Risk inventory essential when altering work processes on board ships

When existing work processes are altered, it is essential that they be assessed for safety by performing a risk inventory and evaluation, followed up by adequate measures to remove the risks. This is one of the conclusions from the Dutch Safety Board in the report ‘Tweendeck falls into hold with fatal outcome - Lessons learned from the occurrence on board the FWN Rapide’. The incident, which cost one person its life, occurred on 2 September 2019 on board a Dutch cargo ship in the port of Georgetown (Guyana). At the time of the incident, maintenance works on height were being carried out using an altered work process. This included the use of a tweendeck, which was both unsuitable and unsafe as a work platform.

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.