TEEKAY ONBOARD ROOT CAUSE ANALYSIS (ORCA) DEFINITIONS
LEVEL 3 (Direct Cause) continued from front side LEVEL 4 (Root Cause) LEVEL 4 (Root Cause) continued Incident Investigation Guidelines
16. Incorrect Use of Equipment/Machinery or Use Without 1. Inadequate Design / Material / Construction / Installation 9. Inadequate tools
I. Form the Investigation Team
" Inadequate assessment of loss exposures " Inadequate assessment of needs and risks
Authority " Take Control
" Inadequate consideration of human aspects in design " Inadequate human factors/ergonomics considerations
" Ensure first aid and proper notification
" Using tools / equipment/machinery without first checking for defects /
" Inadequate standards, specifications and/or design criteria " Inadequate standards or specifications
" Control potential secondary incidents
deficiencies / hazards
" Inadequate monitoring of construction/installation " Inadequate availability
" Identify information
" Using tools/equipment/machinery for purpose or in a manner for which it
" Inadequate adjustment/repair/maintenance
" Preserve information form alteration or removal
was not intended
2. Inadequate Leadership " Inadequate salvage/reclamation
" Notify shore management or others as required
" Overloading equipment/machinery
" Inadequate removal/replacement of worn/broken/otherwise unsuitable/
" Using equipment outside of intended environment " Unclear or conflicting reporting relationships
unsafe items
II. Determine Facts
" Using inherently hazardous methods/procedures/practices " Unclear or conflicting assignment of responsibility
" Wrong tool for job
" Using equipment with incompatible materials (e.g. wrong type of blade on " Setting conflicting objectives, goals and/or standards
" Visit area
" Unauthorized/unsafe modification
band saw for cutting plastic) " Inadequate instructions, orientation and/or training
" Gather information - 4 P s
" Incompatible with work process (e.g. use of non- intrinsically safe light
" Operating equipment at improper speed " Providing inadequate reference documents, directives, and/or guidance
" Position: Sketch, map, diagram, photographs, video, measurements, etc.
source, such as spark-proof flashlight, in explosive environment)
" Servicing/maintaining equipment machinery in operation/energized documents
" People: Interview people involved, get expert opinions
" Welding/repairing/modifying tanks without purging/gas-freeing " Inadequate identification and evaluation of loss exposures/risks
" Parts: Secure physical evidence, mechanical evidence, record weather
10. Lack of Knowledge or Skill
" Using equipment/machinery without proper authorization (e.g. hot work " Improper production incentives
and other conditions
permit) " Lack of experience
" Paper: Log books, historical inspections, maintenance records, training
" Using unapproved tools/equipment 3. Inadequate Maintenance or Repair Carried Out " Inadequate orientation
records, checklists, drawings and layouts
" Used by unqualified or untrained/inexperienced personnel " Inadequate initial instructions/training
" Unaware of repair/maintenance schedule
" Used for wrong purpose " Inadequate update training
III. Determine Contributing Factors and Causes
" Unaware of change to schedule
" Releasing/moving loads, starting equipment/machinery without adequate " Misunderstood directions
" Inadequate planning of maintenance
" Analyze evidence
warning " Inadequate practice
" Workload/other pressures
" Review the three (3) main areas of contributing factors to identify direct
" Infrequent performance
" Inadequate inspection and / monitoring
causes:
17. Machinery and Equipment Breakdown or Failure " Lack of coaching
" Inadequate lubrication/servicing
> Materials, Equipment and Environment
" Inadequate working language skills (verbal/writing/reading)
" Incorrect adjustment/assembly
> Risk Management Tools
" Lack of performance feedback
" Inadequate cleaning/resurfacing
18. Making Safety Devices Inoperative > Human Factors
" Inaccurate performance feedback
" Lack of examination of finished work
" Ask 5 why s to determine root causes
" Safety devices turned off or made inoperative
" Improper performance is condoned
" Part substitution
" Proper performance is not rewarded
IV. Determine Level of Corrective Actions Required
19. Outdated or Lack of Charts/Publications and/or Documents
" Lack of incentives
4. Inadequate Maintenance or Repair Procedures / Schedules
" Eliminate the hazard
" Inadequate assessment of maintenance requirements
" Guard against the hazard
20. Poor Housekeeping
11. Personal factors
" Inadequate assessment of design capabilities (fit for purpose)
" Train people to protect themselves against the hazard
" The work area was not kept in a clean and orderly manner
" Injury or illness
" Improper extension of service life
" Excess/waste materials not cleared away
" Fatigue due to physical task load or duration
" Inadequate scheduling of work
V. Recommend Specific Corrective and Preventive Actions
" Unused/unnecessary parts/materials not disposed of properly
" Fatigue due to lack of rest
" The corrective actions should address all direct and root causes
" Tools/equipment not returned to proper storage area, cleaned and in good
