Audit & Compliance

Resolutions and reports

Incident Reports

Incident reporting, assessment and mitigation are a vital element of creating and enhancing the safety of GWO training. To promote good practices and learning GWO publishes its incident reports once investigations are complete. These are published anonymously to encourage collective learning and the sharing of experiences and mitigating actions across the training community. For the GWO Secretariat incident reporting directly feeds into the review and maintenance of GWO standards contributing to the development of safer training.

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Case number:
7500740465
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Module
-
BST Working at Heights
Version
-
V18
Incident Significance
Significant near-miss
-
incident date
September 18, 2024
-
training setting
-
Fixed
Summary
-
A course participant fell from a height of approx. 1m from an evacuation platform. Due to stress the participant did not follow the usual process and was only attached to their back up system when gate was opened. The participant did not get injured and was able to complete the training.
Mitigation action
-
Including verification from the lead instructor that both CRD and back up are attached before lanyards are removed and gate is opened. Instructors encouraged to take time out if anyone appears to be rushing or not following the procedure under stress. Staff training on understanding signs of participants’ stress.
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Case number:
7287012877
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Module
-
ART Hub Rescue
Version
-
V4
Incident Significance
Incident
-
incident date
September 3, 2024
-
training setting
-
Fixed
Summary
-
A course participant pinched the underside of their arm during an exercise of transferring a victim from the hub to the nose cone hatch.
Mitigation action
-
Edge guard placed on the lip of the edge where the participant’s arm was pinched.
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Case number:
7331008332
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Module
-
BST Working at Heights
Version
-
V18
Incident Significance
Significant near-miss
-
incident date
August 30, 2024
-
training setting
-
Fixed
Summary
-
During a lowering exercise, a knot came loose which resulted in the dummy falling to the ground. This was due to the instructor tying a basic knot instead of a “figure-of-eight knot”.
Mitigation action
-
Safety Instructors has been informed about the importance of choosing the correct knot for those exercises. It will be included in the Risk Assessment going forward.
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Case number:
7350365936
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Module
-
SLS
Version
-
v4
Incident Significance
Significant near-miss
-
incident date
August 28, 2024
-
training setting
-
Fixed
Summary
-
During an SLS practical exercise, a crane auxiliary hook got damaged when an operator mistakenly left it in the override function and did not react when the warning alert got triggered. No one was injured.
Mitigation action
-
Training was stopped and an investigation from the crane supplier was initiated. The operator will undergo supplier internal safety procedures and refresher training, and furthermore will not be allowed on the training provider’s premises for any future training.
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Case number:
7216053448
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Module
-
BST Working at Heights
Version
-
V18
Incident Significance
Incident
-
incident date
August 13, 2024
-
training setting
-
Fixed
Summary
-
During a break, a course participant dropped a glass water bottle. The participant picked it up with their bare hands and suffered a cut on their thumb.
Mitigation action
-
Participants will be reminded to wear hand protection when cleaning broken glass.
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Case number:
7169904497
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Module
-
BST First Aid
Version
-
V18
Incident Significance
Incident
-
incident date
July 30, 2024
-
training setting
-
Fixed
Summary
-
Participant fell unconscious in chair during the lesson. The participant recovered after a few seconds and was assessed and offered fruit and water. The participant appeared unharmed but will follow up with their doctor.
Mitigation action
-
No mitigation needed as drinks are provided however the participant is suspected to have drunk too little during the day.
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Case number:
7058149384
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Module
-
ART Nacelle, Tower & Basement Rescue
Version
-
V4
Incident Significance
Incident
-
incident date
July 19, 2024
-
training setting
-
Fixed
Summary
-
A course participant tripped over an uneven floor during an evacuation exercise.
Mitigation action
-
Participants will be warned about the uneven floor and caution tape will be applied to the area.
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Case number:
6884393057
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Module
-
BST Sea Survival
Version
-
V17
Incident Significance
Incident
-
incident date
June 14, 2024
-
training setting
-
Fixed
Summary
-
A participant bumped his thigh against the side of the transfer piece when descending down from the transfer piece during a double evacuation. The injury was minor, leading only to a small bruise on his thigh. The participant was provided with an ice pack.
Mitigation action
-
Internal auditor and instructors reviewed lesson plans and standards associated with this training. A practical review training will also be scheduled to cover adequate coaching techniques and to identify what needs to be looked for when overseeing participant form during double evacuations.
