Whys, etc. The prompt mentions Lucidchart, Miro, ServiceNow integration specifically, indicating interest in how modern collaborative tools and ITIL tools can be used:

  • Lucidchart: It can integrate with Confluence, Jira, Microsoft Teams, etc. You can also attach a Lucidchart diagram link that anyone with access can open to view the live diagram. This is helpful if the RCA is iterative; the diagram can be updated, and the latest version is always seen.
  • Miro: Doesn’t integrate into ServiceNow directly, but you can drop a link to the board. Miro boards can be exported as a PDF or an image to attach to a ticket.
  • ServiceNow: As mentioned, one workaround for integration is using ServiceNow’s Visual Task Board or Flow Designer with some custom logic to maybe track categories and causes. But realistically, attaching the diagram and summarizing key causes in text is what most do.

In terms of templates: Many public templates exist (a quick search yields many fishbone diagram templates from sources like Canva, Vennngage, etc.). Some are tailored to IT issues. For example, Canva offers fishbone templates where one can plug in text and make a nice graphic. This can be useful for presenting RCA findings in a report with an eye-catching visual.

6. Automation and AI in RCA Tools

We should mention emerging trends. Modern ITSM tools (like Freshservice, as Freshworks hints) are starting to offer AI-driven suggestions for root causes (Freshworks, n.d.). They might analyze incident patterns and even populate likely causes. While not exactly fishbone, one could imagine an AI feature that auto-generates a preliminary fishbone diagram from historical data (e.g., it notices that most incidents in category X happened after deployment, so it suggests “Deployment issues” as a cause). NIST and others talk about semi-automated RCA with pattern recognition (National Institute of Standards and Technology [NIST], 2023). However, human expertise remains vital for final analysis. Tools like Splunk or ELK stack can help gather evidence (log analysis), which feeds into RCA but doesn’t replace the fishbone method itself.

7. Storing and Sharing RCA Knowledge

Beyond creating diagrams, enterprises need to maintain a knowledge base of problems and causes. An embedded fishbone image in a problem record helps, but also ensure the textual summary of root cause is stored in a searchable field (so others with similar issues can find it). Some organizations classify problems by cause codes (like a controlled vocabulary of root causes) which can be reported on. For instance, they might tag a Problem with “Root Cause Category: Software Bug / Configuration Error / Training Issue” and use that data for trends (a kind of internal Pareto of causes). Doing so can highlight systemic issues to address. The fishbone diagram process often informs what those cause categories should be.

Security and Permissions: When using cloud tools like Lucidchart or Miro, consider data sensitivity of the incident – e.g., a fishbone might mention specific security weaknesses; ensure the tool is approved and access controlled. If not, you can do it offline or on an isolated network.

Integration Example: Suppose your company uses ServiceNow and also has Lucidchart for Confluence. You might do this: After the RCA meeting, an engineer documents the fishbone in Lucidchart and exports a PNG image. In the ServiceNow Problem ticket, they paste the image and also attach the Lucidchart file link. They then fill the “Root Cause” field in ServiceNow with a succinct summary gleaned from the fishbone (like "Root Causes:

  1. Memory leak in service due to coding error,
  2. Monitoring gap allowed issue to go undetected,
  3. Change management process failed to catch config deviation").

That way, the detailed analysis is there if one wants to see it, but the key points are also recorded structurally. If the company later conducts an audit or metrics, they might pull from those structured fields.

Ease of Use: Many IT pros are already familiar with Office tools or Atlassian tools, so using those reduces friction. For instance, using an Excel sheet with a drawn fishbone (some do that with diagonal connectors) could work in a pinch if nothing else is available on a secure server. But specialized tools like Lucidchart make it look more professional and are faster.

Mobile and On-the-go: With remote work, sometimes RCA sessions may happen over a video call. Tools like Miro have mobile apps or can be used on tablets, so participants could even draw with a stylus (like drawing bones by hand on an iPad in a Teams meeting). It’s about mimicking the in-room whiteboard vibe. After, one can clean it up.

Reporting Upwards: Executives often want a clear summary of what went wrong. A neat fishbone diagram can be included in post-incident reports to management, demonstrating due diligence. For example, ISO/IEC 27001 or ISO/IEC 20000 audits might ask for evidence of problem analysis; showing documented fishbone diagrams can satisfy auditors that a structured method is in use (especially if they see categories like Methods, Machines, etc., which they’ll recognize from quality management) (ISO/IEC, 2018; ISO/IEC, 2022).

In summary, Lucidchart and Miro stand out as modern favorites for creating fishbone diagrams collaboratively (Meegle, n.d.). ServiceNow integration is mostly about attaching outputs or linking knowledge articles, since direct diagramming in SN is limited without customization. Other enterprise apps like Visio, Confluence (draw.io), or even PowerPoint are reliable standbys for making and sharing fishbones. The choice often comes down to what tools the organization has licensed and the preferences of the team. What’s important is that the tool chosen should allow easy sharing (no point in a diagram stuck on one person’s C: drive), versioning or updating as needed, and ideally be simple enough that the tooling doesn’t become an obstacle during the actual analysis brainstorming.

