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general lack of understanding of the tools available to assist in a thorough analysis ofavailable data. Perhaps the most apparent challenge is the tendency to stop once “areason” is found for an event. It is perhaps our nature to stop at the first “AHA!!”moment – to stop looking at the first instance where something is revealed that, ifcorrected, would have prevented the event from occurring. It will take discipline tocontinue from this point, to press for deeper understanding of the chain of events thattranspired. It also takes the commitment of a company to spend the time and moneynecessary to allow this “deep dig” to occur.Several approaches to determining possible causes have been widely used. Theseinclude flowcharts, logic trees, brainstorming, barrier analysis, and change analysis. 14Other tools also exist, such as programs for cause “mapping”. 15No one approach isuniversally accepted, nor should one be used exclusively. The key to this aspect of theanalysis is that the company must commit to its best efforts to identify the variouscauses of an event so that the remaining activities are appropriately focused.14 Id. at 49-62.15 Vanden Heuvel et al., supra at 84-88.9

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