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Hyper-Integrated Causal Analysis 
Light Years Ahead of the Competition

Hyper-Integrated Causal Analysis (HCA) in Action
Case Study: Proactive Program Review

An independent BlueDragon HCA was commissioned by the prime contractor at a Department of Energy installation.  The site Procurement Program was experiencing a stream of issues and more than 20% of procurements that were key to the site's mission were in jeopardy of not meeting required need dates. At stake were future government contracts worth billions of dollars.  

The HCA team consisted of Rob De La Espriella (the BlueDragon Team Lead), a Manager from the Procurement Organization, and two volunteers in support roles. 

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Phase 1

Analysis of the 

Critical Procurements Data Base & Processes

Pareto Analysis 

Procurement "Hot Spots"

Figure 1 - High Level Process Map of the Procurement Program

BlueDragon's Hyper-Integrated Causal Analysis (HCA) is a 3-phased approach that included the following activities, performed in a seamless and efficient manner:

Phase 1 - Analysis of available data and evidence to develop focused, evidence-based Lines of Inquiry.

  • A high-level process map was developed based on the Procurement Program procedures (Figure 1).  This effort identified three areas that were missing guidance, and also created a map that allowed us to chart the results of our Pareto Analysis.  

  • The BlueDragon team conducted Pareto Analysis of the procurement data base for the site.  The results indicated there were key areas that were experiencing the most problems, and these areas were superimposed on the process map (circled on Figure 1), which provided insights on where in the process most of the issues were occurring, as well as which organizations were involved at those points in the process.

  • An analysis of the defenses in place to prevent these kinds of events was conducted. The analysis included approximately 50 administrative requirements that were evaluated for effectiveness.

  • From the insights gained during the Phase 1 data analysis, 124 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

Phase 2 - Facilitated Causal Analysis sessions to identify the root causes and significant contributing factors.

  • There were over a dozen facilitated causal analysis sessions conducted on-site at the client's facilities with users and process owners from 18 organizations, as well with off-site suppliers.  SMEs included Buyers, Suppliers, Procurement Project Management, Engineering, Work Planners, Quality Assurance, Internal Audits, Procurement Authority, Receipt Inspectors, Supplier, and Senior Procurement Managers.  

  • The BlueDragon team facilitated causal analysis sessions with over 100 of the 18 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.  


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. 


Figure 2 - BlueDragon Chart

BlueDragon RCA Team

Rob +3 (1 SME)

Causal Analysis:

124 Lines of Inquiry

18 Organizations

100+ SMEs


  • The BlueDragon HCA was completed in 10-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 5 root causes, 13 significant contributing factors and over 20 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 with the client's CEO and the Executive Leadership Team took place in the afternoon on the 10th day. Briefings are conducted from the BlueDragon chart, which is a storyboard; no documentation was provided to managers at the exit briefing.

  • Senior Procurement Managers participated in the exit briefing by highlighting the cause and effect pathways on BlueDragon chart, from the root causes at the bottom to the issues (the symptoms) at the top. 

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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