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The Lesson That Was Never Learned: Millgarth and a Four-Year Gap Between Fatalities

🕑 5 min read words Safety • Incident • Safety-culture

Vessel: Millgarth, harbour tug (Svitzer), UK flag
Date & location: 27 January 2019, North Oil Stage, Tranmere Oil Terminal, Birkenhead, England
Outcome: Fatal man overboard — the chief engineer fell into the River Mersey while attempting to board Millgarth as she moved away from the oil stage; not recovered alive
Human factors: Normalisation · Complacency · Workload
Source: MAIB Report 15/2019

4 years since a near-identical fatal accident in the same company1 defective MOB recovery unit~6 min read + Knowledge Checker

A Fall Into the Mersey

At 1749 on 27 January 2019, the chief engineer aboard the Svitzer tug Millgarth had released the tug's mooring lines from the north oil stage at Tranmere Oil Terminal, Birkenhead, and was attempting to board as the tug moved away. He fell into the River Mersey. The crew initiated an MOB response, but Millgarth's Jason's Cradle recovery equipment was found to be defective. He was not recovered alive.

The Same Accident, Four Years Later

MAIB's investigation found this accident closely mirrored a fatal accident on another Svitzer vessel, Svitzer Moira, in December 2015. That earlier fatality should have driven systemic change in tug access and egress procedures across the fleet. It did not. A near-miss on a third Svitzer tug, Svitzer Victory, just months before the Millgarth accident, reflected the exact same access and egress failure — and still nothing changed in time.

Equipment That Couldn't Help

Beyond the boarding hazard itself, an internal Svitzer audit had already identified access and egress issues at Tranmere. That non-conformity was closed out without the corrective action actually being verified as complete. And when the emergency happened, the one piece of equipment designed specifically for this scenario — the Jason's Cradle MOB recovery unit — was defective and could not be used.

Recommended Actions

Svitzer A/S: Review and amend procedures to ensure internal audit non-conformities are not closed out before corrective actions have been completed and safety lessons disseminated throughout the fleet (Rec 2019/121).
Svitzer A/S: Adopt measures to ensure all crew are trained in MOB recovery equipment on their vessels, with regular drills completed by all crews irrespective of rotas (Rec 2019/122).
Svitzer A/S: Ensure a thorough assessment of site-specific risks, leading to an agreed procedure, is completed for all locations where Svitzer tugs operate, working jointly with asset owners where risks are shared (Rec 2019/123).
Essar Oil UK Limited: Ensure a thorough assessment of site-specific risks, leading to an agreed procedure, is completed for all locations where tugs provide services, working jointly with tug owners and operators (Rec 2019/124).

Human Element Analysis

Normalisation

Boarding a moving tug from an oil stage with no agreed safe procedure had, in effect, become the accepted way this task was done at Tranmere — not because it was safe, but because nobody had stopped to formally assess it as anything other than routine.

Complacency

An internal audit finding on access and egress at Tranmere was closed out without the fix being verified. That single administrative step — treating a closed finding as a solved problem — left the real hazard exactly where it had been.

Workload

MOB recovery drills had not been completed by all crew due to manning patterns. A defective Jason's Cradle discovered mid-emergency is the direct, foreseeable consequence of equipment checks and training not being built into the working routine for every rotation.

How This Pattern Repeats

Industry	Incident	The parallel
Rail	Southall rail crash, 1997, and Ladbroke Grove rail crash, 1999	The lesson from the first fatal collision — about automatic train protection — was not implemented across the network before a near-identical failure mode caused a second, more deadly crash four years later, the same gap between Svitzer Moira (2015) and Millgarth (2019).
Aviation	Lion Air Flight 610, 2018, and Ethiopian Airlines Flight 302, 2019	A known design/procedure risk identified after the first fatal crash was not made a mandatory fleet-wide fix before a second aircraft was lost to the same failure mode less than five months later — a fleet-level lesson that stayed at single-aircraft level, exactly the pattern MAIB described for Millgarth.
Offshore	Piper Alpha disaster, 1988	A hazard shared across a site or fleet, not addressed at the systemic level, does not stay contained to a single location or vessel — the same shared-risk failure MAIB found between Svitzer's fleet-wide access and egress procedures and the specific hazard at Tranmere.

See How You'd Handle It

The scenario opens as the tug moves away from the oil stage and the boarding window narrows. Play the Millgarth decision scenario and find out where each choice actually leads.

Lessons for Fleet Operators

When a fatality exposes a systemic risk, the fix must be systemic — applied to every vessel, every port, every procedure, not just the one where it happened.
MOB recovery equipment that isn't maintained and tested is functionally the same as having none. A defective Jason's Cradle in an emergency confirms this the hard way.
An audit finding closed before its corrective action is verified is not a closed finding — it's an open hazard with a paperwork trail suggesting otherwise.
Shared risk at a terminal or oil stage requires joint risk assessment between the vessel operator and the site owner. Neither can manage it alone.

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