LEVEL 4 (Root Cause)

LEVEL 3 (Direct Cause) continued from front side

16. Incorrect Use of Equipment/Machinery or Use Without

Authority

Using tools / equipment/machinery without first checking for defects /

deficiencies / hazards

Using tools/equipment/machinery for purpose or in a manner for which it

was not intended

Overloading equipment/machinery

Using equipment outside of intended environment

Using inherently hazardous methods/procedures/practices

Using equipment with incompatible materials (e.g. wrong type of blade on

band saw for cutting plastic)

Operating equipment at improper speed

Servicing/maintaining equipment machinery in operation/energized

Welding/repairing/modifying tanks without purging/gas-freeing

Using equipment/machinery without proper authorization (e.g. hot work

permit)

Using unapproved tools/equipment

Used by unqualified or untrained/inexperienced personnel

Used for wrong purpose

Releasing/moving loads, starting equipment/machinery without adequate

warning

17. Machinery and Equipment Breakdown or Failure

18. Making Safety Devices Inoperative

Safety devices turned off or made inoperative

19. Outdated or Lack of Charts/Publications and/or Documents

20. Poor Housekeeping

The work area was not kept in a clean and orderly manner

Excess/waste materials not cleared away

Unused/unnecessary parts/materials not disposed of properly

Tools/equipment not returned to proper storage area, cleaned and in good

condition for next user

Congestion

Blockage of escape routes

Fire hazards

Injecting/mixing/combining substances or equipment so explosion, fire or

other hazard is created

Improper positioning of equipment for work (e.g. angle of crane boom)

Improper placement of equipment/tools/materials to create hazard (e.g.

congestion, tripping, fire hazard)

21. Suicide/Homicide/Assault

Intentional act

22. Under the Influence of Alcohol/Drugs/Medication

Legally obtained/used

Illegally obtained/used

23. Using Defective Tools

Using obviously defective tools

Improperly designed

Composed of unsuitable/incompatible materials

Improperly assembled

Dull

Rough

Sharp

Slippery

Worn

Frayed

Cracked

Broken

etc...

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ORCA Cause Descriptions Poster - version 2

1. Inadequate Design / Material / Construction / Installation

Inadequate assessment of loss exposures

Inadequate consideration of human aspects in design

Inadequate standards, specifications and/or design criteria

Inadequate monitoring of construction/installation

2. Inadequate Leadership

Unclear or conflicting reporting relationships

Unclear or conflicting assignment of responsibility

Setting conflicting objectives, goals and/or standards

Inadequate instructions, orientation and/or training

Providing inadequate reference documents, directives, and/or guidance

documents

Inadequate identification and evaluation of loss exposures/risks

Improper production incentives

3. Inadequate Maintenance or Repair Carried Out

Unaware of repair/maintenance schedule

Unaware of change to schedule

Inadequate planning of maintenance

Workload/other pressures

Inadequate inspection and / monitoring

Inadequate lubrication/servicing

Incorrect adjustment/assembly

Inadequate cleaning/resurfacing

Lack of examination of finished work

Part substitution

4. Inadequate Maintenance or Repair Procedures / Schedules

Inadequate assessment of maintenance requirements

Inadequate assessment of design capabilities (fit for purpose)

Improper extension of service life

Inadequate scheduling of work

5. Inadequate Management of Change

Lack of standards to support change

Inadequate standards to support change

Inadequate implementation of standards to support change

6. Inadequate Procedures (excluding maintenance)

No existing applicable standards

Inadequate development of standards

Inadequate communication of standards

Inadequate application of standards

Inadequate maintenance/updating of standards

Inaccurate/unsafe standards with respect to existing work conditions

7. Inadequate Purchasing or Storing

Inadequate specifications or requisitions

Inadequate research on materials or equipment

Inadequate specifications to suppliers/vendors

Inadequate mode/route/protection of shipment

Inadequate receiving/inspection/acceptance

Untimely/late delivery

Inadequate information/communication regarding safety/health/other loss

control data/information

Improper handling

Improper storage (stock rotation, protection from deterioration)

Improper transporting

Using out-of-date/post-expiry-date materials

Inadequate identification of hazardous items

Improper salvage and/or waste disposal

8. Inadequate Supervision

Improper or insufficient delegation

Lack of supervisory/management skills knowledge

Inadequate matching of individual qualifications and job/task requirements

Inadequate performance monitoring (job/task supervision), measurement

and evaluation

Inadequate or incorrect performance feedback

Improper supervisory example

Inadequate reinforcement of proper behavior

Substandard actions/conditions condoned (implied or expressed)

