Operations & Maintenance · Practice Area 02

Root Cause
Analysis

Structured elimination of recurring failures — going beyond the immediate cause to the physical, human and latent systemic roots that allow failures to repeat. RCA is not a report. It is a discipline that permanently removes failures from your operating environment.

Discuss an RCA Engagement Benchmark with GARPI™ →

Practice AreaOperations & Maintenance

MethodologiesApollo™ · TapRooT® · Cause Mapping

Delivery ModelEvent investigation or programme

Typical Engagement5 days – 6 months

SectorsAll asset-intensive industries

The Challenge

The same failures.
Over and over.

Most failure investigations find a cause and fix a component. The failure returns three months later. True root cause analysis finds the physical root, the human root and the latent organisational root — and addresses all three. Most organisations never get past the physical root.

Symptom fixing — replacing components without understanding why they failed, ensuring the failure repeats.

Blame culture — investigations that attribute failures to human error without examining why the error was possible.

No corrective action tracking — recommendations made but never implemented, or implemented without verification.

Chronic versus acute failures — resources consumed on acute events while chronic low-level failures drain availability unnoticed.

No knowledge retention — findings from previous investigations not feeding back into maintenance strategy or training.

Optimal's RCA Approach

Three roots.
All three must be found.

Every failure has three root types: a physical root (the mechanism that failed), a human root (the action or decision that allowed the physical root to exist or persist), and a latent root (the system, procedure or cultural condition that created the human root). Addressing only the physical root is not RCA — it is component replacement. Optimal's RCA methodology requires all three roots to be identified before corrective actions are recommended, ensuring permanent elimination rather than temporary repair.

Root types every RCA must address: physical, human and latent systemic

85%

Of recurring failures trace to latent organisational roots that are never addressed

Zero

Target recurrence rate for failures that have been properly root cause analysed and actioned

CATWOE

Systems thinking lens applied to latent root identification — customers, actors, transformation, worldview, owners, environment

Investigation Methodology

A structured process. Repeatable outcomes.

Failure Event Capture

Immediate data preservation — securing physical evidence, SCADA data, maintenance records, witness accounts and shift logs before they are lost or modified. The quality of RCA is determined by the quality of evidence collected in the first 24 hours.

Event Timeline Construction

Building a chronological timeline of all events, conditions and actions preceding the failure — using process data, maintenance history, inspection records and witness statements to establish the factual sequence.

Causal Factor Charting

Structured causal factor analysis — identifying every action and condition that contributed to the failure, mapped as a cause-and-effect chain from the event back to initiating conditions. No assumptions; every link evidenced.

Root Cause Identification

Drilling through physical and human causal factors to the latent systemic roots — using structured why-why analysis, barrier analysis and change analysis to find the conditions that made the failure possible.

Corrective Action Development

Developing corrective actions for each root cause — distinguishing between immediate fixes, procedural changes, design modifications and systemic improvements, with SMART action items, owners and verification criteria.

RCA Programme vs Event Investigation

Beyond the single event —
defect elimination

Single-event RCA is reactive by definition — it investigates after failure has already caused damage. Optimal also delivers RCA Programmes: proactive, continuous defect elimination processes that analyse patterns across all failures (including near-misses and chronic minor events) to find and eliminate systemic vulnerabilities before they produce significant failures.

An RCA Programme integrates with your CMMS work order history, condition monitoring alerts and shutdown findings — surfacing chronic failure patterns that individual event investigations miss. It is the difference between eliminating recurring failures and preventing the next generation of failures.

Chronic failure pattern analysis from CMMS data →

Near-miss investigation programme →

Corrective action tracking and verification →

RCA findings fed back to FMEA and maintenance strategy →

RCA capability building for in-house teams →

Root cause analysis investigation and defect elimination

What You Receive

RCA engagement deliverables

RCA Investigation Report

A structured investigation report documenting the complete causal factor analysis, evidence base, root cause identification, corrective action recommendations and implementation priorities for each root found.

Corrective Action Register

A tracked register of all corrective actions — categorised by root type, assigned to owners, with completion dates and verification criteria. Designed for integration with existing CMMS or action tracking systems.

FMEA Update Recommendations

Recommendations for updates to the asset's FMEA or RCM analysis based on findings — ensuring that newly discovered failure modes are captured in the maintenance strategy and do not recur.

Management Presentation

A structured management briefing presenting findings, root causes, corrective actions and programme risk — designed for asset owners, operations management and board-level reporting where required.

Lessons Learned Document

A portable lessons learned document suitable for distribution across the organisation — capturing transferable findings that may apply to similar assets or processes at other facilities.

Verification & Close-Out Protocol

A follow-up verification protocol to confirm corrective actions have been implemented and are effective — typically conducted 3–6 months after initial implementation with documented close-out.

Related Services

Services that connect to RCA

GARPI™ 2026 · Global Asset Reliability & Performance Index

How mature is your
defect elimination culture?

GARPI™ assesses your organisation's defect elimination maturity as part of Dimension 3 (Maintenance Execution) and Dimension 6 (Reliability Governance). Find out how your RCA capability compares to industry peers — and where the highest-value improvement opportunities lie.

Take the GARPI™ Survey View Methodology →

Asset Strategy & Planning

Reliability Engineering

Maintenance Execution

Condition Monitoring

Digital & Data Maturity

Reliability Governance

Workforce Capability

Spares & Materials

Next Steps

Eliminate recurring
failures permanently

Whether you have a specific high-cost failure to investigate, or want to build a systematic defect elimination programme, the starting point is a scoping conversation to understand your failure history, current investigation capability and priorities.

Discuss Your Requirements Benchmark First with GARPI™

Global — Africa & Middle East

Dr Leslie Moyo · Director Africa
enquiries@optimal.world
+44 7932 581 317

Africa — Project Delivery

Danie Fourie CA(SA) · Project Manager
enquiries@optimal.world
+27 82 566 0047

Root CauseAnalysis

The same failures.Over and over.

Three roots.All three must be found.