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Chapter 1. The Accident
1.1 The 'Estonia'
Some particulars of the ship 'Estonia' from the data book of Lloyd's Register 1994 are listed below.
Loa 155.43 meter,
An Estonian/Swedish joint venture company, Estline, operated the ferry. The ferry was registered in Estonia.
One survivor (CÖ) told Swedish newspaper Dagens Nyheter recently (November 30, 1997) that when he was embarking the 'Estonia' on the afternoon of September 27, 1994, he found that the Tallinn port area was sealed off and that his friend in his car could not drop him at the ship in the normal way. CÖ had travelled twenty times with the 'Estonia' and this was the first time he had this problem to join the vessel. CÖ went to the reception aboard and tried to get a cabin and after a long wait he got a bed in a cabin (no. 1049) on no. 1 deck below the car deck. CÖ states more than three years after the accident that he thought that all the crew behaved differently than at all previous trips.
Another survivor (LB) has written a book about his experiences before, during and after the accident, that the Commission has ignored, but he does not mention the observations of CÖ. LB had a car, which he parked on the car deck, and had a cabin on deck no. 5. Many other cars, lorries and trailers were loaded and the car deck was almost full. It has been established that, due to confusion or bad cargo planning, the 'Estonia' was listing to starboard at the end of the loading. To sail upright the port trim tank was filled.
The Swedish Maritime Administration was training Estonian PSC (Port State Control) surveyors in the port of Tallinn at the time and they had visited the 'Estonia' during the afternoon. The bow visor was in the open position and the inner ramp was down and the group noted that some rubber packings were missing. No action was taken.
The ship left Tallinn around 19.00 hrs and then the inner ramp and the visor itself had been closed. The last voyage of the 'Estonia' had begun.
On the night September 28, 1994, the ferry 'Estonia' then sank in the Baltic Sea en route between Tallinn, Estonia, and Stockholm, Sweden. 852 people died including more than 500 Swedes. During a meeting on the same day at Helsinki, Finland, September 28, 1994, the prime ministers of Estonia, Finland and Sweden decided that a Joint Accident Investigation Commission (JAIC or the Commission) should be formed to investigate the accident. They also decided that the chairman of the Commission should be Estonian. They did not agree anything else, e.g. that the Commission should follow the working rules and procedures of the IMO.
Five days later, October 2, 1994, searchers found the wreck at 70 meters depth and fixed its position, 1.13. The wreck was in international waters but inside the Finnish economic zone. A remote control underwater camera was sent down and the ship's bow door (the visor) was found missing. The search for the visor started, but it was not found until October 18, 1994, 1 570 meter West of the wreck, because they searched for two weeks in vain East of the wreck.
Note August 2000 - correction - the wreck was in fact found with echo-sounder already on September 30, 1994 by the Finnish ship the 'Suunta'. A false wreck position was later announced 2 100 meters NE of the real one. The visor was therefore > 3 000 meters from the false wreck position. If the visor position was correct is another question. JAIC could never explain how the visor could have been lost there.
Note January 2001 - addition - it is probable that the visor was found adjacent to the wreck on the same day September 30, 1994 visor on bottom. Four sonar pictures were taken of the wreck and the sourroundings. On all four pictures a pyramid shaped object was seen, which Dr. Nuorteva, a Finnish scientist, thought was the visor. The object was filmed by an ROV on October 2, 1994. The Commission did not elaborate what the object was and the film has later been edited. Instead the head of the Finnish delegation in the Commission - Mr. Lehtola - announced a false position of the wreck 1.13. The object was filmed a second time by an ROV on October 9, 1994 and four films were made and registered under act B2 in the Swedish archive, where it was stated that the films were i.a. of the visor. A fax exchange between two Commission members were made on October 10, acts I15 and I16 in the Swedish archive, about the visor, the two members then looked at the four films, act B2, on October 11,where no doubt they could see the visor. These films have also later been edited not to show the 'object'. Furthermore, on the same day the Commission informed the media that the visor had not been found and that the search continued. However, no real search was done by ships between 12-17 October and then the visor was allegedly suddenly found on October 18 by a Finnish ship 1.13. It is probable that the visor was found already on September 30, 1994. The four films in act B2 do not exist any more. Act B2 consists today of two 'original' films and one 'summary'! The faxes I15 and I16 exist and refer to an attached 'picture' showing i.a. the visor. However, the attached 'picture' today does not show any visor. It is instead a sketch of the bow of the wreck with no visor.