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9. Inadequate tools

Inadequate assessment of needs and risks

Inadequate human factors/ergonomics considerations

Inadequate standards or specifications

Inadequate availability

Inadequate adjustment/repair/maintenance

Inadequate salvage/reclamation

Inadequate removal/replacement of worn/broken/otherwise unsuitable/

unsafe items

Wrong tool for job

Unauthorized/unsafe modification

Incompatible with work process (e.g. use of non-“intrinsically safe” light

source, such as spark-proof flashlight, in explosive environment)

10. Lack of Knowledge or Skill

Lack of experience

Inadequate orientation

Inadequate initial instructions/training

Inadequate update training

Misunderstood directions

Inadequate practice

Infrequent performance

Lack of coaching

Inadequate working language skills (verbal/writing/reading)

Lack of performance feedback

Inaccurate performance feedback

Improper performance is condoned

Proper performance is not rewarded

Lack of incentives

11. Personal factors

Injury or illness

Fatigue due to physical task load or duration

Fatigue due to lack of rest

Fatigue due to sensory overload

Fatigue due to health hazards

Fatigue due to mental task load or speed

Extreme judgment or decision demands

Routine, monotony, or demand for uneventful vigilance beyond capacity

Extreme concentration/perception demands

“Meaningless” or “degrading” activities

Confusing or conflicting demands or directions

Preoccupation with problems

Excessive frustration

Exposure to health hazards

Exposure to temperature extremes

Oxygen deficiency/surplus

Atmospheric pressure (too high/too low/variation)

Constrained movement

Blood sugar imbalance

Effects of drugs/chemical imbalance in body

Emotional overload

Inappropriate aggression

Inappropriate peer pressure

12. Physical Capability / Health Factors

Inappropriate height/weight/size/strength/reach, etc...

Restricted range of body movement

Limited ability to sustain body position(s)

Sensitivities to sensory extremes (e.g. temperature, sound, etc...)

Vision

Hearing

Other sensory (touch, taste, smell, balance)

Respiratory incapacity

Fears and phobias

Emotional disturbance

Mental illness

Intelligence level

Inability to comprehend

Inability to sustain attention to task

Poor judgment

Poor coordination

Slow reaction time

Low mechanical/mental aptitude

Memory deficiencies

Other permanent physical/mental disability

Temporary physical/mental disability

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T E E K A Y - T H E M A R I N E M I D S T R E A M C O M P A N Y

®

TEEKAY ONBOARD ROOT CAUSE ANALYSIS (ORCA) DEFINITIONS

LEVEL 4 (Root Cause) continued

Incident Investigation Guidelines

I. Form the Investigation Team

Take Control

Ensure first aid and proper notification

Control potential secondary incidents

Identify information

Preserve information form alteration or removal

Notify shore management or others as required

II. Determine Facts

Visit area

Gather information - 4 P’s

Position: Sketch, map, diagram, photographs, video, measurements, etc.

People: Interview people involved, get expert opinions

Parts: Secure physical evidence, mechanical evidence, record weather

and other conditions

Paper: Log books, historical inspections, maintenance records, training

records, checklists, drawings and layouts

III. Determine Contributing Factors and Causes

Analyze evidence

Review the three (3) main areas of contributing factors to identify direct

causes:

Materials, Equipment and Environment

Risk Management Tools

Human Factors

Ask 5 why’s to determine root causes

IV. Determine Level of Corrective Actions Required

Eliminate the hazard

Guard against the hazard

Train people to protect themselves against the hazard

V. Recommend Specific Corrective and Preventive Actions

The corrective actions should address all direct and root causes

The recommended corrective and preventive actions should prevent re-

occurrence of similar event

If systemic issue, a systemic preventive actions must be implemented

VI. Report the Incident

Always give a comprehensive description of the incident

VII. Communicate findings

Determine what, to whom and how

VIII. Follow up

Show that we are involved

Show that we care

Show that it is important for the company to learn and close out

systemic issues

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What is Important

Get the Root Cause right
Determine and implement effective corrective and
preventive actions
Look at each incident as an opportunity to improve our
performance on a ship and in the fleet

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LEVEL 1 (Incident Category)

LEVEL 2 (Type of Incident—Operational)

6. Improper Position for Task

Moving/standing/working under overhead load (or potential path of hazard

release)

