Hyper-Integrated Causal Analysis 
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Hyper-Integrated Causal Analysis (HCA) in Action
Case Study: Repetitive Failures

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An independent BlueDragon Root Cause Analysis (RCA) was commissioned by the prime contractor at a Department of Defense installation.  During a period of 11 months, the three installed Compressed Air System (CAS) motors had experienced 7 failures (Figure 1).  The three trains of CAS motors provide vital breathing air for site operations.  

The RCA team consisted of Rob De La Espriella (the BlueDragon Team Lead), the motor System Engineer, and two volunteers in support roles. 

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The BlueDragon Hyper-Integrated Causal Analysis (HCA) is a two-phased approach that included the following activities, performed in a seamless and efficient manner:

Phase 1 - Analysis of available data and evidence to develop focused, evidence-based Lines of Inquiry.
 

  • A detailed timeline was developed for each of the three trains of CAS motors. Additional details were added to the timeline from the results of the causal analysis sessions. 
     

  • The BlueDragon team facilitated the development of a Fault Tree (Figure 2) using the two motor vendors and other subject matter experts (SMEs).  The mechanical and electrical failure modes for this motor were identified.  The Fault Tree allowed the team to establish a comprehensive troubleshooting plan to rule out as many of the failure modes as possible.  A major component of the troubleshooting plan involved the installation and testing of a CAS motor.  After extensive troubleshooting, the RCA Team was able to identify the probable causes of the seven motor failures. 
     

  • An analysis of the defenses in place to prevent these kinds of events was conducted. The analysis included a total of 92 administrative requirements that were evaluated for effectiveness, as well as physical barriers and equipment interfaces.
     

  • Approximately 80 focused, evidence-based Lines of Inquiry were developed as the starting point for the causal analysis (Figure 3). To develop the Lines of Inquiry, HCA used available information from the chart to conduct a seamless and integrated analyses that included: Comparative Timeline Analysis,Task Analysis, Change Analysis and Barrier Analysis.
     

Phase 2 - Facilitated Causal Analysis sessions to identify the root causes and significant contributing factors.

  • There were a dozen facilitated causal analysis sessions conducted on-site at the client's facilities, which included Maintenance personnel, Subcontract Technical Representatives (STRs), Engineering personnel, Millwrights, Work Control Planners and Schedulers, Quality Control personnel, three different vendors, and managers from across the project.  
     

  • The BlueDragon team guided the organization's SMEs through the causal analysis process, using their expertise to answer the Lines of Inquiry and identify the deepest-seated (root) causes and significant contributing factors. 
     

  • The BlueDragon chart captured the results of the causal analysis sessions live (in real-time), with the participants observing how their answers were documented (total transparency).  There are very few notes taken during this HCA process as the results are captured on the chart.
     

  • HCA calls for the results of the causal analysis to be validated by every group that participates.  By the end of the analysis, the results had been validated up through the senior managers that participated in the process.  

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Results: 

  • The BlueDragon HCA was completed in 10-days.  This level of efficiency can only be achieved by integrating many of the methods and techniques that are customarily done separately. 
     

  • The RCA investigation identified four root causes, five significant contributing factors and a number of opportunities for improvement.  Note that the results are derived by the SMEs participating in the causal analysis process, and not by the RCA team in a vacuum. 
     

  • The exit briefing with the client's senior managers took place at noon on the 10th day. Briefings are conducted from the BlueDragon chart; no documents are provided to managers.
     

Hyper-Integrated Causal Analysis (HCA) in Action

Case Studies 

NEAR MISS

At a Federal Government site, a non-electrical worker received a shock when he cut into a live wire with a current of 20 amps and 208 volts.  The area was being torn down in preparation for renovation...read more

Construction workers on work site

PROGRAM EVALUATION

The Procurement Program at a Federal Government site (part of the nuclear weapons complex) was analyzed to determine why there were recurring issues...read more 

Image by Daria Nepriakhina

REPETITIVE FAILURES

A Department of Defense Chemical Weapons Destruction Plant experienced seven consecutive failures of 4160v motors supplying three trains of vital breathing air...read more 

Image by Hoover Tung

NEGATIVE TREND

At a Federal Government construction site (part of the nuclear weapons complex), a negative trend of dropped objects from two cranes was proactively investigated before there were any major incidents...read more  

Image by david carballar

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