The members of the Commission were announced on October 10, 1994 at 17h00 (GMT+2) as follows (1):-
Other experts and observers were also then, and later, appointed to assist the Commission. Denmark and Norway got observers. Germany, where the ship was built, was excluded from the Commission. The public was never invited to attend any hearings. The president of the Swedish Master Mariner's Association was refused access to the meetings, when he tried to attend. It was also stated that:
'the Commission's terms of reference depend on finding and inspecting of the Estonia's bow door which will determine the course of future activities'.
The Commission ignored completely any terms of reference given by the Estonian, Finnish and Swedish prime ministers, because only one week later, before even finding the visor, it told the public what had happened! 1.7 and 1.10. The next meeting of the Commission was decided to be at Tallinn on October 17, 1994.
Actually the members of the Commission had appointed themselves already on September 29 at an informal meeting held at Turku, Finland (3). The provisional Commission had then made its first public statement already on October 4 - a First Interim Report - stating that the accident was caused by water collecting on the car deck. In retrospect that report was complete guesswork - a simple stability calculation should have shown that water collecting on the car deck could not have caused the accident.
Only 30 minutes after the announcement of the Commission the Foreign Ministry of Estonia issued a correction (2) to the appointments. Indrek Tarand of Estonia was replaced by Enn Neidre - Member - Captain, Estonian Shipping Company.
While the Swedish and Finnish members were civil servants, mariners, educators and consultants who previously had been involved with accident investigations in their respective countries and had no relation at all with the vessel of the accident, the same cannot be said of the Estonian members, none of whom had ever participated in a casualty investigation.
Andi Meister was, politically responsible for safety at sea in Estonia, and formally head of the government Estonian Shipping Company (ESCO) owning the vessel.
Uno Laur was introduced as the managing director of the Average Agency CMM, an ex ESCO employee and an experienced maritime specialist. It was not said that he was the predecessor of Enn Neidre at ESCO.
Enn Neidre, was the head of the Navigation Department of ESCO and Safety Advisor of Estline and the supervisor ashore of the crew of the vessel.
The Estonian prime minister had appointed three persons, who were very much involved with 'Estonia' and its operations and safety to investigate an accident to the same ship. The Finnish and Swedish members did not complain about this conflict of interest among the Estonian members.
At the meeting at Tallinn October 17, 1994, the Commission reviewed new information available to it as a result of additional video films taken from the sunken ship and confirmed two things in a Second Interim Report (4) signed by Meister, Forssberg and Lehtola.
1. The visor was lost underway.
The visor had not yet been found, and naturally, it had not been inspected, when the Commission stated this! 1.4. Even if the two conclusions seemed innocent and obvious, in retrospect one can conclude that (A) the visor was not lost underway, and (B) water did not enter the car deck at the forward ramp.
The reasons for this suggestion are (1) that underwater videos of the wreck could not show when the visor was lost and (2) that the visor was found the next day almost one nautical mile West of the wreck according to Lloyd's List October 20, 1994. 'Estonia' had been on a westerly course from Tallinn to Stockholm, so a rational person would have expected to find the visor South East of the wreck, if it had been lost underway. The search of the visor started East of the wreck and the visor had not been found for two weeks. When the visor was found West of the wreck, it was clear that the ship may have listed and turned first and lost the visor later, and finally the vessel could have drifted back to sink at the position, where the wreck was found. Alternatively, the vessel may have turned before the accident and was heading back to Tallinn, when the visor was lost - in either case evidently the vessel was not underway to Stockholm anymore 1.13.
It is likely that the first statement about the accident by the Commission was not true or a guess. The visor could have been lost after the real accident took place, that is because of the accident, when the ship was not any longer underway to Sweden.
It is not clear how the Commission could have made its second statement based on some underwater video films.
The forward ramp (or the bow ramp, or the inner ramp - the Commission uses different words) was found in a closed position at the wreck as seen from outside by remote controlled underwater cameras.
Divers had not yet examined the forward/inner bow ramp from inside. (It was never done, 1.14, 4.8 and 4.11). In Stern 18/96 (8) Forssberg stated that the ramp opening was too small for a diver to enter into the garage and that cutting away of steel structure was necessary (which was why the interior of the garage was never examined). Other information says that the seven metres long inner ramp was open 60-70 cms or much less at its upper part (it was hinged at the car deck). The Commission was very vague regarding how open the ramp was.
