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:
4000736374
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Module
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ART Hub Rescue
Version
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N/A
Incident Significance
Incident
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incident date
February 16, 2023
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training setting
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Fixed
Summary
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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
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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
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BST Working at Heights
Version
-
N/A
Incident Significance
Incident
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incident date
October 22, 2022
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training setting
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Fixed
Summary
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A course participant climbing down from a ladder, stepped on a manikin that was lying on the floor and sprained an ankle.
Mitigation action
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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
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BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
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incident date
October 18, 2022
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training setting
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Fixed
Summary
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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
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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
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BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
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incident date
September 15, 2022
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training setting
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Fixed
Summary
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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
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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
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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
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Fixed
Summary
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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
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Reminder to all instructors of the applicable instructions
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Case number:
3238704336
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Module
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ART Hub Rescue
Version
-
N/A
Incident Significance
Incident
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incident date
September 10, 2022
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training setting
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Fixed
Summary
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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
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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
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BST Sea Survival
Version
-
N/A
Incident Significance
Significant near-miss
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incident date
May 21, 2022
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training setting
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Fixed
Summary
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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
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N/A
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