BlueDragon Uncovers Significant Program Weaknesses That Nearly Caused a Fatality


BlueDragon's Investigation of an Electrical Shock Event (a Near Miss) Led to the Identification of a Significant Programmatic Weaknesses in the Site's Industrial Safety Program

The Client
A subcontractor for the Department of Energy at the Oak Ridge National Laboratory.

The Problem
A subcontract laborer received an electrical shock while cutting conduit during the demolition of a government facility. The live wire was carrying a 208 volt, 20 amp current. The arc shocked the worker and melted the snips.  Note: it takes less than 1 amp to kill a person.

The BlueDragon Mission
Conduct an independent BlueDragon investigation of the industrial safety near miss and identify the root causes and significant contributing factors.

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The BlueDragon Integrated Problem-solving System (IPS) is a 3-phased approach that included the following activities, performed in a seamless manner on one chart:

Critical Thinking: develop evidence-based questions that will form our lines of inquiry.    
    • Gather and organize performance evidence and applicable standards and procedures onto a BlueDragon chart. This includes timelines, oversight reports, keep performance indicators, corrective action program databases, quarterly trend reports, and any other charts and graphs that provide insights into performance. 
    • Conduct a Systems Inventory, to establish a holistic approach to the investigation. This includes the identification of the applicable programs that are in place to ensure activities are performed safely and effectively. 
    • Conduct an Analysis of Defenses, to determine the effectiveness of the administrative requirements, physical barriers and cyber barriers that should have prevented the events. Analyze any available data that might shed some light on performance. This could include using any number of Lean 6 Sigma tools, and any other data analysis tools such as fault trees, control charts and human performance evaluation surveys. The goal of our data analysis is to identify non conformances, non-compliance with requirements and any other irregularities where performance does not match standards and expectations, which are actually the manifestation of the problem or event (i.e., the breadcrumbs left behind by the event that we can readily identify). In BlueDragon terms we call these irregularities “symptoms.”  
  • Using insights gained from the analysis of defenses, the data analysis and the identification of as many symptoms as possible, we generate focused, evidence-based questions to explore what causes those symptoms.  These questions will form our lines of inquiry.  
Causal Analysis: determine the deep-seated causes and contributing factors.    
    • Organize and schedule a series of facilitated causal analysis sessions with the organizations subject matter experts. 
    • Using cause and effect analysis, we reverse engineer our way from the symptoms identified in Phase 1 back to their points of origin (i.e., the deepest-seated causes) by pursuing the lines of inquiry.  
    • It’s important to understand that bias can creep into the analysis at any point during the investigation, which requires facilitation skills to ensure that does not happen. 
  • There are three levels of validation of causal factors that take place during the causal analysis. The first level is the validation of each individual answer as they are provided during a session.  The second level is the review of the BlueDragon chart conducted by every new group that participates in these sessions.  The third level of validation comes from the senior management team, which validates the entire chart. 
Corrective Actions to Prevent Recurrence: develop corrective actions that address the deep-seated causes and have a high likelihood of preventing recurrence.    
    • Issue owners are identified for each of the root causes and contributing factors identified on the blue dragon chart. 
    • The issue owners are coached by the BlueDragon team on using the “Hierarchy of Hazard Controls” and Lean “Mistake Proofing” to develop an effective set of corrective actions. 
  • To dramatically increase the likelihood of preventing recurrence, the extent to which the root causes and contributing factors are causing damage in other program areas, or equipment performance, or human performance, must also be evaluated. Therefore actions to conduct “extent of the cause” determinations are also required.  


Using our 3-phased approach, the BlueDragon facilitators completed their investigation in 4 days. The investigation identified 3 root causes and 5 significant contributing factors that combined to create the environment that allowed a non-electrical worker to cut into a live cable

There were two particularly noteworthy underlying causes identified: (1) less than adequate subcontractor controls, which shows up in nearly 50% of all significant industrial safety incidents; and (2) the lack of a formal program for establishing a safe electrical work boundary using proper controls for an “air gapping” methodology (controls similar to Lockout Tagout).   



10 SMEs

4 SMEs


1 month

4 days


3 weeks

1 week

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