BLUEDRAGON IN ACTION
Negative Trend
Case Study
Proactive Review of a Negative Trend of Dropped Objects
An independent BlueDragon HCA was commissioned by the prime contractor at a Department of Energy installation that was under construction. The site was experiencing a negative performance trend of dropped objects from cranes that were over 300 feet high. A total of 5 incidents had taken place over a period of 6 months. And although no one was injured, there were a few near misses.
According to the Bureau of Labor Statistics (BLS), for the past few decades the leading causes of death on construction job sites in the United States have been “Falls” and “Struck by Object.” There are more than 50,000 “struck by falling object” OSHA recordable incidents every year in the United States. Because of the potential for serious injury, site management proactively decided to conduct a root cause analysis on the adverse trend of dropped object events.
The HCA team consisted of Rob De La Espriella (the BlueDragon Team Lead), and four site volunteers in support roles.
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.
Since this is a proactive RCA, there was no timeline. However, every other element of the BlueDragon Framework was still used.
A review of the Corrective Action Program database was conducted, to evaluate previous events, causal analyses and corrective actions taken to date.
An analysis of the defenses in place to prevent dropped objects was conducted. The analysis included approximately 32 administrative requirements that were evaluated for effectiveness.
From the insights gained during the Phase 1 data analysis, over 40 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.
Facilitated Causal Analysis sessions to identify the root causes and significant contributing factors.
There were approximately 8 facilitated causal analysis sessions conducted on-site at the client’s facilities with users and process owners from 15 organizations, including Construction, Project Management, Engineering, Environmental Safety & Health, Quality Assurance, Subcontracts, Training, Human Resources, and the National Nuclear Site Security site office.
The BlueDragon team facilitated causal analysis sessions with over 50 of the 15 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.
The entire on-site portion of the BlueDragon RCA was monitored by the Federal Government’s Site Project Office.
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 HCA team provided informal recommendations to the organization for addressing the identified root causes and contributing factors.
Results
The BlueDragon HCA was completed in 3.5-days. This level of efficiency can only be achieved by integrating many of the methods and techniques that are customarily done separately.
The HCA investigation identified 2 root causes, 5 significant contributing factors and 13 additional opportunities for improvement. Note that the results are derived by the SMEs participating in the causal analysis process, and not by the HCA team in a vacuum.
The exit briefing took place at the end of the 4th day. Briefings are conducted from the BlueDragon chart, which is a storyboard; no documentation was provided to management at the exit briefing.
