Case Study: When RCA Misses the Apex – And How Brake Dust Told the Truth
One of my clients—sharp operator, good team, decent systems—was struggling to understand why their incident reviews kept circling the same problems.
They were doing RCA.
They were asking “what happened?”
But they weren’t asking “why does this keep happening?”
So I gave them a V8 Supercar example.
Imagine a car ends up in the kitty litter at the end of Corner 3.
Driver braked too late.
That’s the symptomatic root cause.
But zoom out.
Same driver. Same track.
Last year? No issues.
This year? He’s consistently overshooting.
Turns out they changed brake pad compound.
Less bite. More fade.
Now we’re looking at the systemic root cause.
The symptom is the late braking.
The system is the brake pad spec.
Fixer Insight:
If you only treat the symptom, you’ll keep sweeping gravel.
If you find the system flaw, you redesign the race