" Fatigue due to sensory overload
5. Inadequate Management of Change
" The recommended corrective and preventive actions should prevent re-
condition for next user
" Fatigue due to health hazards
" Lack of standards to support change
occurrence of similar event
" Congestion
" Fatigue due to mental task load or speed
" Inadequate standards to support change
" If systemic issue, a systemic preventive actions must be implemented
" Blockage of escape routes
" Extreme judgment or decision demands
" Inadequate implementation of standards to support change
" Fire hazards
" Routine, monotony, or demand for uneventful vigilance beyond capacity
VI. Report the Incident
" Injecting/mixing/combining substances or equipment so explosion, fire or
" Extreme concentration/perception demands
6. Inadequate Procedures (excluding maintenance)
other hazard is created
" Always give a comprehensive description of the incident
"  Meaningless or  degrading activities
" Improper positioning of equipment for work (e.g. angle of crane boom) " No existing applicable standards
" Confusing or conflicting demands or directions
" Improper placement of equipment/tools/materials to create hazard (e.g. " Inadequate development of standards
VII. Communicate findings
" Preoccupation with problems
congestion, tripping, fire hazard) " Inadequate communication of standards
" Excessive frustration
" Determine what, to whom and how
" Inadequate application of standards
" Exposure to health hazards
" Inadequate maintenance/updating of standards
21. Suicide/Homicide/Assault
" Exposure to temperature extremes
VIII. Follow up
" Inaccurate/unsafe standards with respect to existing work conditions
" Intentional act " Oxygen deficiency/surplus
" Show that we are involved
" Atmospheric pressure (too high/too low/variation)
" Show that we care
7. Inadequate Purchasing or Storing
22. Under the Influence of Alcohol/Drugs/Medication " Constrained movement
" Show that it is important for the company to learn and close out
" Inadequate specifications or requisitions " Blood sugar imbalance
" Legally obtained/used
systemic issues
" Inadequate research on materials or equipment " Effects of drugs/chemical imbalance in body
" Illegally obtained/used
" Inadequate specifications to suppliers/vendors " Emotional overload
" Inadequate mode/route/protection of shipment " Inappropriate aggression
23. Using Defective Tools
" Inadequate receiving/inspection/acceptance " Inappropriate peer pressure
" Using obviously defective tools
" Untimely/late delivery
" Improperly designed
" Inadequate information/communication regarding safety/health/other loss
12. Physical Capability / Health Factors
" Composed of unsuitable/incompatible materials
control data/information
" Inappropriate height/weight/size/strength/reach, etc...
" Improperly assembled
" Improper handling
" Restricted range of body movement
What is Important
" Dull
" Improper storage (stock rotation, protection from deterioration)
" Limited ability to sustain body position(s)
" Rough
" Improper transporting
" Sensitivities to sensory extremes (e.g. temperature, sound, etc...) " Get the Root Cause right
" Sharp
" Using out-of-date/post-expiry-date materials
" Vision
" Slippery
" Inadequate identification of hazardous items " Determine and implement effective corrective and
" Hearing
" Worn
" Improper salvage and/or waste disposal
" Other sensory (touch, taste, smell, balance)
" Frayed
preventive actions
" Respiratory incapacity
" Cracked
8. Inadequate Supervision
" Fears and phobias
" Broken " Look at each incident as an opportunity to improve our
" Improper or insufficient delegation " Emotional disturbance
" etc...
" Lack of supervisory/management skills knowledge " Mental illness performance on a ship and in the fleet
" Inadequate matching of individual qualifications and job/task requirements " Intelligence level
" Inadequate performance monitoring (job/task supervision), measurement " Inability to comprehend
and evaluation " Inability to sustain attention to task
" Inadequate or incorrect performance feedback " Poor judgment
" Improper supervisory example " Poor coordination
" Inadequate reinforcement of proper behavior " Slow reaction time
" Substandard actions/conditions condoned (implied or expressed) " 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
ORCA Cause Descriptions Poster - version 2
TEEKAY ONBOARD ROOT CAUSE ANALYSIS (ORCA) DEFINITIONS
LEVEL 1 (Incident Category) LEVEL 2 (Type of Incident Personnel) LEVEL 2 (Type of Incident Personnel) continued LEVEL 3 (Direct Cause) continued
1. Operational Incident  Property damage (equipment, 1. Caught In/Between 11. Sudden or Chronic Health Disorder 6. Improper Position for Task
" In-running nip point (e.g. gears, conveyor rollers, drive/propeller shaft, " Heart attack " Moving/standing/working under overhead load (or potential path of hazard
machinery, hull, cargo, other), Process loss (delays, off-hire,
rotating equipment) " Stroke release)
loss of operational capability, environmental release/damage,
" In/between moving parts " Seizure " Exposure to swinging loads
security incident or near misses potentially resulting in the
" In/between point of operation of tool or machine " Epileptic attack " Awkward body position
same.
