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Work accidents when entering enclosed spaces (water ballast tank) pose a high risk that can endanger the safety of ship crew. This study aims to identify: 1) the factors causing work accidents during entry into the enclosed space (water ballast tank) on MT. Emmanuel; and 2) efforts to minimize the risk of such accidents. This research was conducted over 12 months during onboard practical training on MT. Emmanuel using fishbone analysis as the data analysis technique. Based on the analysis, accident causes include worker overconfidence, non-compliance with the permit to enter procedures, lack of oxygen and toxic gas monitoring, and poor communication among crew members. Suggested measures to minimize accidents are the regular implementation of safety meetings, internal sanctions for SOP violators, periodic drills for entering hazardous spaces, and disciplined enforcement of the permit to enter in accordance with ISGOTT 5th Edition Chapter 10 standards. The implementation of these steps is expected to improve crew safety and reduce the risk of accidents in enclosed spaces.

Grounding incidents are among the most critical maritime accidents, posing significant threats to navigational safety, operational efficiency, and logistics continuity. This study aims to analyze the contributing factors behind the grounding of MV. Tanto Luas in the Mahakam River and to identify effective mitigation efforts. A descriptive qualitative approach was employed, with data collected through direct observation, interviews with ship crew, and documentation during onboard sea practice (PRALA). The findings reveal that the grounding incident was primarily caused by poor communication between MV. Tanto Luas and a tugboat, improper navigational decisions, and shallow, wave-affected waters. The Fishbone Diagram (Cause and Effect Diagram) method was used to systematically identify the root causes of the problem. Mitigation efforts included tank sounding, tidal monitoring, optimal use of navigational equipment, and improved inter-vessel coordination. The study concludes that grounding incidents can be prevented through enhanced communication, strict adherence to navigational procedures, and regular crew training. This research offers both practical and theoretical contributions to the enhancement of maritime safety in narrow waterways such as the Mahakam River.

Osha Snack UMKM faces issues related to product defects, which are suspected to arise due to a lack of quality control in the production process. This study aims to identify the causes of product defects, provide improvement suggestions, and determine effective ways to control product quality. Data were collected through interviews with relevant parties and field surveys to gather information on production volume, product defects, and production activities. The data were processed by organizing it into check sheets, performing regression calculations, and analyzing it using scatter diagrams and fishbone analysis. The Statistical Process Control (SPC) method was applied to analyze, control, and improve the production process. The results show a significant relationship between production volume and the number of defective products, with the regression equation Y = 0.0764X and a coefficient of determination R² = 0.9625. The most common type of defect is broken snacks before packaging. In addition, waste products also come from product returns by buyers, which leads to raw material waste and hinders the achievement of production targets. The analysis results suggest that the UMKM should implement quality control measures in the form of process improvements, enhancement of work skills, proper machine maintenance, implementation of SOPs, and improvement of working conditions.

This study aims to analyze the product quality of tofu at Tahu Tansa, a tofu business located in Bogor City, by utilizing quality control tools such as check sheets, Pareto diagrams, and fishbone diagrams. Tofu is a nutritious food product with high consumer demand, but its production process often encounters defects that affect product quality. This research uses primary data obtained through direct observation and interviews and is analyzed using descriptive quantitative methods. The results show that the most dominant defect is non-standard tofu cutting size (50%), followed by overly soft texture (37.87%), and residual cloth stuck on the product (12.13%). Based on fishbone analysis, these defects are caused by suboptimal factors including manpower, machines, methods, raw materials, and measurement. The findings imply that improvements in operational standards, workforce training, and strict monitoring of raw materials and equipment are necessary to maintain quality and improve production efficiency at Tahu Tansa.

This study was conducted to evaluate the quality of banana chips products at My Kripis by using the Check Sheet and Fishbone Diagram methods. The main problem found was the high rate of defective products, which reached 3.79% of the total monthly production. The largest type of defect was recorded as inappropriate banana ripeness during the frying process, which amounted to 18 kg out of a total of 37.2 kg of defective products. Data was collected through direct observation and interviews, then analyzed using an inspection sheet to identify the type and frequency of defects. Results showed that the dominant cause of defective products came from raw material factors, such as non-uniform banana ripeness and inconsistent slice thickness. A Fishbone Diagram was used to identify root causes from various aspects, including man, methods, machines, and materials. These findings served as the basis for recommendations to improve the production process, such as standardizing cutting procedures, training operators, and monitoring the quality of raw materials. This research confirms the importance of simple yet systematic quality control for MSMEs to sustainably improve product quality.

