BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

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A2.A.9. <strong>THE</strong> CAUSE AND EFFECT TOOL A2.A.9.1. FORMAL NAME. The cause and effect tool A2.A.9.2. ALTERNATIVE NAMES. The cause and effect diagram, The fishbone tool, the Ishikawa Diagram A2.A.9.3. PURPOSE. The cause and effect tool is a variation of the logic tree tool and is used in the same hazard ID role as the general logic diagram (i.e. a more rigorous, detailed tool). The special advantage of the cause and effect tool is its origin in the quality management process and the thousands of personnel who have been trained in the tool. Because it is widely used, thousands of personnel are familiar with it and therefore require little or no training to apply it to the problem of detecting risk. A2.A.9.4. APPLICATION. The cause and effect tool will be effective in organizations that have had some success with the quality initiative. As pointed out above, the tool is among the most commonly applied quality procedures and significant numbers of personnel are very comfortable using it. It should be used in the same manner as the logic diagram previously covered and can be applied in both a positive and negative variation. A2.A.9.5. METHOD. The cause and effect diagram is essentially a logic diagram but with a significant variation. The cause and effect diagram is provides more structure than the ordinary logic diagram through the branches that give it one of its alternate names, the fishbone diagram. Figure A2.19 illustrates this structure. Note that there are two basic variations, one for tactical type operations (the 4 “M”) and another for administrative processes (the 4 “P”). Of course the user can tailor the basic “bones” based on special characteristics of the operation or mission that is being analyzed. As in the case of the logic diagram, either a positive or negative outcome block is designated at the right side of the diagram. Then, using the structure of the diagram, the user or team of users completes the diagram by adding causal factors in either the “M” or “P” structure. By using branches off the basic entries, additional hazards can be added to the diagram. The examples provided illustrate this process. The cause and effect diagram is a very effective team hazard ID tool and should be used in a team setting whenever possible. A2.A.9.6. RESOURCES. There are many publications describing in great detail how to use cause and effect diagrams. A2.A.9.7. COMMENTS. This procedure has proven very effective and has established the cause and effect diagram as a powerful hazard ID tool. A2.A.9.8. EXAMPLES. An example of cause and effect tool in action is illustrated at Figure A2.19. 56
Figure A2.19. Example of Cause and Effect. Man Situation: The supervisor of an aircraft maintenance operation has been receiving reports from Quality Assurance regarding tools in aircraft after maintenance over the last six months. The supervisor has followed up but each case has involved a different individual and his spot checks seem to indicate good compliance with tool control procedures. He decides to use a cause and effect diagram to consider all the possible sources of the tool control problem. The supervisor develops the cause and effect diagram with the help of two or three of his best maintenance personnel in a group application. Note: Tool control is one of the areas where 99% performance is not adequate. That would mean 1 in a hundred tools is misplaced. The standard must be that in the tens (or hundreds) of thousands of individual uses of tools over a year literally not one is misplaced. Motivation weak (reward, discipline) OI incomplete (lacks detail) Training weak (procedures, consequences) Tool check procedures weak Supervision weak (checks) Mgt emphasis light Methods No tool boards, cutouts Many small, hard to see tools Many places to lose tools in aircraft Materials Machinery In reviewing the diagram detail the group agrees that in most of these areas the existing procedures are not bad. The problem is that not bad isn’t good enough. Only excellence will do. They decide to use the “positive” variation of the cause and effect diagram. There initial focus is on motivation. People Procedures Participate in development of new procedures Collective & individual awards Self & coworker observation Detailed OI Quick feedback on mistakes Good matrices Commitment to excellence Strong sustained emphasis Extensive use of toolboard cutouts Policies Plant Using the positive diagram as a guide the supervisor and his group proceed to apply all possible and practical options developed from the diagram above. The objective is to develop not just a good set of procedures but an optimum set of procedures. 57 Tool misplaced Strong Motivation
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BY ORDER OF THE AIR FORCE PAMPHLET
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Figure 14. Levels of Command Involv
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Attachment 6 RISK CONTROL IMPLEMENT
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Attachment 7 SUPERVISE AND REVIEW D
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BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

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