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REPORT ON THE INVESTIGATION OF THE FATAL ACCIDENT ON TUG MILLGARTH

REPORT ON THE INVESTIGATION

Report on the investigation of the fatal accident on tug Millgarth. “The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

At 17.49 on 27 January 2019, Ian Webb, the chief engineer on board the tug Millgarth, fell into the River Mersey from the north oil stage at the Tranmere Oil Terminal at Birkenhead, England. He had released Millgarth’s mooring lines and was attempting to re-board the tug. His lifejacket inflated automatically on entering the water and his crewmates were able to recover him alongside the tug within 5 minutes. The crew were unable to lift the chief engineer out of the water because he had quickly become incapacitated in the cold water and lost consciousness. He was recovered at 18.11 by the crew of rescue boat Marine Fire Rescue 1; he had suffered cardiac arrest and could not be revived.

The weather conditions were poor and the chief engineer had tried to board Millgarth via an oil stage fender. The investigation concluded the following sequence of events probably occurred:

● The chief engineer fell through the gap between the fender and the oil stage while attempting to board the tug.

● The chief engineer suffered cold water shock followed by cardiac arrest within minutes of falling into the cold water. It also concluded that:

● Concerns regarding safe access to and from Svitzer tugs at the Tranmere oil terminal had been raised at the safety committee meetings and during company inspections many times prior to this accident.

● Svitzer and Essar Oil UK did not formally identify and evaluate the shared risks associated with access to and from an unmoored tug or discuss how these could be mitigated. Following the accident:

● Essar Oil UK has conducted a joint risk assessment with Svitzer on the use of the Tranmere Oil Terminal.

● The Maritime and Coastguard Agency has issued instructions to its surveyors to ensure that inspections of manoverboard recovery equipment and manoverboard drills are witnessed at biennial inspections.

● Svitzer has reviewed manoverboard recovery equipment across its global fleet and manoverboard drills within its European region.

On 14 June 2019, the MAIB carried out a preliminary examination of a non-fatal man overboard incident on Svitzer Victory. Due to the similarity of this incident with the fatal accident on Millgarth, the Chief Inspector of the MAIB issued an urgent safety recommendation to Svitzer A/S, Denmark, concerning the safe conduct of tug access and egress.

This report makes further safety recommendations to Svitzer A/S regarding the dissemination and closure of audit findings, attendance at man overboard drills and the use of manoverboard recovery equipment. Both Svitzer A/S and Essar Oil UK have been recommended to ensure that a thorough assessment of site-specific risks leading to an agreed method statement of work is completed for all the locations where shared risks are identified.

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Millgarth

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