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:
6789370606
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Module
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BR Blade Repair
Version
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V4
Incident Significance
Incident
-
incident date
May 7, 2024
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training setting
-
Fixed
Summary
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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
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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:
6617012688
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Module
-
BST Fire Awareness
Version
-
V17
Incident Significance
Incident
-
incident date
May 7, 2024
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training setting
-
Fixed
Summary
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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
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Repair, where possible, the floor location where the training occurred. Conduct training where no such hazard exist.
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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
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training setting
-
Fixed
Summary
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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
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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
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training setting
-
Fixed
Summary
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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
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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:
6431456150
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Module
-
ART Nacelle, Tower & Basement Rescue
Version
-
V4
Incident Significance
Incident
-
incident date
April 9, 2024
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training setting
-
Fixed
Summary
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A course participant experienced a type 1 diabetic seizure during a theoretical review on PFPE prior to commencing with activities at height.
Mitigation action
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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
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BST Working at Heights
Version
-
17
Incident Significance
Incident
-
incident date
April 9, 2024
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training setting
-
Fixed
Summary
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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
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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
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ART Single Rescuer - Nacelle, Tower, Basement
Version
-
N/A
Incident Significance
Incident
-
incident date
March 28, 2024
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training setting
-
Fixed
Summary
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Surface cut to course participant´s right ear due to descent device's inability to lock the descent device driver into place.
Mitigation action
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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
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training setting
-
Fixed
Summary
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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
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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
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training setting
-
Fixed
Summary
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A course participant swallowed water during Sea Survival training and began to regurgitate.
Mitigation action
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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
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EFA Enhanced First Aid Training
Version
-
N/A
Incident Significance
Incident
-
incident date
February 5, 2024
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training setting
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Onsite
Summary
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Course participant fainted during a presentation.
Mitigation action
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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
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Onsite
Summary
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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
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Medical team was consulted, but no further medical attention was needed.
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Case number:
5950365918
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Module
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ART Single Rescuer - Hub, Spinner & Inside Blade
Version
-
N/A
Incident Significance
Incident
-
incident date
January 29, 2024
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training setting
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Fixed
Summary
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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
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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
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incident date
January 25, 2024
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training setting
-
Fixed
Summary
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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
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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
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training setting
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Fixed
Summary
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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
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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
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training setting
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Fixed
Summary
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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
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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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