This research aims to identify and analyze service quality issues in the Foxxsniff perfume startup using the Fishbone diagram method. A qualitative descriptive approach is employed with data collection techniques through observation, in-depth interviews, and documentation studies. Data analysis utilizes check sheets, pareto charts, and fishbone diagrams. The research results are expected to identify service quality dimensions that require improvement and their root causes. The implementation of the Fishbone method in service quality management is expected to contribute to the development of service quality improvement strategies for the Foxxsniff perfume startup.

Product quality is described as the characteristics of a product that supports its ability to meet customer needs standards or manufacturer feasibility standards. This research was conducted on potato chip products at Osha Snack by analyzing the types of defects in potato chips and their causative factors. In this study, the method used is the seven tools method, namely fishbone diagram, pareto diagram, and flowchart diagram. In one month, 57 units of defective potato chips were obtained. The purpose of this study using the seven tools method is to find out the types of defects in potato chips and the factors that cause defects in the product to minimize the level of defects in the production period in the next period. Based on the data obtained, there are two types of defects in potato chips, including 35 units of product returns and 22 units of burnt chips and inappropriate potato cutting. On the application of quality chips.    

This study aims to analyze the causes of bottlenecks in lip balm production at PT Rumah Rumput Laut by using a survey approach and fishbone diagram analysis method. The research method used is a descriptive method with survey approach which was conducted at PT Rumah Rumput Laut, Bogor Regency, West Java. Data were collected through observations and interviews with related parties in the production process based on previously identified problems. A fishbone diagram was used to identify the factors causing bottlenecks, which were grouped into six main categories, namely: manpower, machine, method, material, measurement, and environment. The results of the fishbone diagram analysis show that bottlenecks in lip balm production are caused by the irregular flow of material transfer, long waiting time for the quality control process, and limited production capacity. To overcome this problem, it is necessary to improve the operator supervision system, implement a regular machine maintenance schedule, rearrange the production space layout, and use technology to monitor machine conditions in real time.

The loading and unloading process involves moving goods from one place to another, often requiring specialized equipment such as a wire crane. In maritime operations, unexpected incidents like wire crane breakage can occur. Wire crane breakage refers to damage in the sling wire of a ship's crane, reducing its lifting capacity and causing the wire fibres to unravel. During sea-based fieldwork on the MV. Pacific Bulk, researchers observed a wire crane failure during loading and unloading operations, which caused delays and financial losses. This study aims to identify the causes of wire crane breakage on the MV. Pacific Bulk and examine its technical and operational impacts. Using a qualitative descriptive method and fishbone analysis for data interpretation, the study found several contributing factors: wire corrosion, crane age, lack of standard operating procedures (SOPs) for crane maintenance, insufficient crew, inadequate maintenance, lack of routine inspections, and challenging environmental conditions. The research also highlights the technical and operational consequences of such failures, including delays and economic loss. To address the issue, the study suggests implementing scheduled periodic inspections following SOPs, applying regular lubrication, and maintaining data records of the wire crane’s lifespan. These preventative measures aim to improve operational efficiency and avoid future wire crane failures.

The role of Cargo Handling on the Loading and Unloading Process at PT Terminal Teluk Lamong is very important for the loading and unloading process at the port. This research aims to identify various technical and non technical obstacles in the operation of cargo handling equipment such as ASC, forklift, and reach stacker. The interview results showed that there are four main factors that become obstacles in the loading and unloading process, namely machines, methods, facilities, and manpower. Further analysis using fishbone diagrams reinforced these findings by outlining the causes of each factor, ranging from machine interference, wrong container placement methods, limited technological facilities such as Container Scanner Reader (CSR), to the driver’s lack of understanding of the automation system. Quantitatively, the efficiency of cargo handling was evaluated through the 2023 container throughput, which showed a positive trend with a significant increase in load activity, especially in October which recorded the highest number of 39.106 Boxes. The analysis concluded that although there are various obstacles in cargo handling practices, the system implemented by PT Terminal Teluk Lamong has generally been able to improve the efficiency of the loading and unloading process, as evidenced by the volume of container handling.

The dredging activity at Tanjung Pakis General Terminal is carried out to support the construction of the jetty and the deepening of turning basin to enhance the berthing capacity of ships. However, the actual dredger volume did not meet the meet the initial plan, potentially affecting maritime safety and security. This study aims to analyze dredging productivity and identity the factors causing discrepancies between the planned and actual dredging volumes. This study employs a mixed methods approach, combining quantitative analysis through descriptive statistics and qualitative analysis using a fishbone diagram. The research findings indicate a significant decline in dredged volume, with the total realized volume reaching only 221.619,47 m3 out of the planned 500.000 m3. The primary factors contributing to this discrepancy include administrative issues, environmental factors such as high waves, and fishing activities in the area.

