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What constitutes a cause is a particularly important question for those who teach or study technical writing. This article describes a case that helps students look beyond the technical "causes" of a commuter airplane crash in order to address the complex web of policies, practices, actions and events that contributed to the crash. Using an approach grounded in stakeholder theory and ethical theory, students use real documents ranging from news accounts to FAA policies to NTSB hearing exhibits to identify systemic problems that contributed to the disaster. Working from particular stakeholder perspectives, they work collaboratively to develop and argue for policy changes that will prevent future tragedies. The abundance of real documents that drive this case make it an especially useful tool for engaging students in difficult-to-teach subject matter including the role of writing in the failure of technical systems, deliberative and judicial rhetoric, stakeholder theory, visual rhetoric, and ethics.