What If IBM Used the Fishbone and 5 Whys To Fix Their Crashing Tape Drives?

By Elisabeth Swan | April 14, 2016 | Application Tips, Featured, Using Lean Six
Sigma

In the early 1980s there was a countrywide failure of computer tape drives. The tape
drives were all made by IBM, they were crashing in large and small businesses alike
and no one knew why.
This was a big problem for business and definitely a big problem for IBM. Well take a
stab at this problem with the advantage of 20-20 Hindsight by reconstructing the
historic mystery using two classic Lean Six Sigma Tools: The Fishbone Diagram &
The 5 Whys technique.

The Fishbone Diagram

The Fishbone Diagram is one of the Seven Basic Tools of Quality (a shortlist of basic
process improvement methods) popularized by the quality guru Kaoru Ishikawa. Its also
known as the Ishikawa Diagram and some inspired folks have dubbed it the Fishikawa
to honor both the shape and the man famous for this user-friendly quality tool.

What Does a Fishbone Diagram Look Like?

How the Fishbone Works

The Fishbone is a structured brainstorming tool focused on exploring potential root
causes of an issue. The bones of the fish are labeled for general categories of
analysis such as:

Policies
Procedures
Environment
The idea is to ask what, within each category, could be causing the specific problem. As
an example, What about the environment could be causing the tape drives to crash?
And there could be many answers to that question:

The heat
The humidity

The air flow

The proximity of other equipment
Etc.
The idea is to switch from category to category while brainstorming potential root
causes with a diverse group of people.
For the best range of ideas, its important to gather people together who have different
views and roles within the process. In the case of IBM it would have been good to
gather folks from:

Engineering
The Lab
Production
Shipping
Larger Customers
to understand what was happening to the tape drives.
The idea is to switch from category to category while brainstorming potential root
causes with a diverse group of people.

Using the Fishbone Diagram to Understand the Crashing Tape Drives

Working the Fishbone Diagram

Taking the category of Materials one question would be, Were the tape heads made
of inferior raw materials? Another category that youll find on most Fishbone diagrams
is People.
Even though Dr. Deming said that 80% of problems are process related, theres still
20% that might be due to the work force.
Even though Dr. Deming said that 80% of problems are process related, theres still
20% that might be due to the work force. Were people mishandling the drives? They
could look at the Process did they have an inferior cleaning procedure? Many of the
brainstormed root causes might have been worth exploring if the problem had been
happening at a single location with one group of people in one environment. But this

problem was happening across the country, which meant that the root cause had to be
common to all of their customers.
At some point it became clear that something was wrong with the tape heads. But if
there had been no changes in the manufacturing processes, no new suppliers and they
used the same quality of raw materials, why would there be something wrong with the
tape heads? Most of these tape drives were brand-new.
Time for another classic quality tool!

The 5 Whys
Combining the 5 Whys with The Fishbone Diagram constitutes the Peanut Butter and
Jelly Sandwich of Root Cause Analysis.

The 5 Whys is deceptively simple and bears a striking resemblance to the average
conversation with a 5-year-old child. And thats almost all you need to know to use this
tool. Its also known as the Why-Because tool for the same reason. The goal is to push
past presenting symptoms and dig to root cause. It might take 5 Whys, 10 Whys or it
might take just 1 Why.

Using Five Whys on the Bad Tape Heads

The Root of the Problem

It turns out that Legionnaires Disease had always been present but the specific
temperature and level of humidity being maintained by modern HVAC systems created
a perfect breeding ground for the disease. The tape drives were often positioned near
ventilation ducts so once they added the bactericide to the system to combat
Legionnaires, the tape heads became coated with the tin contained in the solution. And
the tin on the heads made them crash.

Solving for Root Cause

When a team of IBM chemists confirmed the root cause, the company considered the
aspects they had control over. Eliminating the spread of Legionnaires completely was
ideal, but no workplace would subject their people to uncomfortable environments. This
left the option of revisiting the ingredients of the bactericide. It turned out to be easy to
reformulate the solution without tin. Problem solved. They could have spent lots of time

and money on the symptom by endlessly replacing expensive tape heads, but the
Fishbone and the 5 Whys present the way to a permanent fix.

Challenges to using the Fishbone and the 5 Whys

Theres No Time and other Myths
Classic root cause analysis begins with the goal of moving past symptoms and solving a
problem at its root, once and for all. But we often respond to problems by instituting
immediate, temporary fixes. If my boss says, Dont bring me problems, bring me
solutions I might be tempted to put a patch in place because Im so busy. Im working
hard just to keep up so I assume I have no time to get to the root. But, as the saying
goes, We dont have time to fix it, but we have time to do it twice.

Fishing Alone
Another mistake made in the interest of saving time is completing a Fishbone Diagram
with a team of one you. A key to the effectiveness of the Fishbone Diagram is the
wisdom of the group. One person has only one view of the process whereas inviting the
observations of others expands the problem-solving potential. The goal is to include
diverse and even conflicting perspectives in order to increase the effectiveness of the
brainstorming session. This also has the unintended consequence of increasing
ownership of the inevitable changes that using this tool might lead to.

Selecting What to Pursue

Another hurdle, once the Fishbone is populated with ideas, is narrowing the list of
causes down to a manageable number to investigate. If done right, the resulting
diagram should be covered with bones or potential causes, but limited resources
dictate that not every cause is a candidate for verification. Nor should they be. MultiVoting, also known as N/3, is a simple tool that provides a quick visual prioritization.
To Multi-Vote:
1.
2.
3.

Add up the number of potential causes

Divide the total by 3
Give each member of the group the resulting number of votes

For example, if there are 21 potential root causes, 21/3 = 7. Everyone gets to put a
mark next to the 7 causes theyd like investigated (sticky dots are good for this). The
result is an instant shortlist to pursue.

Multi-Voting on the Fishbone Diagram

Pants on Fire
In the case of the crashing tape drives, the problem was so pervasive, public and costly
that IBM had no choice but to immediately apply resources to solve the problem. But in
our workaday lives we dont always feel the urgency. That leaves us fighting fires all
day just to keep things rolling. Consider this if were choosing not to get to the root of
process problems then were not just the firefighters, were also the arsonists!
If were choosing not to get to the root of process problems then were not just the
firefighters, were also the arsonists!

Spending the time is always worth it, and these are quick and easy tools that require no
advanced training. No more excuses make a Fishbone & 5 Whys Sandwich and be a
root cause hero!