Mustofa Bakery is one of the businesses in Sukoharjo that operates in the food sector. The purpose of this study is to analyze product quality control using the Statistical Quality Control (SQC) method to reduce the number of damaged products and analyze the factors that cause product damage at Mustofa Bakery. The type of data used in this study is quantitative data. The data source used in this study is secondary data. Data collection methods by interview and observation. The data analysis technique used in this study uses the Statistical Quality Control (SQC) method. Based on the results of the research that has been done, it can be concluded that in March, April, and October it still exceeds the standard limit of production damage that has been set by Mustofa Bakery in Sukoharjo by 2%. The application of quality control with SQC can reduce the number of damaged products at Mustofa Bakery in Sukoharjo, proven to be true. The results of the Pareto Diagram of the types of damage that often occur are damage due to burning, 1,719 breads or 35.25%, damage due to inappropriate shape, namely 1,607 breads or 32.96%, and damage due to inappropriate texture as much as 1,550 breads or 31.79%. The results of the cause-and-effect diagram (fishbone) of the factors of product damage that occurred at Mustofa Bakery in Sukoharjo occurred due to machines, humans, methods, and raw materials.

In health care, the interaction between nurses and patients is essential to build good relationships, increase trust, and meet patient needs and expectations. The success of nursing services depends on the ability of nurses to communicate effectively. One of the causes of unexpected events (KTD) is due to communication errors both verbally and in writing between multidisciplinary and between shifts. Bedside handover can reduce patient safety incidents caused by miscommunication and strengthen employment relations between nurses, thus creating a more collaborative work environment. The purpose of this community service activity in this study is to improve the interaction of nurses when handover to the management of patient-centered care. Data collection techniques are carried out using questionnaires, interviews and direct observations in the treatment room of Karunia Kasih Hospital. In analysing the problems of the data obtained in this study, researchers used Fishbone Analysis which outlined existing problems and analysed using the method of USG (urgency, seriousness, growth) to determine the priority of the problem. The implementation carried out was changing the traditional handover method to bedside handover with the SBAR technique, revising the SOP, conducting socialisation about bedside handover conducting supervision and auditing the implementation of bedside handover. From the data analysis on observations, it can be concluded that bedside handover is an effective strategy to improve interaction between nurses and patients. The results of the analysis of the observation data can conclude that bedside handover is an effective strategy to improve the interaction between nurses and patients in patient-centred care. 

Product quality is a key factor in enhancing a company's competitiveness. PT Nugraha Potong Tekuk, a producer of MPGG products, experienced a significant increase in the defect rate, reaching 11% of total production during the period from June 24 to July 16, 2024. This study aims to analyze the defect rate, identify the main causes, and provide improvement recommendations. The study follows the Six Sigma methodology, including the Define, Measure, Analyze, Improve, and Control (DMAIC) phases. Based on P-Chart analysis, the production process is within statistical control limits, but the defect rate still requires improvement. Two main types of defects were identified: unevenness and size defects, each accounting for 50% of the total defects. Fishbone diagram analysis revealed four main contributing factors: people, machines, materials, and environment. The people factor includes lack of operator skills and operator fatigue, while the machine factor covers worn-out tools and uncalibrated measuring instruments. The material factor is related to low-quality raw materials, and the environmental factor includes poor lighting and unstable work surfaces. Improvement recommendations include operator training, routine machine maintenance, quality control of raw materials, and improvement of the work environment. This study is expected to help PT Nugraha Potong Tekuk enhance product quality, reduce defect rates, and maintain competitiveness in the market.

Didik Bag Convection is a manufacturing business specializing in bag production. However, its production activities often encounter issues related to product quality, such as defects caused by employees' lack of understanding of new sewing machines, the absence of standard operating procedures (SOPs), and an unsupportive work environment. To address these issues, quality control measures are necessary, which can be analyzed using Statistical Process Control (SPC) to identify the root causes of defects in product quality and production processes. The quality control analysis techniques employed include Check Sheets, Pareto Diagrams, Control Charts (P-Charts), and Fishbone Diagrams (Cause-and-Effect Diagrams). The results of this study indicate that the quality control at Didik Bag Convection is within acceptable limits as it falls within normal control boundaries. The number of defective products remains within a reasonable threshold. Based on the Pareto Diagram, damaged stitching defects account for the highest proportion of defects, making up 43.28% of the total defects. Improvements to address stitching defects are needed, which can be achieved using the Fishbone Diagram by focusing on the factors of Man (human resources), Material (raw materials), Machine, Method, and Environmental indicators that influence product defects during production.