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Case number:
6860511174
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Module
-
BST Working at Heights
Version
-
V17
Incident Significance
Incident
-
incident date
June 14, 2024
-
training setting
-
Mobile
Summary
-
A participant had a tough time breathing, felt faint and dizzy, during a break after a ladder rescue practical exercise. On inquiry, the participant mentioned they had a history of heart issues at which point the decision was made to take them to the emergency room.
Mitigation action
-
N/A - awareness of personal emergency occurrences have been developed and implementation through instructor meetings has occurred.
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Case number:
6677901092
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Module
-
BST First Aid
Version
-
V17
Incident Significance
Incident
-
incident date
May 21, 2024
-
training setting
-
Fixed
Summary
-
As part of the practical exercise for rescuing casualties from a wind turbine, a course participant tripped over their own feet and hit their right elbow against a steel girder.
Mitigation action
-
N/A
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Case number:
6663545709
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Module
-
ART-R Nacelle, Tower, Basement Rescue Refresher
Version
-
V4
Incident Significance
Incident
-
incident date
May 17, 2024
-
training setting
-
Fixed
Summary
-
After the 2nd training scenario of the day, a course participant expressed that they had strained their lower left back while on their hands and knees working on a dummy during the 1st training scenario. Root cause of the incident was that the participant did not stop when they felt pain.
Mitigation action
-
The participant was placed in a non-strenuous role for the 3rd scenario. Communication was given to course participants to speak up if they ever feel any discomfort.
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Case number:
6660932092
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Module
-
BST First Aid
Version
-
V17
Incident Significance
Incident
-
incident date
May 17, 2024
-
training setting
-
Fixed
Summary
-
A course participant choked during the lunch break. The participant lost consciousness for 45 seconds. A fellow participant performed the Heimlich maneuver. The participant regained consciousness and normal breathing and was taken to the hospital for further evaluation.
Mitigation action
-
Staff were informed to remind participants not to rush through lunch. Heimlich maneuver poster was posted in the dining area.
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Case number:
6657624644
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Module
-
BST-R First Aid Refresher
Version
-
N/A
Incident Significance
Incident
-
incident date
May 13, 2024
-
training setting
-
Fixed
Summary
-
A course participant fainted after watching a video during the training session. First aid and support applied. The participant was able to continue the course after a short break and continuous hydration.
Mitigation action
-
Working on further communication and higher awareness measures. Awareness around health issues that cause fainting. Will be added to the introductions
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Case number:
6617012688
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Module
-
BST Fire Awareness
Version
-
V17
Incident Significance
Incident
-
incident date
May 7, 2024
-
training setting
-
Fixed
Summary
-
While egressing to the evacuation point (ladder) while staying low to the ground, a course participant brushed their elbow against a surface that caused a small abrasion. The participant was not aware of when or how it happened.
Mitigation action
-
Repair, where possible, the floor location where the training occurred. Conduct training where no such hazard exist.
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Case number:
6789370606
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Module
-
BR Blade Repair
Version
-
V4
Incident Significance
Incident
-
incident date
May 7, 2024
-
training setting
-
Fixed
Summary
-
Course participant cut their finger due to not putting hand tool to a full stop before putting it on the bench. The left hand unintentionally touched the rotating hand tool and therefore made a cut to the finger. First aid applied and course participant was sent to a doctor for further treatment.
Mitigation action
-
Slides to remind trainees on the usage and handling of the equipment, e.g. to ensure that the grinder comes to a full stop before the next operation.
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Case number:
6593484724
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Module
-
BST-R Sea Survival Refresher
Version
-
V17
Incident Significance
Incident
-
incident date
May 3, 2024
-
training setting
-
Fixed
Summary
-
As evacuation was carried out from scaffolding, a course participant stepped out of the scaffolding to evacuate into the water. Leaning out from the scaffolding, they fell into the water from a height of approx. 1-2 meters. No injuries were sustained.
Mitigation action
-
Instructors must physically check the participants´ PPE. Also, before the evacuation, the instructor will ensure all students place their front towards the scaffolding.
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Case number:
6564865060
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Module
-
BST Fire Awareness
Version
-
V17
Incident Significance
Incident
-
incident date
April 25, 2024
-
training setting
-
Fixed
Summary
-
Instructor decided to include an unauthorised exercise which involved extinguishing a fire in a small container using a CO2 extinguisher. A course participant, wearing arc flash and fire retardant workwear, goggles, helmet and gloves stood too close to the fire and sustained minor burns to the neck.
