EXERCISE 3: FISHBONE CHART

Agdigos, A.P., Galingana, C.L.T., Gualberto, S.R.S., Lopez, J.P., and Samaniego, K.P.
Department of Food Science and Nutrition, College of Home Economics, University of the Philippines
Diliman

I. Abstract
Fishbone charts are tools of quality used in root cause analysis of specific product defects. This
type of analysis was used in determining the possible causes of product defects in Ultra High Temperature
(UHT) processed milk. Two types of defects were identified: bacterial contamination of raw milk prior to
processing and underfilled milk cartons for the finished product. For each defect, two types of diagrams
were used, the dispersion analysis and process classification. From the process classification, bacterial
contamination may be mainly caused by milking, cooling and storage, transport, and secondary transport.
Possible causes for underfilling were packing and storage. Dispersion analysis was found to be more
suitable for root cause analysis, since it covers a wider range of categories, whereas the process
classification lacked some primary causes of defects.

II. Introduction
Humans had considered milk staple thousands of years ago (Chandan 2008).Milk can come from
different domesticated animals (goat, water buffalo etc.) of which cows milk is mostly predominant for
human consumption. Today, several forms of cows milk (fresh, powdered, sweetened, etc.) are
commercially available to cater a wide market (infant, children, people with special dietary needs and
adults). One example of commercially available milk product is UHT processed milk in cartons.
Ultra High Temperature (UHT) processing of milk involves heating of raw milk (depends on the
product) at temperature relatively higher (135C -150C for 1-4s) than the temperature used for other
milk heat treatment such as sterilization (Harding 1995). This method eliminates possible chemical
reaction that may occur for heat treatment requiring longer time.

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Basu (2009) enumerated nine tools of measurement which include the seven (7) basic tools of
quality. Among these are tools for identifying degree of defect occurrence such as the Pareto diagram.
After identifying the defect that should be addressed (as priority), root cause analysis should be done. One
tool for identifying root cause of a given defect is called the cause-and-effect diagram or Ishikawa
diagram (named after Ishikawa) (Basu 2009).
There are three types of cause-and-effect (CE) diagrams: dispersion analysis, process
classification, and cause enumeration (Reshef 2000). However, the third type is not generally discussed as
often, since it is a more difficult way of constructing CE diagrams. The dispersion analysis is the most
common type, and is done by enumerating the broad areas in branches wherein the cause of the effect
may lie (Reshef 2000). These branches are basic categories, namely: man, manpower, method, machine,
material, measurement, and environment (Armstrong 2011). The more specific root causes are then listed
down as twigs on the branches (Reshef 2000). Once the chart is finished, the branch with the most twigs
can indicate the need for further analysis and focus (Improhealth 2009). The disadvantage to this is that
root causes which do not fall under any of the basic branches are excluded from the diagram. This may
possibly end up in the root cause not being in the diagram at all (Reshef 2000). The process classification
is done in a similar way to the dispersion analysis, only the process steps, in consecutive order, are the
major causes (Reshef 2000). The root causes are then classified based on the step in which they may
occur. An advantage of this is that the root causes can be more easily identified, since it follows the
sequence of the process. A disadvantage, on the other hand, is that it is difficult to place root causes which
may fall under a combination of process steps (Reshef 2000).
IOn this exercise, possible root causes of bacterial contamination of raw milk for UHT milk
production and underfilled milk (in cartons) were identified using two types of fishbone charts: dispersion
analysis type and production process classification type. Root causes were identified and corresponding
practical solutions were given.

III. Methodology
Fishbone diagram construction
Two defects were identified for the product: one for the raw material and the other one for the
finished product. For each defect, two fishbone diagrams were constructed (dispersion analysis and
process classification). In constructing each fishbone diagram, the quality problem was determined, and
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then placed at the right side of the backbone. Main causes were linked to the backbone, and under these,
minor bones, inducing each main cause were connected. Smaller bones were added until no further causes
were identified.

Fishbone analysis
After the fishbone diagrams were constructed, each figure was analyzed. The causes were first
identified whether they are root or secondary. Possible solutions were also determined, and examined
based on feasibility, cost effectiveness, and applicability. Corrective actions were also suggested to
eliminate the defects cited.
IV. Summary of Results
Cause and effect diagrams on the causes of bacterial contamination
The fishbone diagrams on Figures 1 and 2 identify various causes onfor the bacterial
contamination of raw milk. The main causes on Figure 1 are environment, method, machine, manpower,
and material as it is called a dispersion analysis diagram. Figure 1 constitutes both root and secondary
causes. As shown on Figure 1, having a sick lactating cow as material is caused by contaminated feeds,
inflammation of udder tissue (Mastitis), and catching a virus.

