BLUEDRAGON IN ACTION
Recurring Equipment Failures
Recurring Motor Failures at an Army Chemical Weapons Depot
The subcontractor managing the destruction of the Army’s stockpile of Serin and Mustard gas projectiles.
During a period of 11 months, the motors that drove the safety-related Compressed Air System (CAS) experienced 7 consecutive failures in an 11-month period. A series of investigations after each incident had not prevented subsequent failures. The three trains of CAS motors provide vital breathing air to the workers in the plastic bubble suits that protect them from Serin and Mustard gasses.
The BlueDragon Mission
Identify the failure modes for the 7 motor failures and conduct an in-depth investigation into the deeper-seated causes of the failure modes. Then, address the failure modes and install the 8th motor.
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.
- 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.
- 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.
The BlueDragon facilitator, supported by the motor System Engineer and the motor vendors, identified the mechanical and electrical failure modes for the seven motor failures. An in-depth analysis of the failure modes identified latent organizational and programmatic weaknesses. At the end of the second week, the 8th motor was installed after addressing the issues identified during the BlueDragon investigation, and it ran without incident.