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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:
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
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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
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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
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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
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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
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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
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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
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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
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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:
4332350009
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
April 19, 2023
-
training setting
-
Fixed
Summary
-
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.
There are currently no incidents matching your search. Please edit your search.
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