Mitigation action
-
Fire training temporarily suspended. The instructor will repeat the full GWO instructor qualifications before proceeding as an instructor. FAW training will include face shield, arc flash and fire retardant neck gaiter. A fire tray will replace the containers used for fire extinguisher exercises.
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Case number:
6417186103
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Module
-
BST Working at Heights
Version
-
17
Incident Significance
Incident
-
incident date
April 9, 2024
-
training setting
-
Fixed
Summary
-
Participant slipped while climbing a ladder and was caught by the fall arrest systems. During the fall, the participant hit their right knee against the ladder causing an abrasion. After the fall, the participant was treated by a first aider and examined in hospital.
Mitigation action
-
All participants were reminded that they should climb the ladder slowly and without haste. In adult learning activities, instructors are guided on how to assist participants according to their individual skills and experience. In addition, consideration of the incident was added to emergency procedures.
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Case number:
6431456150
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Module
-
ART Nacelle, Tower & Basement Rescue
Version
-
V4
Incident Significance
Incident
-
incident date
April 9, 2024
-
training setting
-
Fixed
Summary
-
A course participant experienced a type 1 diabetic seizure during a theoretical review on PFPE prior to commencing with activities at height.
Mitigation action
-
No corrective actions identified, however, discussions of this specific ailment are under way, noting that type 1 diabetes incidents are trending upwards and are expected to increase by 50% within 10 years.
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Case number:
6348343509
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Module
-
ART Single Rescuer - Nacelle, Tower, Basement
Version
-
N/A
Incident Significance
Incident
-
incident date
March 28, 2024
-
training setting
-
Fixed
Summary
-
Surface cut to course participant´s right ear due to descent device's inability to lock the descent device driver into place.
Mitigation action
-
Removal of the manufacturer’s descent device from all training requirements where the use of a powered driver is required. Safety alert issued.
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Case number:
6413350314
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Module
-
BST Working at Heights
Version
-
17
Incident Significance
Incident
-
incident date
March 21, 2024
-
training setting
-
Fixed
Summary
-
During a ladder rescue exercise, a participant suffered an abrasion to their right arm while reaching across the SRD cable to retrieve a carabiner. The rubber cable handle slid up, exposing the SRD cable swage termination resulting in the abrasion.
Mitigation action
-
Replacement of the SRL with model that does not allow for the exposure of the steel cable swage.
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Case number:
6213135605
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Module
-
BST Sea Survival
Version
-
N/A
Incident Significance
Incident
-
incident date
March 7, 2024
-
training setting
-
Fixed
Summary
-
A course participant swallowed water during Sea Survival training and began to regurgitate.
Mitigation action
-
No corrective measures were needed or taken. It was not a system or procedural failure. The safety swimmer pulled the course participant to the ladder where personnel pulled them out of the water. The course participant could return to the water after a short while.
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Case number:
5997674015
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Module
-
EFA Enhanced First Aid Training
Version
-
N/A
Incident Significance
Incident
-
incident date
February 5, 2024
-
training setting
-
Onsite
Summary
-
Course participant fainted during a presentation.
Mitigation action
-
None. Course participant suffered a vast vagal response which cannot be predicted.
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Case number:
5954439218
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Module
-
ART Nacelle, Tower & Basement Rescue ART Single Rescuer - Hub, Spinner & Inside B
Version
-
N/A
Incident Significance
Incident
-
incident date
January 29, 2024
-
training setting
-
Onsite
Summary
-
They were practicing releasable anchors; a course participant was conducting rescue at the time. The course participant moved hands above head to release work positioner. At that time, the course participant felt a pain in the back - possibly a pinched nerve.
Mitigation action
-
Medical team was consulted, but no further medical attention was needed.
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Case number:
5950365918
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Module
-
ART Single Rescuer - Hub, Spinner & Inside Blade
Version
-
N/A
Incident Significance
Incident
-
incident date
January 29, 2024
-
training setting
-
Fixed
Summary
-
A dummy was being lifted using a CRD through an access hatch. During the manoeuvre, the course participant´s hand became caught between the dummy and the hatch, leading to a small abrasion of the skin around the nail bed.
Mitigation action
-
All participants will be told that while the raising/lowering system is in operation, no further positioning or manoeuvring of the dummy or object being raised or lowered can occur.
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Case number:
5929607736
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
January 25, 2024
-
training setting
-
Fixed
Summary
-
Defective rescue device. During the passive evacuation, the handwheel came loose and fell to the ground. No personal injury or material damage except to the affected device.
Mitigation action
-
Consultation with the manufacturer and return of the damaged and a second rescue device from the same delivery to the manufacturer.
