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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
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
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
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)
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
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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
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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
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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
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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
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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
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17. Machinery and Equipment Breakdown or Failure
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18. Making Safety Devices Inoperative
Safety devices turned off or made inoperative
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19. Outdated or Lack of Charts/Publications and/or Documents
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
IV. Determine Level of Corrective Actions Required
Eliminate the hazard
Guard against the hazard
Train people to protect themselves against the hazard
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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)
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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
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
5. Inadequate Management of Change
Lack of standards to support change
Inadequate standards to support change
Inadequate implementation of standards to support change
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VI. Report the Incident
Always give a comprehensive description of the incident
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
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VII. Communicate findings
Determine what, to whom and how
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21. Suicide/Homicide/Assault
Intentional act
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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22. Under the Influence of Alcohol/Drugs/Medication
Legally obtained/used
Illegally obtained/used
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
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...
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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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
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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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 - ver sion 2
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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,
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.
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)
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...
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)
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2. Personnel Incident – Injuries or illnesses, or near misses
potentially resulting in the same.
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)
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7. Improper Stepping, Handling or Lifting
Jumping from elevation or across opening
Working at excessive speed for conditions
LEVEL 2 (Type of Incident—Operational)
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
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)
1. Blackout
Electrical power generator failure
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LEVEL 3 (Direct Cause)
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2. Breach of Security
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)
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
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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
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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
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4. Collision
5. Contact Damage (with stationary object or impact from tug or
barge)
Docks
Locks
Buoys
Bunker barges
Tugs
etc...
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
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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
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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
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)
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6. Deck and Structural Damage / Failure
cracks
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7. Fire/Explosion/Implosion and/or High/Low Pressure/Vacuum
and/or High/Low Temperature
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)
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
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
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8. Foundering (Sinking)
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9. Grounding / Touching bottom
10. Hull and Watertight Integrity (not caused by any other
operational incident)
8. Man Overboard (Including falling from jetty if on ship’s
business)
Intentional
Unintentional
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)
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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
11. Loss of Control System / Major Equipment Damage / Failure
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12. Loss of position keeping (DP-equipped ships only)
9. Overstress or Over-Exertion
Lifting
Pulling
Pushing
Throwing
Catching/receiving
Other stress or strain
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13. Loss of Stability
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14. Spills / Emissions (Oils, LNG, LPG, unauthorized discharges /
emissions)
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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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13. Inadequate Ship Security Measures
Sabotage
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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14. Inappropriate Behavior (Unsuitable Conduct)
Intentional act
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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 - ver sion 2
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