Hyper-Integrated Causal Analysis 
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Hyper-Integrated Causal Analysis (HCA) in Action
Case Study: Program Evaluation

An independent BlueDragon Root Cause Analysis (RCA) was commissioned by the prime contractor at a Department of Energy installation.  The site Procurement Program was experiencing a stream of issues and more than 20% of procurements that were key to the site's mission were in jeopardy of not meeting required need dates.  

The RCA team consisted of Rob De La Espriella (the BlueDragon Team Lead), a Manager from the Procurement Organization, and two volunteers in support roles. 

SRNS Procurement - Process Map.jpg

BlueDragon's 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 high-level process map was developed based on the Procurement Program procedures (Figure 1).  This effort identified three areas that were missing guidance, and also created a map that allowed us to chart the results of our Pareto Analysis.  
     

  • The BlueDragon team conducted Pareto Analysis of the procurement data base for the site.  The results indicated there were key areas that were experiencing the most problems, and these areas were superimposed on the process map (circled on Figure 1), which provided insights on where in the process most of the issues were occurring, as well as which organizations were involved at those points in the process.
     

  • An analysis of the defenses in place to prevent these kinds of events was conducted. The analysis included approximately 50 administrative requirements that were evaluated for effectiveness.
     

  • From the insights gained during the Phase 1 data analysis, 124 focused, evidence-based Lines of Inquiry were developed as the starting point for the Phase 2 causal analysis (Figure 2). 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 over a dozen facilitated causal analysis sessions conducted on-site at the client's facilities with users and process owners from 18 organizations, as well with off-site suppliers.  SMEs included Buyers, Suppliers, Procurement Project Management, Engineering, Work Planners, Quality Assurance, Internal Audits, Procurement Authority, Receipt Inspectors, Supplier, and Senior Procurement Managers.  
     

  • The BlueDragon team facilitated causal analysis sessions with over 100 of the 18 organization's SMEs, using their expertise to answer the Lines of Inquiry and identify the deepest-seated (root) causes and significant contributing factors. 
     

  • The BlueDragon chart (Figure 2) 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 two phases of the BlueDragon HCA were 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 5 root causes, 13 significant contributing factors and over 20 additional 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 CEO and the Executive Leadership Team took place in the afternoon on the 10th day. Briefings are conducted from the BlueDragon chart; no documentation was provided to managers.
     

  • Senior Procurement Managers participated in the exit briefing by highlighting the cause and effect pathways on BlueDragon chart, from the root causes at the bottom to the issues (the symptoms) at the top. 
     

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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