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Case number:
5890610262
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
January 19, 2024
-
training setting
-
Fixed
Summary
-
A course participant bruised a hand as they picked up a dummy for rolled edge with roll gliss. Anchor broke free and the participant´s hand got hit by the device.
Mitigation action
-
Epoxy anchor removed and new anchors installed. All epoxy anchors will be deadline and only steel anchors will be used in the steel frame.
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Case number:
5882325072
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
January 18, 2024
-
training setting
-
Fixed
Summary
-
An instructor, who had suffered a luxation several months before the course but had recovered, injured their knee. The incident occurred while the instructor was preparing for evacuation and had a course participant connected to them.
Mitigation action
-
The instructor was immediately replaced by another instructor and consequently went on leave while recovering. Before returning to training with real participants, the instructor carried out several simulated practices.
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Case number:
5646185133
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
December 7, 2023
-
training setting
-
Fixed
Summary
-
While descending, a course participant performing self-rescue with Sterling PDQ let go of the control rope on the sterling PDQ personal descender. As a result the participant descended rapidly and deployed the backup fall protection. All equipment functioned as intended and there were no injuries.
Mitigation action
-
All WAH modules were halted until equipment was inspected and replaced. Policies and procedures were reviewed and a post-incident analysis was conducted. Retraining was provided on the specific action that caused the incident to occur with the course participant.
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Case number:
5646539831
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
December 7, 2023
-
training setting
-
Fixed
Summary
-
During the two-man evacuation exercise, a course participant suffered a slight injury to their face (redness), turning the dial from the rescue device to the left cheek of the participant. Due to unclean rope management, the wheel came too close to the face.
Mitigation action
-
Instructors must emphasize possible hazards of the rescue device and also pay close attention to rope control.
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Case number:
5632110385
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Module
-
BST First Aid
Version
-
N/A
Incident Significance
Incident
-
incident date
December 5, 2023
-
training setting
-
Fixed
Summary
-
A course participant suffering from hypoglycemia experienced discomfort stemming from a personal experience when viewing a first aid video on puncture wounds.
Mitigation action
-
Contacted a medical helpline for advice. HSE representative for region was notified.
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Case number:
5545413591
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Module
-
BST Sea Survival
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
November 21, 2023
-
training setting
-
Fixed
Summary
-
When a course participant attempted to inflate a life vest by pulling the manual release trigger, no gas was fed into the life vest and with the pressure on the CO2 cylinder side, it detached from the vest and fell out. The flying cylinder did not come into contact with anyone.
Mitigation action
-
Staff informed and instructed on the proper cylinder installation method. A note added to the lesson plan to ensure that staff double-checks life vests before participants put them on. Manufacturer contacted.
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Case number:
5508108211
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
November 14, 2023
-
training setting
-
Fixed
Summary
-
A pair of course participants fell during a descent exercise. It was determined that one of them was not wearing any gloves during the descent causing them to release the rope as it heated up in their hands. No one was injured.
Mitigation action
-
In addition to a Buddy Check system already in place where participants inspect their partners´ PPE before the exercise, corrective actions entailed an inspection of all PPE required for each participant by the instructors immediately before performing an exercise.
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Case number:
4457188739
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Module
-
ART Hub Rescue/ART Nacelle, Tower & Basement Rescue
Version
-
N/A
Incident Significance
Incident
-
incident date
November 5, 2023
-
training setting
-
Fixed
Summary
-
During a rescue exercise, a course participant sustained arm injury (detached bicep tendon) when reaching forward to take hold of a casualty´s harness to pull them onto a ledge.
Mitigation action
-
Communication was sent out to all instructors to ensure that a warm up of the major muscle groups of the body, the ankles, wrists and back is conducted prior to all practical training.
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Case number:
5341662432
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
October 17, 2023
-
training setting
-
Fixed
Summary
-
During ladder rescue practice, a course participant sustained a slight scratch on the right arm from a splinter that was in the ladder's anchoring structure.
Mitigation action
-
The damaged ladder fixing piece was replaced. Checklists for inspecting WAH equipment were amended, including the ladder fixing brackets as a check element.
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Case number:
5327040126
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Module
-
ART Hub Rescue
Version
-
N/A
Incident Significance
Incident
-
incident date
October 13, 2023
-
training setting
-
Fixed
Summary
-
A course participant experienced pain in the neck when an X collar was fitted around their neck for practice.
Mitigation action
-
Training was stopped and the situation addressed with all course participants in the class. A decision was made to complete training and to notify manager and HSE specialist.
