In order to safely execute an altered work process, a qualified expert in the field of occupational safety must be involved. On board the FWN Rapide, a working method developed on board for practical reasons was described and included in the safety management system (SMS). As a result, there were no effective mitigating measures available to allow safe working with the tweendeck as a work platform. The tweendeck was neither suitable nor safe for this use.
Risk inventory by qualified expert
In the report, the Board aims a few of its recommendations to the ship manager. Before implementing altered work procedures, they must ensure that a risk inventory and evaluation for the altered process is carried out by duly qualified experts. Also, these experts must be involved in preparing safety management measures necessary for mitigating the risks that emerge from the inventory.
Refer to the full investigation page 'Tweendeck falls into hold with fatal outcome - Lessons learned from the occurrence on board the FWN Rapide' for the report and the recommendations.