Exposure to swinging loads

Awkward body position

Unable to properly see/hear/operate controls

Entering enclosed space without proper clearance

Riding vehicles/cranes/moving equipment in unsafe positions

Working outside of protective barriers/guardrails without proper PPE (e.g.

fall protection)

7. Improper Stepping, Handling or Lifting

Jumping from elevation or across opening

Working at excessive speed for conditions

8. Inadequate Air Quality

Lack of circulation of air

Low oxygen level

Excessive oxygen

Excessive levels of toxics

Excessive levels of explosive/flammable gases

Excessive levels of combustible particulates

9. Inadequate Guards, Barriers or Warnings

Unguarded hazard (removed or non-existent)

Inadequately guarded hazard (guard too small, damaged, cracked, partially

removed)

Lack of or inadequate physical support (e.g. inadequate scaffolding)

Ungrounded / uninsulated electrical hazard

Unshielded/inadequately shielded radiation hazard

Unlabelled or inadequately labeled materials

Inadequate (e.g. not required, not posted, unreadable, not understandable)

warning signs / tags

Inadequate (e.g. missing, broken, undetectable) audible/visual alarms

Inadequate (e.g. missing/broken/out of calibration) hazard monitoring

systems

10. Inadequate or defective PPE

Inadequate fit (e.g. too large, too small)

Not properly adjusted

Unsafe / unauthorized modifications (e.g. drilling holes in safety helmet,

removing one-way valve from respirator)

Safety rope/lanyard too long

11. Inadequate or Excess Illumination (Insufficient lighting)

Light level too low for task

Light level to high for task

Glare

Position of lighting relative to task

Moving from bright to low light or low to bright light conditions

(adjustment time insufficient)

12. Inadequate Preparation/Planning

No/inadequate job planning

No/inadequate hazard identification/pre-work control of hazards

Preexisting in work location

Introduced to work location because of work to be done (equipment/

tools/materials/personnel)

Due to interaction of equipment/tools/materials/personnel with the work

environment or each other

No/inadequate selection criteria applied to people/equipment/material

selected for work/task

Hazard(s) not recognized prior to work (e.g. no/inadequate Job Safety

Analysis)

Inadequately completed hot work/tank entry/etc. permit process

No/inadequate safety information provided for work process/material (e.g.

MSDS)

13. Inadequate Ship Security Measures

Sabotage

14. Inappropriate Behavior (Unsuitable Conduct)

Intentional act

15. Incorrect Navigation or Ship Handling

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1. Adverse Weather and/or Sea Conditions

Wind (sail effect on hull/superstructure – loss of manoeuvering control/

steerage, damage to superstructure, deck equipment/machinery, cargo on

deck)

Current / Tide Effect

Wind-chill

Icing on superstructure, deck

Overheating (Solar thermal loading)

Heavy seas (movement of ship, stress on vessel / hull / equipment /

machinery / cargo stability/security, ship stability, rolling seas, wave impact

on hull)

Seas breaking over ship (damage to superstructure, hatches, watertight

integrity, hull, deck-mounted machinery, ingress of water into ship

Ice damage to hull (icebergs, “growlers”, pack ice)

2. Congested or Restricted Condition

Cramped area affecting ability to operate hand tools, lift properly, or

manipulate valves, etc...

Low overhead, requiring constant crouching/crawling

Physical environment makes it difficult to maintain safe distance from

hazard (e.g. rotating machinery, overhead loads)

Inadequate passageway/access space

Inadequate egress/exits

Insufficient work space

3. Failure to Follow Rules and Regulations

Unaware of rule/regulation

Unaware of rule/regulation change

Aware of rule/regulation and forgot

Aware of rule/regulation and could not follow in given circumstances

Aware of rule/regulation but does not understand how to follow

Decided to not follow rule/regulation

4. Failure to Secure

Load during on or off-loading operations (e.g. inadequate slings, hooks,

netting, other materials)

Cargo prior to sailing

Tools, spare parts, spare equipment, consumables, etc...

Inadequately / not tied off when working at height

Not shutting off flow of hazardous gas/liquid

Inadequately / not securing hatches, doors, manually operated dampers,

portable ladders, moveable equipment, etc...