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Case number:
4999662223
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
August 16, 2023
-
training setting
-
Fixed
Summary
-
Course participant experienced a sudden pop on the right side of his lower rib cage (possible rib strain) while performing a descent along the rolled edge. Participant managed to complete the task and subsequent activities without any complications.
Mitigation action
-
Contacted a medical helpline for advice.
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Case number:
5128212404
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
August 9, 2023
-
training setting
-
Fixed
Summary
-
A course participant gave an additional push whilst leaning out in preparation for a decent, causing the davit to swing too far from the platform and then swinging back so that the participant hit their right shin. Injury sustained was a lump and a graze to the shin.
Mitigation action
-
All instructors were of the incident and hazards associated with course participants pushing off with additional force causing the davit to swing out too far from the platform.
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Case number:
4949386749
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Module
-
EFA Enhanced First Aid
Version
-
N/A
Incident Significance
Incident
-
incident date
August 8, 2023
-
training setting
-
Fixed
Summary
-
Course participant trips over a manikin and falls to floor but is not injured.
Mitigation action
-
All course participants highlighted to be aware of tripping hazards with practical equipment and manikins.
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Case number:
4871316779
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Significant incident
-
incident date
July 25, 2023
-
training setting
-
Fixed
Summary
-
A course participant sustained a upper arm bone fracture during the an evacuation practice.
Mitigation action
-
Training slides updated to share this case with future course participants, i.e. the proper way to grasp ropes, how to position oneself before descending, and how to eliminate nervousness before descending.
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Case number:
4835067936
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Module
-
BST First Aid
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
July 19, 2023
-
training setting
-
Fixed
Summary
-
A course participant felt dizzy and unwell when looking at slides explaining catastrophic external bleeding.
Mitigation action
-
Medical self-assessment form improved to include a new condition of sensitivity to bleeding injuries. Instructors will also inform participants of slide content before showing graphic pictures.
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Case number:
4666149186
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Module
-
ART Hub Rescue
Version
-
N/A
Incident Significance
Incident
-
incident date
June 19, 2023
-
training setting
-
Fixed
Summary
-
Instructor was hit by a hatch and broke two fingertips.
Mitigation action
-
Updated operating instructions and a mechanism installed to secure the hatches.
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Case number:
6245560990
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Module
-
ART Hub, Spinner & Inside Blade Rescue Refresher
Version
-
N/A
Incident Significance
Incident
-
incident date
June 15, 2023
-
training setting
-
Fixed
Summary
-
A course participant bent down during course and strained their back.
Mitigation action
-
The course participant was to helped and the course was paused. No further actions needed.
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Case number:
4595755881
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
June 6, 2023
-
training setting
-
Fixed
Summary
-
A course participant rubbed the middle finger of their right hand on the screw in the outer side of a ladder when descending with an injured person on the ladder.
Mitigation action
-
When practicing on (infrastructure) ladders, instructors are to ensure that all participants have gloves on before starting the exercise.
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Case number:
4471568004
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Module
-
BR Blade Repair
Version
-
N/A
Incident Significance
Incident
-
incident date
May 15, 2023
-
training setting
-
Fixed
Summary
-
An instructor and course participant carried a safety glass shield to the vacuum infusion table using glass-carrying suction cups. While attempting to position the shield on the table, it slightly scraped the ground and shattered into pieces. Both suffered minor cuts.
Mitigation action
-
Glass shields no longer to be used and replaced with aluminium shields.
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Case number:
4410243368
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Module
-
ART Nacelle, Tower & Basement Rescue
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
May 3, 2023
-
training setting
-
Fixed
Summary
-
During the raising of the manakin, the R550 rope attached to the manikin, became caught in the pelican hook, and tore apart the rope. After lowering it, the instructor noticed that the rope had gotten wedged in a small gap between the gate and hook side of the pelican hook, resulting in the tear.
Mitigation action
-
Moving forward the rigging has to be confirmed by competent individuals before a lift or movement takes place.
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Case number:
4333908295
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
April 19, 2023
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training setting
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Fixed
Summary
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Training provider had bought new gloves for fire exercises, which were believed to be leather gloves, all over. However, during an exercise, a course participant felt the heat on their hand. On inspection, the outer layer of the new gloves turned out to have some plastic areas.
Mitigation action
-
New gloves ordered.
