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Hyper-Integrated Causal Analysis 
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Hyper-Integrated Causal Analysis (HCA) in Action
Case Study: Investigation of a Near Fatality During Construction


208v, 20a


6 More Raceways

Were found energized


Melted by Arc

Electrical Conduit

Still Energized

This entire area should have been de-energized prior to start of demolition.

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 (Figure 1) causing an electrical arc resulting in damage to the snips (Figure 1 - inset).  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. 


208v, 20a


Typical Chart

Causal Analysis Storyboard

BlueDragon RCA Team

(Rob and three volunteers)

The root cause analysis of the near miss was completed in 4 days.  

The BlueDragon Hyper-Integrated Causal Analysis (HCA) is a 3-phased approach that  included the following activities, performed in a seamless manner on one chart:

Phase 1 - 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, 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

Phase 2 - 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 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.  

Phase 3 - 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. 


  • The BlueDragon HCA 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 HCA 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 HCA 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.  

Hyper-Integrated Causal Analysis (HCA) in Action

Case Studies 


At a Federal Government site, a non-electrical worker received a shock when he cut into a live wire with a current of 20 amps and 208 volts.  The area was being torn down in preparation for renovation...read more

Construction workers on work site


The Procurement Program at a Federal Government site (part of the nuclear weapons complex) was analyzed to determine why there were recurring issues...read more 

Image by Daria Nepriakhina


A Department of Defense Chemical Weapons Destruction Plant experienced seven consecutive failures of 4160v motors supplying three trains of vital breathing air...read more 

Image by Hoover Tung


At a Federal Government construction site (part of the nuclear weapons complex), a negative trend of dropped objects from two cranes was proactively investigated before there were any major incidents...read more  

Image by david carballar
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BlueDragon Logo-MANTRA.jpg

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