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Insight: 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.

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Brake Failure Race Car

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

Jason Bresnehan Yacht in Hobart
Jason Bresnehan Yacht in Hobart

About Jason

Jason Bresnehan is the founder of Evahan Group and a fixer. With over two decades of experience in quality systems, operational risk, and business transformation, Jason has a knack for cutting through complexity and getting to the crux of what’s really holding a business back.

He designs ISO 9001-certified Quality Management Systems that are practical, auditable, and built for real-world messiness—not textbook perfection. His work spans high-risk, high-compliance industries from marine engineering and dangerous goods transport to modular construction, defence manufacturing, and robotic point-of-sale systems.

Jason’s Fixer Principle is simple:
Cut to the Jase. Keep it simple. Act.

Whether you’re chasing certification or just want a system that works, Jason helps organisations embed quality into every decision, repair, and customer interaction—without the fluff.

Let’s Talk
If you’re tangled in systems, drowning in documentation, or just need a fresh set of eyes, reach out. Jason’s known for saving businesses tens of thousands—and he reckons he could save a global giant millions in weeks.

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