Deeper Incident Investigations and Learning using the ‘Risk & Incident Analysis (RIFA)’ Method

The initial internal investigation determined an objective weight over 120kg fell from a height of approximately 4.5m.

Key findings included:
– Worker failed to identify the hazard
– Worker absent spatial awareness
– Regular toolbox talks

Within the span of 10 days, a deeper analysis determined several contributing factors to the incident, rather than focusing purely on the worker. These factors included the pallet, operator, forklift selection, assessment of risk, procurement and forklift standards.

The main contributing factor was the incomplete assessment of risk for using a specific type of plant to ensure compatibility with the racking system and pallets.

Recommendations included site actions, as well as broader human and organisations factors, e.g.
1. Critical controls​
2. Risk ​management
3. Procurement of plant & equipment ​
4. Incident investigations ​
5. Implementation, e.g. Job demands, job resources, expectation setting, accountability, team effectiveness,
6. Assurance.

Effective investigations provide an opportunity to reflect, learn and improve systematic organisational factors to have a meaningful impact.