Ultimately, the focus should remain on the analysis, not the drawing – tools are there to facilitate capturing the team’s thinking. As one source quips, Ishikawa diagramming “requires no investment in software or tools” and can be done with just paper and pens. That’s true in principle, but in practice, leveraging digital tools can ensure the valuable insights from a fishbone session are recorded, disseminated, and acted upon effectively in an enterprise setting (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

Conclusion

The Fishbone Diagram (Ishikawa cause-and-effect diagram) is a time-tested and versatile technique that continues to prove its value in modern IT service management. By providing a structured yet flexible visual framework, it helps IT professionals and service managers systematically dissect problems and identify root causes across technical, procedural, and human dimensions. In the context of ITIL-based Problem Management, fishbone diagrams facilitate collaborative analysis, which is critical for preventing incident recurrence and improving service reliability (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

Throughout this deep dive, we explored how the fishbone method originated in manufacturing quality control and has since been embraced by industries such as healthcare and IT. We examined its anatomy – the spine, head, and branching bones – and the standard cause categories from the 6 M’s to IT-centric variations (people, process, technology, etc.). We provided guidance on running effective fishbone sessions, emphasizing clear problem definition, inclusive brainstorming, iterative questioning (5 Whys), and validation of causes. Common pitfalls were identified (like vague causes, analysis paralysis, or jumping to conclusions) along with strategies to avoid them.

Integration with other ITSM techniques was a recurring theme: the fishbone diagram complements the 5 Whys, Pareto analysis, and other RCA approaches by combining breadth of exploration with depth of inquiry. Real-world scenarios – from recurring downtime to major outages – illustrated the practical application and benefits of fishbone analysis, showing how it often uncovers multiple interrelated root causes and drives holistic solutions (technical fixes and process improvements). We saw that the fishbone’s collaborative nature not only identifies the causes of problems but also builds shared understanding and learning among teams, aligning with the continual improvement ethos of frameworks such as ITIL and ISO/IEC 20000.

When compared to other RCA tools, the fishbone diagram stands out for its ease of use and broad applicability. It may not provide the quantitative precision of a fault tree or the step-by-step logic of Kepner-Tregoe, but its strength lies in engaging cross-functional expertise to ensure no major angle is overlooked. Its visual format is particularly effective in IT, where problems often span multiple domains (applications, infrastructure, operations) and require collective insight to solve.

In today’s enterprise environments, digital tools like Lucidchart and Miro have modernized the way fishbone diagrams are created and shared, enabling real-time collaboration even in distributed teams (Meegle, n.d.). Meanwhile, integration of RCA outputs into ITSM platforms ensures that the findings are documented and linked to corrective actions in systems like ServiceNow, maintaining the traceability and accountability that IT governance demands. Adopting these tools and integrating them into the Problem Management workflow helps make root cause analysis more efficient and accessible, without sacrificing the rigor of the analysis.

For senior ITSM and infrastructure leaders, the fishbone diagram is more than just a diagramming technique – it is a catalyst for a problem-solving culture. When teams gather around a fishbone (virtually or physically), they practice open communication, critical thinking, and proactive mindset. Over time, this leads to faster resolution of problems, fewer recurring incidents, and a deeper collective knowledge of systems and processes. It aligns with the proactive Problem Management goal of eliminating problems before they manifest as incidents.

In cybersecurity as well, the fishbone approach can strengthen incident response by ensuring all contributing factors (from technical vulnerabilities to policy lapses) are identified and addressed. It enforces the principle that behind every incident is a chain of causes – if we break the chain at multiple points, we harden our services (Avertium, 2021).

To conclude, the Fishbone Diagram remains a cornerstone technique for root cause analysis in IT Problem Management. Its enduring relevance is backed by both industry best practices and standards – from ITIL’s recommendation of structured RCA tools to ISO’s alignment of corrective action methods with tools like Ishikawa diagrams. By using fishbone diagrams thoughtfully – in conjunction with data analysis, good facilitation, and follow-through on actions – IT organizations can significantly improve their problem resolution outcomes. Problems become opportunities for learning and improvement rather than recurring failures, contributing to higher uptime, better performance, and greater customer satisfaction (ASQ, n.d.; CMS, 2018; Kumah et al., 2023).

In essence, a Fishbone Diagram session epitomizes the shift from a reactive firefighting culture to a proactive improvement culture. It turns the abstract task of “finding root causes” into a tangible, collaborative process. For any IT team striving for excellence in service quality and reliability, mastering the fishbone technique and embedding it into their Problem Management practice is a step well worth taking. As the experiences and references cited throughout this article attest, when wielded properly, this humble fishbone becomes a powerful spear in spearing problems at their source.

References

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Avertium. (2021, August 10). Why root cause analysis is crucial to incident response (IR). Avertium Cybersecurity Blog. https://www.avertium.com/resources/threat-reports/why-root-cause-analysis-is-crucial-to-incident-response

Axelos. (2019). ITIL Foundation: ITIL 4 edition. TSO (The Stationery Office). https://www.axelos.com/resource-hub/book/itil-foundation-itil-4-edition

Freshworks. (n.d.). A guide to ITIL root cause analysis (RCA). Freshworks. https://www.freshworks.com/explore-it/guide-to-itil-root-cause-analysis-rca

International Organization for Standardization & International Electrotechnical Commission. (2018). ISO/IEC 20000-1:2018 – Information technology – Service management – Part 1: Service management system requirements. ISO. https://www.iso.org/standard/70636.html

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International Organization for Standardization. (2015). ISO 9001:2015 – Quality management systems – Requirements. ISO. https://www.iso.org/standard/62085.html

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Kumah, A., Nwogu, C. N., Issah, A.-R., et al. (2023). Cause-and-effect (fishbone) diagram: A tool for generating and organizing quality improvement ideas. Global Journal on Quality and Safety in Healthcare, 00(0), 000–000. https://doi.org/10.36401/JQSH-23-16

Lucidchart. (n.d.). What is a fishbone diagram? Retrieved from https://www.lucidchart.com/pages/tutorial/what-is-a-fishbone-diagram

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