" Between/under a moving and a stationary object " Allergic reaction " Unable to properly see/hear/operate controls
" Between/under collapsing structure " Chemical sensitization (e.g. to latex) " Entering enclosed space without proper clearance
" Between/under collapsing materials/cargo " Diabetic reaction (insulin shock or hyperglycemia/hypoglycemia) " Riding vehicles/cranes/moving equipment in unsafe positions
2. Personnel Incident  Injuries or illnesses, or near misses
" Between/under piled materials/cargo " Chronic hearing loss " Working outside of protective barriers/guardrails without proper PPE (e.g.
potentially resulting in the same.
" Between/under material under pressure (e.g. hydraulic, pneumatic, spring) " Chronic eyesight problem (e.g. colour-blindness, loss of peripheral vision, fall protection)
glaucoma, cataracts, etc...)
2. Exposure to Biological/Viral/Illness " Muscle spasms/cramps/loss of muscle tone 7. Improper Stepping, Handling or Lifting
" Joint inflammation/rheumatism
" Communicable disease (e.g. influenza, hepatitis, Norwalk, SARS) " Jumping from elevation or across opening
" etc...
" Contaminated food/water (e.g. salmonella) " Working at excessive speed for conditions
" Surface contamination (e.g. tetanus)
LEVEL 2 (Type of Incident Operational) 8. Inadequate Air Quality
3. Exposure to Electricity/Noise/Radiation
" Lack of circulation of air
1. Blackout
" Electrical burn " Low oxygen level
" Electrical power generator failure " Electrical shock " Excessive oxygen
LEVEL 3 (Direct Cause)
" Continuous sound level " Excessive levels of toxics
2. Breach of Security " Impact sound level " Excessive levels of explosive/flammable gases
" Natural light radiation (e.g. sunburn) 1. Adverse Weather and/or Sea Conditions " Excessive levels of combustible particulates
" Artificial light radiation (e.g. lasers, welding flash)
3. Cargo Damage and/or Loss " Wind (sail effect on hull/superstructure  loss of manoeuvering control/
9. Inadequate Guards, Barriers or Warnings
steerage, damage to superstructure, deck equipment/machinery, cargo on
" Quality degradation (e.g. contamination of oil/chemical/other cargo from
4. Exposure to Extreme Temperature (Heat/Cold)
deck) " Unguarded hazard (removed or non-existent)
previous cargo, bulkhead deterioration)
" General heat of atmosphere/environment " Current / Tide Effect " Inadequately guarded hazard (guard too small, damaged, cracked, partially
" Damage during on or off-loading operations
" Hot objects or substances " Wind-chill removed)
" Loss due to weather conditions, insecure or unstable loading/stowage
" Molten metal/plastic/other contact " Icing on superstructure, deck " Lack of or inadequate physical support (e.g. inadequate scaffolding)
arrangements
" General cold of atmosphere/environment " Overheating (Solar thermal loading) " Ungrounded / uninsulated electrical hazard
" Cold objects or substances " Heavy seas (movement of ship, stress on vessel / hull / equipment / " Unshielded/inadequately shielded radiation hazard
4. Collision
machinery / cargo stability/security, ship stability, rolling seas, wave impact " Unlabelled or inadequately labeled materials
on hull)
5. Exposure to Toxins/Aerosols (Cargo, emissions, chemicals and " Inadequate (e.g. not required, not posted, unreadable, not understandable)
5. Contact Damage (with stationary object or impact from tug or
" Seas breaking over ship (damage to superstructure, hatches, watertight warning signs / tags
dust)
barge)
integrity, hull, deck-mounted machinery, ingress of water into ship " Inadequate (e.g. missing, broken, undetectable) audible/visual alarms
" By absorption through skin
" Docks " Ice damage to hull (icebergs,  growlers , pack ice) " Inadequate (e.g. missing/broken/out of calibration) hazard monitoring
" By inhalation through respiratory tract
" Locks systems
" By ingestion through digestive tract
" Buoys
2. Congested or Restricted Condition
" By injection through skin
" Bunker barges
10. Inadequate or defective PPE
" Cramped area affecting ability to operate hand tools, lift properly, or
" Tugs
manipulate valves, etc... " Inadequate fit (e.g. too large, too small)
6. Falls from Elevation
" etc...
