On 2 September 2019, two Filipino deckhands fell into the hold on board the Dutch cargo vessel FWN Rapide. One of the crew members died and the other was injured. The occurrence took place in the port of Georgetown, Guyana. The two victims stood on a tweendeck while it was being moved by the hatchcover crane.

During the occurrence, the tweendeck was being used to fill the gaps between the walls of the hold and a vertically installed transverse bulkhead, from top to bottom. One of the two hoisting cables of the hatchcover crane from which the tweendeck was suspended broke. As a result, the port side of the tweendeck fell approximately 5 metres, ending up in the bottom of the hold. As a result of the fall, the other hoisting cable also broke.

Investigation publication

No effective mitigating measures for working safely

On the day of the occurrence, gaps had to be sealed between installed transverse bulkheads and the walls of the hold. These had to be sealed in order to prevent the different types of cargo becoming mixed. This work requires working at height, and lifting persons up and down. The work approach designed for this task - working in a man cage - was perceived as impractical for multiple reasons by crew members on board vessels of the shipping company. For that reason, on the shipping company’s vessels, a working procedure was introduced whereby the smallest tweendeck on board was used as a work platform, suspended from the two hoisting cables of the hatchcover crane. The use of the tweendeck as a work platform has become part of the procedure described in the safety management system (SMS) for sealing gaps between walls of the hold and transverse bulkheads, on the shipping company’s vessels. Although the use of the tweendeck as a work platform is described in the SMS of vessels of the shipping company, there is no description of how the work should be carried out. The SMS does however contain a general procedure for working at height, which includes constant supervision of the work, from a safe distance, and wearing of fall protection.

Despite the fact that tweendecks were regularly used to carry out work and thereby involved safety risks, no specific instructions were drawn up for working with tweendecks as work platforms. In addition, no risk inventory and evaluation were carried out. In effect, a working method developed on board for practical reasons was described and included in the SMS. As a result, there were no effective mitigating measures available to allow safe working with the tweendeck as a work platform.


The Dutch Safety Board issues the following recommendations:

With regard to maintenance of hoisting and lifting equipment on board ships, the alteration of work procedures, safe working at height and the provision of physical supervision during high-risk activities on board:

To ForestWave Navigation B.V. (Ship Manager):

1. Before implementing altered work procedures, ensure that a risk inventory and evaluation for the altered process is carried out by duly qualified experts. Also involve these experts in preparing safety management measures necessary for mitigating the risks that emerge from the inventory.

2. On board vessels managed by ForestWave Navigation B.V, ensure that maintenance on hoisting and lifting equipment is performed according to the manufacturer’s instructions. Ensure that maintenance schedules and instructions from the manufacturer or supplier are fully integrated in the operational maintenance routines on the vessels.

3. On each vessel managed by ForestWave Navigation B.V, identify which types of fall protection equipment are necessary. Ensure that this equipment is available on board and issue the crew with information about how and when which type of fall protection equipment should be used. In addition, organize work on board in such a way that the work can only be started once all risk management measures have been taken.

With regard to the necessary expertise during annual inspections of hoisting and lifting equipment on board ships:

To the Royal Association of Netherlands Shipowners (KVNR):

4. Together with the sea shipping sector, develop a set of regulations, protocols and rejection criteria relating to the inspection of hoisting and lifting equipment on seagoing vessels. Also develop profiles according to which the expertise of the persons tasked with performing inspections can be assessed, measured and reinforced.

To the Dutch Minister of Social Affairs and Employment:

5. Ensure the development by the sea shipping sector of the system of expertise profiles as intended in recommendation 4.

Noting that a less strict regime of examination, inspection and testing is embedded in legislation and regulations for specific types of hoisting and lifting equipment on board ships:

To the Dutch Minister of Social Affairs and Employment:

6. Amend legislation and regulations regarding the examination, inspection and testing of hoisting and lifting equipment on board ships in such a way that equipment of this kind is subject to the regime of examination, inspection and testing that currently applies exclusively to hoisting and lifting equipment used for loading and unloading.




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    Risk inventory essential when altering work processes on board ships

Investigation data

Theme Shipping

Investigation start date

Report publication date

Type Shortened Investigation

Status Completed

Phase Publication