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Figure 1. Dispersion analysis diagram on the causes of bacterial contamination of raw milk

On the other hand, the production process classification diagram lacked specific secondary
causes. The main causes on this diagram are milking, cooling and storage, transport, and secondary
transport. Figure 2 shows various root causes per production process step on the treatment of raw milk.

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Figure 2. Production process classification diagram on the causes of bacterial contamination of raw milk

Cause and effect diagrams on underfilling of milk in carton

The problem identified on Figures 3 and 4 is the underfilling of milk in carton. The dispersion
analysis diagram consists of four main causes: environment, machine, measure, and manpower. Secondary
causes were also identified such as rodent infestation on leakages, and leakage and blockage on the slow
outflow of milk.

Figure 3. Dispersion analysis diagram on the causes of underfilling of milk in carton

Figure 4, however, is a production process classification program consisting only of two main
causes: packing and storage. It is further detailed with secondary causes such as leakage and blockage on
the slow outflow of milk product during packing, and bioterrorism, rodent infestation, and improper
handling of equipment during storage.

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Figure 4. Production process classification diagram on the causes of underfilling of milk in carton

V. Interpretation of Results
Based on the diagrams, it can be seen on the product process classification diagrams that some
root causes appear on 2 or more steps, like the mishandling of equipment for the underfilling of milk and
unclean hose on the microbial contamination of raw milk, making it easily identifiable and determine
which step it appears on, compared to the dispersion analysis diagrams, where they appear on a single
branch. In both dispersion analysis diagrams, the manpower branch had the highest number of twigs,
indicating a high possibility of the root cause happening due to personnel actions. However, it cannot be
said on which step it occurred, inducing the need to search the whole process, which may consume a lot
of time and/or manpower.
The most probable root cause of the underfilling, based on the two cause-and-effect diagrams, is
the process of filling either on the machine or on the measuring/calibration. This is most likely due to the
process being automated, as no personnel were seen in this video of carton milk production (see
https://www.youtube.com/watch?v=EoYF2eHTKAI). The filling machine should be cleaned and
maintained frequently in order to prevent the possible causes. The root cause for the microbial
contamination is hard to determine since there are no specific category or process step in which has the
most number of branches. More information is needed, like the specific type of bacteria, in order to
narrow down the search and lessen the options.
Generally, the two types of cause-and-effect diagram, namely the dispersion analysis and the
production process diagram have their own advantages and disadvantages. However, one could use first
the dispersion diagram in order to narrow the category, then the process diagram to locate the root cause,

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or vice versa. The cause-and-effect diagram is effective at determining the root cause, however, it depends
largely on the experience and imagination of the one implementing the diagram.
VI. References
Armstrong FE. 2011. Cause-and-Effect Diagram [Internet]. Quality Tools Web Site; [cited 2016 Mar 1].
Available from http://thequalityweb.com/cause.html
Basu R. 2009. Implementing six sigma and lean: a practical guide to tools and techniques. UK: Elsevier
Ltd.
Chandan RC. 2008. Dairy industry: production and consumption trends. In: Chandan RC (Ed), Kilara A &
Shah NP (Assoc. Eds). Dairy processing and quality assurance. Iowa: John Wiley & Sons Inc.
Harding F. 1995. Processed milk. In: Harding F (Ed.). Milk quality. Dordrecht: Springer Science +
Business Media. [cited 2016 Mar 2] Aavailable at: https://books.google.com.ph/books?
id=h5_wBwAAQBAJ&printsec=frontcover&hl=fil#v=onepage&q&f=false
Improhealth. 2009. Fishbone Diagram [Internet]. Improhealth Collaborative; [cited 2016 Mar 1].
Available from
http://www.improhealth.org/fileadmin/Documents/Improvement_Tools/Fishbone_diagram.pdf
Reshef Y. 2000. Fishbone Diagram [Internet]. University of Alberta; [cited 2016 Mar 1]. Available from
http://www.ualberta.ca/~yreshef/orga432/fishbone.html

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