The Fishbone Diagram—also known as the Ishikawa Diagram—is a powerful tool for uncovering the root causes of incidents by organizing contributing factors into logical categories. In Serenity, this methodology helps investigators dig deeper into why an incident occurred by examining contributing factors from multiple angles.
Getting Started
Once the investigation has reached the Root Cause Analysis stage, users can choose the Fishbone Analysis option. This opens up a structured environment where users can begin to analyze the incident across various causal factor categories.
Add Causal Factor Categories
Each investigation starts with a blank fishbone canvas. Click “Add new category” to begin building your fishbone. Common categories include:
Human Factors
Workplace Factors
Organizational Factors
Absent or Failed Defenses
Individual/Team Factors
These categories can be customized (by admins) to reflect your organization's investigation methodology.
Add Contributing Factors
To begin building your root cause analysis, click the "Add contributing factor" button under any category. This will open a dialog where you can define the specific issue that contributed to the incident.
đź“ť The form includes the following fields:
Cause description:
Provide a clear, concise explanation of the contributing factor. This should describe a condition, behavior, or failure that played a role in the incident.Primary cause:
Use this dropdown to indicate whether this particular factor is considered the primary cause of the incident. You may have several contributing factors, but usually only one or two should be flagged as primary.Create finding (optional):
Check this box if you'd like to automatically generate a finding based on the contributing factor. Findings can later be linked to corrective or preventive actions.
âś… Click Save to add the contributing factor to your fishbone diagram.
đź’ˇ You can even use the AI-powered suggestion tool to auto-generate potential contributing factors based on prior data and contextual cues.
Identify the Primary Cause
Among your list of contributing factors, one or more may emerge as the primary cause—the issue that had the greatest impact or was the most direct contributor to the incident. You can toggle “Primary cause: Yes” to flag it appropriately.
đź“ť Next Step: Draft Recommendations
Once your Fishbone analysis is complete and a root cause is identified, you're ready to proceed to the next stage: drafting corrective and preventive recommendations to reduce the likelihood of recurrence.