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MAIB: fatal man overboard incident whilst boarding tug

What happened?

The UK Marine Accident Investigation Branch (MAIB) has published Accident Investigation Report 15/2019 into a fatality whereby a man fell overboard whilst boarding a tug at an oil terminal at Birkenhead, England.

At 1749 on 27 January 2019, the chief engineer on-board the tug Millgarth, fell into the water 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 1811 by the crew of rescue boat Marine Fire Rescue 1; he had suffered cardiac arrest and could not be revived.

What went wrong?

The MAIB notes:

  • Accessing the tugs via the oil stage fenders at the Tranmere Oil Terminal was a common practice and was extremely dangerous, particularly in poor weather conditions;
  • The lack of safe access to and from Svitzer tugs at Tranmere Oil Terminal had been recognised for at least 14 years prior to this accident and had been raised at safety committee meetings and during company inspections many times prior to this accident;
  • Svitzer UK and Essar 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;
  • The crew had not been fully prepared to deal with the emergency situation and were unfamiliar with the use of the tug’s MOB rescue-sling


  • On 14 June 2019, the MAIB carried out a preliminary assessment 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 (2019/115) to Svitzer A/S concerning the safe conduct of tug access and egress;
  • This report makes further safety recommendations (2019/121 and 2019/122) to Svitzer A/S regarding the dissemination and closure of audit findings, attendance at man overboard drills and the use of man overboard recovery equipment.

Members may wish to refer to MAIB report 19/2016: fatal accident while manoeuvring Svitzer Moira alongside an unmanned tug Royal Portbury Dock, Bristol on 29 December 2015.

Members may wish to refer to:

Safety Event

Published: 30 January 2020
Download: IMCA SF 03/20

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