An important tool in the root cause analysis of any safety related event or incident is the fishbone diagram. Take some time to read case study 3.4 on page 56 of your text and using the fishbone template provide on the site complete a root cause analysis by filling out the fishbone with the information understood from your reading. I understand that the case study will only give you so much so please feel free to make any assumptions you may need to help you fill this out. Use your imagination if you have to I just want to get you all exposed to this tool.
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