This study aims to use the fishbone diagram as a tool to identify the causes of damage to the feeder mechanism of scrap machines and to develop Standard Operating Procedures (SOP) that can improve performance and reduce the level of damage. This diagram is used to evaluate various elements that contribute to the damage of the feeder mechanism, such as human, machine, material, method, and environmental factors. Through this evaluation, the main causes of the damage can be identified, and appropriate corrective actions can be formulated. In addition, this research also aims to design SOPs that ensure more efficient operation of the scrap machine and reduce the likelihood of operational errors. The implementation of mechanism improvements and SOPs is expected to enhance the reliability of the scrap machine, reduce downtime, and increase productivity in the mechanical technology laboratory. The findings of this study are expected to make a significant contribution to the development of management systems and equipment maintenance in both industrial and educational sectors.  

Batik Banten Mukarnas is a company that produces stamped batik designs with various patterns and varieties of batik. Problems frequently arise in the company due to increased stamped batik production capacity to meet the demand for stamped batik design products, which continues to rise from stamped batik suppliers. Another impact of growing demand capacity is the high number of defects in stamped batik cloth products, because overall, the company's management, including human resources, tools, and methods, is not prepared for the increase in production capacity to meet the surge in consumer demand, resulting in an impact on the quality of the products produced—consequently, the organization endeavors to regulate the quality of stamped batik cloth at PT. Batik Banten Mukarnas establishes objectives that employ Six Sigma with the DMAIC method (Define, Measure, Analyze, Improve, and Control) in the production of batik stamp designs to meet production objectives. The results of the data processing that has been done obtained a sigma value before improvement for 3 CTQ of 3.54. After improvement, the sigma value increased to 3.86. While for the sigma value before improvement for 1 CTQ of 3.04, the sigma value increased to 3.42 after improvement. The factors contributing to defective products, as illustrated by the fishbone diagram, include methods, personnel, materials, machinery, and environmental conditions. The division leader consistently oversees and regulates operations, enhances the number of brushes, and trains operators to ensure proficient adherence to standard operating procedures (SOP).

Background: The application of electronic signatures (TTE) is an essential step in supporting digitalization efforts to authenticate medical record documents (RME) in a secure and efficient manner. This study aims to review the readiness for TTE implementation at Puskesmas Ngebel using the Fishbone Diagram analysis (5M: Man, Method, Material, Machine, Money). Subjects and Methods: This research uses a qualitative method with data collection conducted through interviews with respondents including the Head of Puskesmas (for triangulation), medical record officers, registration staff, doctors, and nurses. Research Results: The results show that Puskesmas Ngebel is still in the initial stage of implementation and faces various obstacles as identified through the Fishbone Diagram analysis. This study is expected to review the level of readiness for TTE implementation and offer solutions to overcome the identified challenges. By applying the Fishbone Diagram approach, this research successfully identifies institutional barriers in preparing for the implementation of electronic signatures for authenticating medical record documents. The findings are expected to contribute to strategic planning for digitalization in community health centers.

Retention preparation is the process of identifying, assessing, and grouping archives in accordance with the applicable retention schedule, before final action is taken on the archive. This study aims to determine the obstacles to retention preparation from manual to electronic at the Kauman Baru Ponorogo Health Center and the challenges of retention preparation. The research used descriptive qualitative method with data collection method. Data were obtained through observation of 33,445 medical record documents, as well as interviews with medical record officers. The research instrument included an observation sheet with five assessment components. The results showed that retention preparation still faced obstacles, especially in terms of facilities and infrastructure. One of the main obstacles is the limited storage space, which is narrow and not suitable to support the process of digitizing medical records. This study recommends increasing training, providing a new building that is suitable and safe for storage and the process of digitizing medical record documents can run effectively and in accordance with regulations.

In an era of increasingly fierce competition in the energy sector, companies are required to not only meet customer needs, but also to improve service quality and customer satisfaction in a sustainable manner. This study aims to analyze and improve the performance of the Marketing and Customer Service Division at PT XYZ by applying the 5W1H method and the Fishbone Diagram.  The study identified a number of factors that contributed to the division's low performance, including a lack of adequate training and decreased work motivation. Through in-depth analysis, this study provides strategic recommendations to improve the quality of training, the development of an integrated information system, and the establishment of clear service standards. The implementation of these recommendations is expected to improve productivity, service quality, and customer satisfaction, as well as strengthen the company's position in a competitive market.