UK MAIB Investigation report: Accessing a tug via the oil stage fenders can lead to fatal incident

The UK MAIB published its latest investigation report, focusing on a chief engineer’s fatal accident onboard the tug “Millgarth”. Specifically, the chief engineer fell into the River Mersey from the north oil stage at the Tranmere Oil Terminal at Birkenhead, England, in January 2019.

The incident

Under poor weather conditions, the tug was sailing at 1749 when the chief engineer fell into the river, while he had released the vessel’s mooring lines and was attempting to re-board the tug. The chief was wearing a lifejacket which automatically inflated when we fell into the water.

The personnel acted immediately and within 5 minutes tried to recover him alongside the tug. Although their efforts, the crew was unable to lift him up since the chief was already disabled to respond as the cold water made him to lost his awareness.

The chief engineer sufered a cardiac arrest and died after falling from an oil stage fender into the River Mersey. He was alive and functioning for several minutes after he entered the river, but he could not be recovered before he lost consciousness and stopped breathing.

as the Investigation report notes.

At 1811, the crew managed to recover him onboard with the rescue boat Marine Fire Rescue 1, but unfortunately couldn’t revived him as the chief had suffered cold water shock followed by cardiac arrest.

Findings

• The chief engineer was attempting to board the tug via an oil stage fender under poor weather conditions and most likely slipped on its wet surface.
• The lack of safe entering to and from Svitzer tugs at Tranmere Oil Terminal, had been recognized for at least 14 years prior to this accident and had been raised at safety committee meetings.
• The crew wasn’t well-prepared to face such emergency situation, while they were unfamiliar using the tug’s MOB rescue-sling.
• 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 reduced.

Recommendations

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 to Svitzer A/S concerning the safe conduct of tug access and egress, which are the following:

• Review and amend its procedures, as necessary, to ensure that observations and non-conformities identified during internal audits are not closed out before corrective actions have been completed and safety lessons disseminated throughout the feet.
• Adopt new measures to make sure that all the personnel is well-trained in the manoverboard recovery equipment on board every vessel.
• Ensure that a a thorough assessment of site-specifc risks, leading to an agreed procedure, is completed for all the locations where Svitzer tugs provide their service. Where shared risks are identifed, work jointly with the asset owners and operators to achieve this.

Lessons learned: 

• Approaching a tug through the oil stage fenders is a common practice, but extremely dangerous when in bad weather conditions.
• The incorrect closing out of an audit observation that identifed hazardous practices on board one of the tugs due to misalignment of the tug access door with the oil stage steps.

Explore more by reading the full report: