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A woodsman was once asked, "What would you do if you had just five minutes to chop down a tree?" He answered, "I would spend the first two and a half minutes sharpening my axe."
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Your purpose is to identify where in the process things go wrong, not who messed up. Look for systemic causes, not culprits.
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the system that people work in and the interaction with people may account for 90 or 95 percent of performance.
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