Applying the Continuous Improvement Process: Fishbone Diagram

There are two parts to this project. For Part I, you will use the information and data compiled in your Unit V Job Hazard Analysis (JHA). You must develop a fishbone diagram that illustrates the relationship between the causal factors and the blown or flat tire incident.

Recall that the elements of a fishbone diagram include a head, backbone, ribs, and small bones:
Head: The head of the fish represents the problem statement. Clearly identify your problem statement for this scenario.
Ribs: These are the main contributing factors. You may end up with multiple branches from the main ribs as you treat each contributing factor as its own mini-rib and keep asking why each factor is occurring.

For this project, the contributing factors could fit into the following categories:

  • Person
  • Procedures
    Environment
    Equipment
    Conditions

Small bones: In many cases, smaller bones are included on the rib bone to represent a deeper root cause analysis or weakness in the process.

Note: Look for deeper causes that repeatedly appear to contribute within categories or across major categories. For example, weather may be a main factor, but failure to have checked the forecast before traveling or not having proper gear for the weather may have exasperated the situation.

You may create your fishbone diagram in any program you choose. You can search online for fishbone diagram templates or tutorials in programs, such as PowerPoint, Word, and Excel. Alternatively, you can use a different program and submit the final product image as a PDF or graphics file. Be sure to review the acceptable file formats in the assignment submission area of Blackboard. Do not submit a hand-drawn diagram.

For Part II of this project, you will write a two-page paper that addresses the following:
Describe how factors identified in the fishbone diagram exposed other potential hazards not considered in the JHA.
Explain how the discovered deeper causes can assist in reevaluating the JHA and modifying overall risk management and safety management efforts.
Based on your JHA and fishbone diagram, recommend two changes or additions to the original manufacturer instructions for changing a tire on your vehicle. How will these recommendations improve safety?

You are encouraged to offer your opinion and experience. Although your opinion or belief may be based on experience and not necessarily a truth claim, you should incorporate resources that support your opinions. You must use at least two peer-reviewed or academically reliable sources to support Part II of your project. All sources used must have citations and references formatted in proper APA Style. APA formatting of the project is otherwise not required.

You may submit Part I and Part II as separate documents in Blackboard, or combine them into a single document, provided all listed requirements are met. The title page (if used), or any reference pages do not count toward the listed page requirement.