There was no proof whatsoever on the videos available to the Commission on October 17, 1994, that water had entered the car deck at the forward ramp as the ramp was almost closed 1.15.5. Furthermore, it was evidently not clear from the videos, if/when the forward/inner ramp had opened up a little - underway, before the accident, after the accident or when the vessel sank to the bottom, 2.21 and 4.11. What was the accident?
Three engine crew members in the soundproof engine control room (ECR) midship, 3/E Treu, a motorman and a systems engineer, had said to the Estonian police (Priit Männik? 1.18) that they had seen water entering at the forward ramp on a TVmonitor of the garage in the ECR. 3/E Treu said it was at 01.15 hrs, before the vessel started to list, the others said that they saw the water in the garage after the list had occurred. Further questioning of these crew members at a later stage by the Commission, March 1995, has shown that their statements are contradictory, suggesting that they may have been mistaken. The systems engineer later retracted his statement completely (10) 4.23.
1.10 The Meeting October 17, 1994, (Part II)
The Commission also presented the cause of accident at the meeting (4). Thus, only nineteen traumatic days after the accident, when the Commission met for the second time, the cause was known!
How could the Commission have found the cause of accident so fast? The diving underwater survey of the wreck had not started, the visor had not been found nor inspected, no suspect parts of the wreck had been salvaged and investigated, the 137 survivors had not been interviewed, no stability calculations had been done, etc. Many survivors had given early statements, that water had been seen on deck no. 1 before the first abrupt listing, but these statements were ignored by the Commission. No statement confirmed water in the garage, unless you believed what one junior engineer in the control room said that he had seen on a video display of the garage.
What normally takes many months or even years to do, the Commission did in less than two weeks during two meetings. A record?
It is not known if the Commission discussed any other causes of accident than the one that was presented on October 17, 1994, as 'one of the most probable causes of the accident'.
The heads of the three member nations of the Commission, Meister, Lehtola and Forssberg, signed a document (4) that was forwarded to the government of Estonia, the Council of State of Finland, and the Swedish National Maritime Administration. It said:
1. The bow door (visor) has separated from the ship as a result of failure of all three locking mechanisms. According to the observations made by members of the crew this happened at about 01.15 when water was simultaneously observed on the TV-monitor, entering the car deck from openings along the vertical sides of the forward (/inner - my note) ramp. The failures have taken place, in case of the two side locks, in the welding of the locking eye plates to the bow visor and in case of the centre lock (as previously shown) by failure of the lugs carrying the locking plunger unit.
No other possible causes were mentioned then or later by the Commission to the governments of Estonia, Finland and Sweden. Nobody in the governments has ever questioned and inquired into the work of the Commission, if it meets acceptable international standards. The writer made the following analysis before the Final Report (13) was issued:-
Item 1 is mainly observations that three locks have burst and how. Regarding the time 01.15 hrs it must be noted that many surviving passengers (11) had given a completely different time, 01.02 hrs, for another earlier event - abrupt listing of vessel first 50° to starboard and then back to upright and then to about 15° starboard list 3.16 - which was not mentioned by the Commission then or later (13). It is a fact that nobody saw, heard or felt that the visor separated from the ship, so the time for that event cannot be given. 3/E Treu 1.9 had said that he saw water entering the garage at the forward ramp at 01.15 hrs before the vessel listed. Considering the passengers' statements the vessel was probably already listing 40° then. 3/E Treu has later been found to give contradictory statements, 1.19, 1.22, 4.7 and 4.23.
Item 2 is a suggestion that the visor flipped up and down around the hinge points. There is no proof whatsoever, that it happened. Nobody witnessed such an event 3.9. You wonder how the Commission could have made up such an idea? One passenger, V. Kikusts, a Latvian police officer, stated that he saw the visor flipping at 00.26 hrs, i.e. 49 minutes before Treu saw water enter at the forward ramp. Kikusts never warned the crew at the time (10).