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Case number:
4332350009
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
April 19, 2023
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training setting
-
Fixed
Summary
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Course participant complained of pain in their ankle at completion of training. During a “side of the ladder” rescue exercise, the casualty´s body pressed against the participant´s legs, pressing their ankle into the ladder.
Mitigation action
-
Re-iterate importance of all participants being comfortable in saying “stop” at any point during practical training. Also, instructors will encourage participants to consider the placement of rescue devices for ladder rescues, incl. position of rescuer and orientation of casualty.
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Case number:
4185965339
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Module
-
BST Sea Survival
Version
-
N/A
Incident Significance
Incident
-
incident date
March 22, 2023
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training setting
-
Fixed
Summary
-
During an exercise in a life raft, a participant got one foot stuck under another participant and twisted the knee, causing swelling and pain.
Mitigation action
-
Sea Survival instructors trained more intensively on the topic of stress among participants.
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Case number:
4049398793
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
-
incident date
February 27, 2023
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training setting
-
Fixed
Summary
-
While participating in an evacuation from a smoke-filled room, a course participant cut their wrist on the corner of a cabinet. The participant was blind folded, on hands and knees sweeping floor with hands when the wrist came in contact with a sharp corner, resulting in a cut.
Mitigation action
-
The sharp corner covered and protected from further contact. Ensure that course participants wear all PPE, including gloves.
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Case number:
4000736374
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Module
-
ART Hub Rescue
Version
-
N/A
Incident Significance
Incident
-
incident date
February 16, 2023
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training setting
-
Fixed
Summary
-
While setting up a fall arrest lanyard and positioning lanyard, a course participant went to step up on ladder structure when his left knee struck the side railing of the structure. The participant felt the need to rush during the rescue activity which lead to hitting the railing.
Mitigation action
-
Going forward, focus will be put into slowing down and making a clear plan.
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Case number:
3434471411
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
October 22, 2022
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training setting
-
Fixed
Summary
-
A course participant climbing down from a ladder, stepped on a manikin that was lying on the floor and sprained an ankle.
Mitigation action
-
Ensure unobstructed access to and from ladder. Remind participants to keep their composure until the end of the training, and that every step of the ladder must be stepped until the ground is reached.
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Case number:
3389720296
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
-
incident date
October 18, 2022
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training setting
-
Fixed
Summary
-
While simulating chaotic conditions during fire evacuation with participants assembling harness with Y-lanyards and Lad-Saf while donning blackout goggles and helmet, a participant felt a metal object (presumably the Lad-Saf or pelican hook) brush against their mouth, resulting in a chipped tooth.
Mitigation action
-
Scenario to be conducted with participants donning only the harness (no additional PFPE).
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Case number:
3273101315
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
-
incident date
September 15, 2022
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training setting
-
Fixed
Summary
-
During a FAW exercise with a fake fire in an electrical cabinet, two course participants felt an electric shock using a training CO2 fire extinguisher in a training Nacelle. Severity level low.
Mitigation action
-
A grounded multiplug has replaced the other multiplug in the cabinet, and has been moved away from any direct contact with the CO2.
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Case number:
3259473852
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Significant near-miss
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incident date
September 14, 2022
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training setting
-
Fixed
Summary
-
A participant positions a fire blanket on a fire training pan to extinguish the fire. At the request of the instructor, the participant removes the fire blanket resulting in self-ignition of the fire training pan (air supply, hot tank) with flashback on the participant causing minor eyelash burn
Mitigation action
-
Reminder to all instructors of the applicable instructions
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Case number:
3238704336
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Module
-
ART Hub Rescue
Version
-
N/A
Incident Significance
Incident
-
incident date
September 10, 2022
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training setting
-
Fixed
Summary
-
While tightening a strap on the "victim"'s spec-pak, a course participant felt a sharp pain in the lower back. Upon questioning, the instructor discovered that the participant had a sore back at the beginning of the training and had exacerbated the injury during the course of the class.
Mitigation action
-
JHA to include a musculoskeletal checkbox to ensure instructors will discuss injuries/limitations with participants at the beginning of each day. Additionally, instructors must have a continuous and ongoing conversation throughout lesson plans about rescuer safety, including ergonomics, hydration, state of mind to ensure rescuers do not become victims themselves.
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Case number:
2852928659
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Module
-
BST Sea Survival
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
May 21, 2022
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training setting
-
Fixed
Summary
-
A course participant panicked when a life raft came towards them causing them to become entangled in the ropes of the life raft. The participant did not respond to instructions of the safety guards in the water and refused to be helped and eventually had to be held and cut free from the ropes.
Mitigation action
-
N/A
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