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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:
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:
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:
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:
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:
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:
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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