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Investigating a Near Fatality

An electrical conduit at a construction site with notations describing mistakes made by workers

Case Study

Investigation of a Near Fatality During Construction

A subcontract laborer was removing conduit in preparation for the demolition of an interior partition wall on the second floor of a government building. At approximately 2:53 pm, the subcontract laborer pulled and cut a conductor passing through a receptacle box causing an electrical arc resulting in damage to the snips. The conductor was carrying a 208 volt, 20 amp current.  The laborer immediately stopped work and made notifications to his supervision. ​

An independent BlueDragon HCA team was established by the organization to investigate the near miss. The HCA team consisted of Rob De La Espriella, the BlueDragon Team Lead, and three of Rob’s students in support roles. 

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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:

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

  • A detailed timeline was developed, and additional details were added from the results of the causal analysis sessions.  

  • An analysis of the defenses in place to prevent these kinds of events was conducted. The analysis included a total of 90 administrative requirements that were evaluated for effectiveness, as well as physical barriers, such as Personal Protective Equipment, and the Air Gapping Program that was used to physically isolate electrical penetrations and create the safe electrical work boundary.  

  • Approximately 40 focused, evidence-based Lines of Inquiry were developed as the starting point for the causal analysis.  

  • To develop the Lines of Inquiry, IPS 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

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

  • There were nine facilitated causal analysis sessions conducted on-site at the client’s facilities, which included Facility Managers, Engineers, Subject Matter Experts (SMEs), Quality Assurance Engineers, Health and Safety Representatives, Construction Managers, Project Managers, Subcontract Technical Representatives, Work Planners and Managers from Capital Projects.    

  • 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 IPS process as the results are captured on the chart. 

  • IPS 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.  

The proposed corrective action plans and extent of the cause reviews to close performance gaps and prevent recurrence of the deepest-seated causes.

  • Corrective action plans are usually the responsibility of a separate group and requires additional input that includes the organizations budget and resources.    

  • The IPS team provided informal recommendations to the organization for addressing the identified root causes and contributing factors. 


  • The BlueDragon IPS was completed in 4-days.  This level of efficiency can only be achieved by integrating many of the methods and techniques that are customarily done separately.

  • The IPS investigation identified 3 root causes, 5 significant contributing factors and 4 opportunities for improvement.  Note that the results are derived by the SMEs participating in the causal analysis process, and not by the IPS team in a vacuum.

  • The exit briefing with the client’s senior managers took place at noon on the fifth day. Briefings are conducted from the BlueDragon chart, which is a storyboard; no documents are provided to review at the exit briefing.

  • The final report was prepared the following week. BlueDragon reports are written straight from the BlueDragon charts, which have already been validated.