The Deformable Secondary Mirror (DSM), a vital component in Very Large Telescope (VLT) adaptive optics systems, is responsible for correcting optical aberrations in high-resolution imaging. During February 2023 it was affected by an unusual condition that led it to a critical failure. This paper presents an extensive analysis of such critical failure and the application of Root Cause Analysis (RCA) methodology to systematically identify and rectify the underlying issues. The RCA process seeks to uncover the core reasons that allowed a problem to manifest, looking into various contributing factors such as human error, equipment failure, organizational issues, or procedural shortcomings. By understanding and addressing the root cause of a problem, organizations can implement more effective solutions, improving processes, systems, and preventing similar issues from occurring in the future. The goal is not just to fix immediate problems but to institute changes that create more resilient and reliable systems. This investigation employed an array of advanced diagnostic methods, data acquisition, and fault tree analysis to pinpoint the root causes of the failure. This in-depth research aims to prevent similar failures in the future and, ultimately, enhance the reliability and performance of the DSM within the domain of adaptive optics. As a result of this research, distinct risk mitigation methods were suggested to safeguard against potential future failures, and several personnel training recommendations were given. These methods will be integrated into the DSM's operational protocols and maintenance procedures, thereby minimizing the risk of new failures, and ensuring the uninterrupted operation of adaptive optics systems in critical astronomical observations.
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