To Shipping Company Groningen:
1. Ensure that the ship is manned and equipped in such a way that all work on board can be carried out safely. This incident shows that the following conditions must be taken into account:
a. Bring the crew into line with the strength described in ship-specific procedures.
b. Ensuring that the regulative rest hours for the crew members are guaranteed.
c. Ensuring clear communication on board by requiring a walkie-talkie for all crew members.
d. Ensure a clear warning method for working in and near a snap-back zone.
2. Promote that crew members are sufficiently safety-aware and safety-competent to prevent accidents on board and to act appropriately in the event of imminent danger. This incident shows that several methodologies are desirable to achieve effective behavioural change, such as:
a. Regular discussion of procedures with the crew so that they understand them and see them as necessary. Review of procedures where they are no longer appropriate.
b. Talk through potential incidents (based on experience, earlier or elsewhere) which may occur on board and have the crew explore how to respond to them. This should include exercises and simulations.
c. Use the risky situations identified on board and discuss them during safety meetings. The premise is to call each other to account for actions that do not comply with the safety agreements, regardless of rank or seniority.
d. Organising specific training and exercises to further develop skills that appear to be underdeveloped.
e. Devote specific attention to training and supervision of trainees.
To the Minister of Infrastructure and Water Management:
3. Ensure that the manning proposed in a submitted manning plan is always checked for feasibility with regard to the work to be carried out, type of ship, safety procedures and emergency procedures. A safe manning certificate should only be issued if all conditions are met.
To the Royal Association of Netherlands Shipowners and to the Minister of Infrastructure and Water Management:
4. Investigate together whether the basic principle can be maintained that a crew member charged with the physical supervision of safety can also perform other duties. Apply the results when drawing up manning plans and issuing safe manning certificates.
To the Royal Association of Netherlands Shipowners:
5. Bring the lessons learned from this accident to the attention of the sector and specifically focus attention on the safe deployment of trainees and the problems mentioned in the investigation regarding manning plans and safe manning certificates.