" Low overhead, requiring constant crouching/crawling " Not properly adjusted
" Fall from platform or walkway
" Physical environment makes it difficult to maintain safe distance from " Unsafe / unauthorized modifications (e.g. drilling holes in safety helmet,
" From ladder
6. Deck and Structural Damage / Failure
hazard (e.g. rotating machinery, overhead loads) removing one-way valve from respirator)
" From stairs
" cracks " Inadequate passageway/access space " Safety rope/lanyard too long
" From ramp or sloping walkway
" Inadequate egress/exits
" Into opening (e.g. shaft, excavation, hole, hold)
7. Fire/Explosion/Implosion and/or High/Low Pressure/Vacuum " Insufficient work space
11. Inadequate or Excess Illumination (Insufficient lighting)
and/or High/Low Temperature " Light level too low for task
7. Falls from Same Level (Slips & trips)
3. Failure to Follow Rules and Regulations
" Light level to high for task
" Fall to the walkway or floor/deck surface
" Unaware of rule/regulation " Glare
8. Foundering (Sinking)
" Fall onto object or structure
" Unaware of rule/regulation change " Position of lighting relative to task
" Fall against object or structure
" Aware of rule/regulation and forgot " Moving from bright to low light or low to bright light conditions
9. Grounding / Touching bottom " Fall on moving surface
" Aware of rule/regulation and could not follow in given circumstances (adjustment time insufficient)
" Aware of rule/regulation but does not understand how to follow
8. Man Overboard (Including falling from jetty if on ship s
10. Hull and Watertight Integrity (not caused by any other
" Decided to not follow rule/regulation
12. Inadequate Preparation/Planning
business)
operational incident)
" No/inadequate job planning
" Intentional 4. Failure to Secure
" No/inadequate hazard identification/pre-work control of hazards
" Unintentional
11. Loss of Control System / Major Equipment Damage / Failure " Load during on or off-loading operations (e.g. inadequate slings, hooks, > Preexisting in work location
netting, other materials) > Introduced to work location because of work to be done (equipment/
9. Overstress or Over-Exertion
" Cargo prior to sailing tools/materials/personnel)
12. Loss of position keeping (DP-equipped ships only)
" Lifting " Tools, spare parts, spare equipment, consumables, etc... > Due to interaction of equipment/tools/materials/personnel with the work
" Pulling " Inadequately / not tied off when working at height environment or each other
13. Loss of Stability
" Pushing " Not shutting off flow of hazardous gas/liquid " No/inadequate selection criteria applied to people/equipment/material
" Throwing " Inadequately / not securing hatches, doors, manually operated dampers, selected for work/task
14. Spills / Emissions (Oils, LNG, LPG, unauthorized discharges /
" Catching/receiving portable ladders, moveable equipment, etc... " Hazard(s) not recognized prior to work (e.g. no/inadequate Job Safety
emissions) " Other stress or strain " Failure to lock / block / secure against unexpected motion Analysis)
" Failure to shut off equipment / machinery not in use " Inadequately completed hot work/tank entry/etc. permit process
10. Struck Against/By " Failure to cut off/secure energy sources prior to inspection/maintenance / " No/inadequate safety information provided for work process/material (e.g.
entry / disassembly MSDS)
" Stationary person struck by moving person/ship
" Failure to use prescribed lockout / tagout procedures
" Moving person struck by moving person/ship
" Improper loading / stacking / stowage
13. Inadequate Ship Security Measures
" Falling object (free falling from higher level)
" Flying object/particle (free object/particle propelled through air) " Sabotage
5. Failure to Use PPE / Failure to Use PPE Properly
" Person struck by contents under pressure
" Wrong PPE for hazard (e.g. wrong type of gloves, dust mask instead of
14. Inappropriate Behavior (Unsuitable Conduct)
respirator)
" Intentional act
15. Incorrect Navigation or Ship Handling
Level 3 (Direct Cause) continued on flip side -->
®
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
ORCA Cause Descriptions Poster - version 2