BLUEDRAGON IN ACTION
Recurring Procurement Program Failures
EVENT DESCRIPTION
Longstanding Trend of Recurring Procurement Program Issues at a National Laboratory Holds up a Multi-Billion Dollar Contract
The Client
A Department of Energy National Laboratory that is part of the nuclear weapons complex.
The Problem
The site Procurement Program was experiencing a stream of issues over an extended period of time. More than 20% of procurements that were key to the site’s mission were in jeopardy of not meeting required need dates. The inability to correct the procurement management issues was holding up government contracts worth billions of dollars.
The BlueDragon Mission
Conduct an in-depth and holistic BlueDragon investigation into the laboratory’s Acquisition and Procurement Program that included the organizations that used the procurement program and their vendors. The goal was to identify the deep-seated causes of the issues

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.
Results
The BlueDragon facilitators completed an in-depth investigation in 2 weeks, identifying a complex set of deep-seated organizational and programmatic weaknesses covered under 5 root causes, 13 significant contributing factors and over 20 opportunities for improvement. The corrective actions for the in-depth analysis paved the way for a multi-billion dollar government contract.
| CLIENT PROJECTIONS | BLUEDRAGON ACTUAL |
RESOURCES | 50 SMEs | 4 SMEs |
DURATION | 6 months | 2 weeks |
REPORT PREPARATION | 1 month | N/A |


