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After clearing its berth at Burnie, Tasmania on the morning of Sunday 15 March 1998, the ro-ro vessel City of Burnie stopped within the harbour to conduct a lifeboat drill. The drill involved the launching of the port lifeboat with a crew of eight.

The lifeboat was duly launched and, coxswained by the Mate, it cruised around the harbour for about ten minutes. After the lifeboat had returned and the boat's crew had hooked on the falls, the recovery party, under the charge of the 2nd Mate, found that the electric motor for the falls winch would not start. The Chief Engineer went to the motor contactor panel, located in the funnel, where he operated the falls winch motor by manually pushing in the contactor. He used a portable radio to maintain contact with the 2nd Mate.

The lifeboat was hoisted by this method to deck level, where it was necessary to stop the hoisting while the boat's crew aligned the fall hooks with the davit heads. Hoisting was then resumed, in similar fashion, with all the eight men still in the boat. Despite a warning shout, the winch motor was not stopped before the davits brought up hard against the stops and the wire falls parted. The lifeboat fell to the water, turning over as it did so, spilling out most of the crew.

A number of small leisure craft rushed to the scene, rescued all eight crew members from the water and took them to the yacht club launching ramp. From there, ambulances took the crew members to Burnie hospital.

All eight crew members suffered some form of injury, two suffered major bone fractures, but fortunately no one was killed. The lifeboat was extensively damaged.


These conclusions identify the various factors that contributed to the incident and should not be read as apportioning blame or liability to any particular organisation or individual. The fall wires parted when the davits were hauled hard home under electrical power, the force exerted on the wires exceeding their breaking strain. The following factors are considered to have combined to cause the incident:

  • The fracture, at some earlier date, of the winch safety switch cover plate, which had allowed the entry of salt water, causing corrosion within the switch and an electrical open circuit.
  • The instructions for routine checks of the winch safety switch and davit cut-out switches at lifeboat drills, contained in the manufacturer's Instructional Manual, were not followed.
  • The use of the winch motor to turn-in the lifeboat by means of manually holding in the electrical contactor.
  • Although intermittent faults had been experienced with the operation of the electrical winch motors over a number of years and lifeboats had been raised by holding in the electrical contactors on other occasions, the ship's Safety Committee had not developed a written procedure to be followed under such circumstances.
  • The on-board practice for boat drills which resulted in the 2nd Mate not knowing the procedures followed for restowing the lifeboats, although he had served on City of Burnie for six years.
  • Neither the Mate nor the 2nd Mate was aware that the limit switches were by- passed and so would not operate when the electrical contactor was manually held in to operate the winch motor.
  • The absence of a company organisational mandatory reporting procedure, to keep shore management informed of operational malfunctions.
  • The design and positioning of the guideways, which prohibit safe, unimpeded transfer of persons from the lifeboat to the deck, resulting in the full boat's crew remaining in the lifeboat until it is fully housed.
  • The hook twisting problems experienced with the single wire fall, which resulted in the 2nd Mate's concentration, from habit, being on the davit heads and hooks.
Download Final Report
[ Download PDF: 240KB]
General details
Date: 15 March 1998 Investigation status: Completed 
Location:Burnie Investigation type: Occurrence Investigation 
State: Tasmania  
Release date: 22 September 1998  
Report status: Final Occurrence category: Serious Incident 
 Highest injury level: Serious 
Vessel details
Vessel: City of Burnie 
Flag: Brit 
IMO: 8009038 
Type of Operation: RoRo Cargo 
Damage to Vessel: Minor 
Departure point:Burnie, Tasmania
Serious: 2002
Minor: 6006
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Last update 19 May 2016