Templates · Analysis
Fishbone Analysis
One problem, its possible causes sorted into five families, and fixes that answer the causes rather than the symptom.
- People Causes rooted in skills, staffing or knowledge held by one person
- Process Causes in how the team works: steps skipped, rules unwritten
- Tools Causes in tooling: gaps in alerts, tests, environments
- Program Causes in planning: scope, funding, deadlines
- Environment Causes outside the team: vendors, traffic, org changes
- Solutions Fixes that address the causes above, with an owner
What it is
A fishbone analysis takes one problem and asks where its causes lie. The picture is a fish skeleton: the problem is the head, and each large bone is a family of causes. Here five columns are the bones, and a sixth collects the solutions.
Goal
An agreed account of why the problem happens, wide enough that the team did not stop at the first cause it thought of, and a few fixes aimed at those causes.
When to use it
- A problem that keeps coming back: the same kind of bug, releases that slip, a handover that fails again.
- After an incident whose cause is disputed.
- With a team that jumps to a fix: the columns make it look in five places first.
When to pick another format
Without a single problem, the columns have nothing to hold: for a general look back, use Went well, To improve, Action ideas. After an incident whose cause is already known, Post-mortem goes straight to the gaps and the follow-ups. For a failure that has not happened yet, run a Pre-mortem.
How to run it
Agree on the problem in one sentence before anyone writes a card. Then ask the same question at each of the first five columns: what here contributes to it?
- People: skills, staffing, knowledge held by one person. Describe the situation, do not name a culprit.
- Process: how the work is done. A step skipped, a rule nobody wrote down.
- Tools: alerts, tests or environments that are missing or misleading.
- Program: planning. Scope, funding, deadlines.
- Environment: what lies outside the team. Vendors, traffic, changes in the organisation.
- Solutions: the fixes you already have in mind for the causes you wrote.
Group the causes, and for the larger groups ask “why?” again until the answer is something the team can change. Vote on the causes that matter most. In the discussion, set the cards of Solutions against the chosen causes and keep the fixes that answer one of them, each as an action with an owner.
Columns
| Column | Description |
|---|---|
| People | Causes rooted in skills, staffing or knowledge held by one person |
| Process | Causes in how the team works: steps skipped, rules unwritten |
| Tools | Causes in tooling: gaps in alerts, tests, environments |
| Program | Causes in planning: scope, funding, deadlines |
| Environment | Causes outside the team: vendors, traffic, org changes |
| Solutions | Fixes that address the causes above, with an owner |
To start a retrospective from this template, see Create a retro.