Item 3 - it is correct, if the visor separated from the ship in the upright condition, that it must have hit the forward solid ramp from the rear 3.10. It is then probable, if the top part of the visor is stronger than the ramp, that the visor pulls out the forward ramp completely 80°, after the locks/securing cleats and hydraulics of the inner/forward ramp are broken. The commission gave this impression orally. However, the forward ramp was found only opened 8-10° - (60-70 cms at the top) or much less, 1° or 10 cms; it was partly open according the Commission 1.11.4. In my opinion the ramp was almost closed. This indicates that the visor may have separated, when the ship had >35° list, when it was hit from the side by a transient impactive force 2.8. Interestingly enough internal stiffeners of the upper protrusion of the visor and its thin steel cover plate are hardly damaged 4.10 - the port stiffeners are only bent a little. Why was the aft end of the visor top not more damaged, if it had forced open the inner ramp? It should be recalled that the Commission wrote point 3 before it had located the lost visor, so it is not clear how the Commission could have stated, that the lost visor had hit the ramp from the rear, etc. The Commission had not seen the visor top! The ramp top is not damaged.
Item 4. This statement is most deceptive. The forward ramp was said only to have been partly open. Then much water could not have entered the car deck, even considering heavy seas (the heavy seas would push closed the forward ramp) 2.19. Members of the commission stated orally that the inner ramp was completely pulled out by the visor, 2.21 and 4.23. Nevertheless - as the ship was listing about 1° to starboard due to a SW wind, any water entering the garage should have collected on the starboard side of the garage/vessel and gradually increased the list of the ship, unless it drained out through the scuppers in the deck. However, what surviving passengers state is, that there was a temporary loss of stability, when the vessel suddenly first listed 50° to starboard, and then stability clearly was regained at 15° list to starboard 3.16. Thereafter, the vessel was only very slowly heeling over, until it was on the side. The Commission stated - quote:
'Collection of water on the car deck eventually led to the loss of stability and capsizing of the vessel.'
However, water on the car deck should always have led to the vessel heeling to a certain critical angle - about 34°, after which the vessel should have tipped upside down and floated with the keel up, 2.16, 2.19 and 5.5. The Commission never made any stability and righting arm calculations before issuing its statement! It should be clear to anyone that there could not have been any water on the car deck, because the vessel never tipped upside down.
Item 5 - First is should be noted that with 90° list, the 'Estonia' should have tipped upside down. The Commission did not know that the vessel could not float with 90° list! The Commission then stated:
'The ship disappeared from the radar screen of a Finnish surveillance station at 01.48'.
This meant that the 'Estonia' was under observation from shore and you evidently wonder what this observer saw before 01.48 hrs. Finnish and Swedish newspapers reported October 1 and 2, 1994, that 'Estonia' was off course when the accident took place, and this information can only have originated from the Finnish shore radar observer. However, later the information was retracted. The Commission has never informed, what the shore observer saw before 01.48 hrs, e.g. when and where the 'Estonia' changed course, slowed down, stopped, drifted, etc. 4.20.
Note August 2000 - according to later information the Finnish surveillance station at Utö did in fact plot the 'Estonia' and other ships on its radar screens prior to the accident and this plot was handed over to the Commission. However, later the plot disappeared, because it didn't tally with the sequence of events invented by the Commission!.
Item 6 - it is evidently impossible that a SW wind/wave action turned the vessel (to port). See also 1.13 and Forssberg's statement about the vessel's course and speed after the accident, and figure 2.23. And how did the Commission know that the vessel turned after losing the visor? Why could the vessel not have turned before it lost the visor? According to the Commission nobody observed the 'Estonia' prior to 01.22 - 01.24 hrs, so nobody could have known that the 'Estonia' had turned after it lost the visor at 01.15 hrs. Finnish shore radar and any vessel including the 'Mariella' and the 'Silja Europa' reportedly did not observe the 'Estonia' prior to 01.22-01.24 hrs. According to the 'Mariella' the 'Estonia' was immobile in the water at 01.24 hrs in a position, which later (when the visor was found) turned out to be one mile south of the visor. Who could have seen that the 'Estonia' turned after losing the visor, when it was not known where and when the visor was lost?
Unfortunately, no open discussion of the Commissions cause of accident or events before and after the accident was possible in October 1994. The public had to believe the Commission. The IMO had adopted two resolutions about casualty investigations. Resolution A.440(XI) says that all the details of the accident shall be circulated to the members of IMO and resolution A.637(16) says that the hearings and all protocols, etc., shall be public. Two obvious questions are? Did the Commission intentionally misinform the public and the IMO in October 1994? Why was all information confidential and/or secret? It seems we will never know, unless there is a new investigation.