Failure to lock / block / secure against unexpected motion

Failure to shut off equipment / machinery not in use

Failure to cut off/secure energy sources prior to inspection/maintenance /

entry / disassembly

Failure to use prescribed lockout / tagout procedures

Improper loading / stacking / stowage

5. Failure to Use PPE / Failure to Use PPE Properly

Wrong PPE for hazard (e.g. wrong type of gloves, dust mask instead of

respirator)

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T E E K A Y - T H E M A R I N E M I D S T R E A M C O M P A N Y

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ORCA Cause Descriptions Poster - version 2

1. Operational Incident – Property damage (equipment,

machinery, hull, cargo, other), Process loss (delays, off-hire,
loss of operational capability, environmental release/damage,
security incident or near misses potentially resulting in the
same.

2. Personnel Incident – Injuries or illnesses, or near misses

potentially resulting in the same.

1. Blackout

Electrical power generator failure

2. Breach of Security

3. Cargo Damage and/or Loss

Quality degradation (e.g. contamination of oil/chemical/other cargo from

previous cargo, bulkhead deterioration)

Damage during on or off-loading operations

Loss due to weather conditions, insecure or unstable loading/stowage

arrangements

4. Collision

5. Contact Damage (with stationary object or impact from tug or

barge)

Docks

Locks

Buoys

Bunker barges

Tugs

etc...

6. Deck and Structural Damage / Failure

cracks

7. Fire/Explosion/Implosion and/or High/Low Pressure/Vacuum

and/or High/Low Temperature

8. Foundering (Sinking)

9. Grounding / Touching bottom

10. Hull and Watertight Integrity (not caused by any other

operational incident)

11. Loss of Control System / Major Equipment Damage / Failure

12. Loss of position keeping (DP-equipped ships only)

13. Loss of Stability

14. Spills / Emissions (Oils, LNG, LPG, unauthorized discharges /

emissions)

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1. Caught In/Between

In-running nip point (e.g. gears, conveyor rollers, drive/propeller shaft,

rotating equipment)

In/between moving parts

In/between point of operation of tool or machine

Between/under a moving and a stationary object

Between/under collapsing structure

Between/under collapsing materials/cargo

Between/under piled materials/cargo

Between/under material under pressure (e.g. hydraulic, pneumatic, spring)

2. Exposure to Biological/Viral/Illness

Communicable disease (e.g. influenza, hepatitis, Norwalk, SARS)

Contaminated food/water (e.g. salmonella)

Surface contamination (e.g. tetanus)

3. Exposure to Electricity/Noise/Radiation

Electrical burn

Electrical shock

Continuous sound level

Impact sound level

Natural light radiation (e.g. sunburn)

Artificial light radiation (e.g. lasers, welding flash)

4. Exposure to Extreme Temperature (Heat/Cold)

General heat of atmosphere/environment

Hot objects or substances

Molten metal/plastic/other contact

General cold of atmosphere/environment

Cold objects or substances

5. Exposure to Toxins/Aerosols (Cargo, emissions, chemicals and

dust)

By absorption through skin

By inhalation through respiratory tract

By ingestion through digestive tract

By injection through skin

6. Falls from Elevation

Fall from platform or walkway

From ladder

From stairs

From ramp or sloping walkway

Into opening (e.g. shaft, excavation, hole, hold)

7. Falls from Same Level (Slips & trips)

Fall to the walkway or floor/deck surface

Fall onto object or structure

Fall against object or structure

Fall on moving surface

8. Man Overboard (Including falling from jetty if on ship’s

business)

Intentional

Unintentional

9. Overstress or Over-Exertion

Lifting

Pulling

Pushing

Throwing

Catching/receiving

Other stress or strain

10. Struck Against/By

Stationary person struck by moving person/ship

Moving person struck by moving person/ship

Falling object (free falling from higher level)

Flying object/particle (free object/particle propelled through air)

Person struck by contents under pressure

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TEEKAY ONBOARD ROOT CAUSE ANALYSIS (ORCA) DEFINITIONS

LEVEL 2 (Type of Incident—Personnel)

11. Sudden or Chronic Health Disorder

Heart attack

Stroke

Seizure

Epileptic attack

Allergic reaction

Chemical sensitization (e.g. to latex)

Diabetic reaction (insulin shock or hyperglycemia/hypoglycemia)

Chronic hearing loss

Chronic eyesight problem (e.g. colour-blindness, loss of peripheral vision,

glaucoma, cataracts, etc...)

Muscle spasms/cramps/loss of muscle tone

Joint inflammation/rheumatism

etc...

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LEVEL 2 (Type of Incident—Personnel) continued

LEVEL 3 (Direct Cause)

LEVEL 3 (Direct Cause) continued

Level 3 (Direct Cause) continued on flip side -->