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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:
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
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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
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ART Nacelle, Tower & Basement Rescue ART Single Rescuer - Hub, Spinner & Inside B
Version
-
N/A
Incident Significance
Incident
-
incident date
January 29, 2024
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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
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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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Case number:
5508108211
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
November 14, 2023
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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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