The visor was found on October, 18, 1994, about one nautical mile to the West (!) of the wreck (as reported by Lloyd's List October 20, 1994). Its position was later determined to abt. N59°22',97, E21°39',33 ± abt. 100 meters according to a message from the Swedish Navy December 9, 1994.
The wreck was first reported at N59°23'54.60", E21°42'10.20". This position was later modified to an 'as found' position of N59°22'56.13", E21°41'00.98". These two positions are 2 112 metres apart. The heading of the wreck was 95°, i.e. the bow pointed approximately to the East. The visor was thus about 3 150 meter from the first wreck position and 1 570 meter from the second wreck position or abt. 2 600 m West of the first wreck position and 1 570 meter West of the second position. It was also concluded that the visor was one mile north of the Mayday position.
In spite of this confusion it is sure that the Commission knew early that the visor was found well West of the wreck and North of the Mayday position!
Note August 2000 - the Commission knew very well the correct wreck position already on September 30, 1994, but the Finnish head of delegation - Kari Lehtola - 'isolated' the wreck by announcing to the media the false wreck position 2 112 m NE of the real position. The reason for this was probably that the same ship that found the wreck also found the visor adjacent to the wreck! For unknown reasons the Commission did or would not admit this as they apparently planed to blame the accident on the visor. There are strong reasons to believe that the official visor position was also false, e.g. the Commission never announced the exact position of the visor on October 18, 1994; only that it was about one nautical mile West of the wreck, the position of which was then incorrect - 'isolated'. The visor position determined by the Swedish Navy was that of a red buoy allegedly anchored on top of the visor.
Addendum 4 January 2001 - the above thoughts were further confirmed in December 2000 when a sonar picture of the wreck and visor (!) made 1996 was published. One reason for hiding the fact that the visor was found adjacent to the wreck already on September 30, 1994, may be the fact that all four key witnesses of the crew had previously (on the day of the accident before the wreck was located) stated that they saw the visor missing at the bow when the ship was sinking. Thus, when the visor was in fact found adjacent to the wreck, these testimonies were easily proven false. To protect the lying witnesses the Commission apparently decided not to inform the public that the visor was found adjacent to the wreck.
In Stern 18/96 (8) Forssberg stated that:
"the Commission knows the two positions, where the visor and 'Estonia' sank. From the distance between the two points can the course and the speed of the ship be calculated".
The reader is referred to figure 2.23. According to Forssberg the course of the ship at the accident was 90° (i.e. due East!) and the speed was 1 570 meter in 40-45 minutes i.e. about 1 knot! Was 'Estonia' underway between Tallinn and Stockholm in these circumstances? In the Final Report (13) the ship changes course 180° to port after losing the visor 4.20.
The visor was salvaged end November and brought to Hangö, Finland, where it can still be seen today. No efforts to preserve or protect the visor were taken.
A diving survey of the wreck was carried out December 3 and 4, 1994 by the Norwegian company Rockwater A/S for a cost exceeding US$ 1 million. The Swedish maritime authority paid for the survey to establish whether dead bodies and/or the whole wreck could be salvaged. The Commission was invited to inspect the wreck for damages that caused the accident. Stenström was in charge. It seems however that the Commission's survey was done only to confirm its cause of accident 1.11. Below items have been established based on different sources.
(i) Three bodies on the bridge were never identified 1.22.
1.15 The Meeting December 15, 1994
The Commission met at Stockholm, December 15, 1994. The Commission then confirmed in point 3 of the Press Release (5) that the strength of the locking devices for the bow visor in combination with the sea load on the visor in the prevailing wave condition and headway of the ship is the main cause of the accident. Point 5 of the Press Release is quoted in its entirety here:
5. The diving investigation carried out on the wreck has revealed that the ramp was locked in closed position prior to the accident. After loss of the visor the ramp has been significantly more open than the present position on the wreck, at least during some phase of the development of the accident.
How the Commission could have concluded after the diving inspection that the ramp was locked in closed position before the accident is not known. How could divers establish how the ramp had been locked nine weeks earlier? As shown above the divers did not even examine the inside of the forward ramp, where the locks are located 1.14 (v) and (xi).
It is not known how the Commission managed to conclude that 'the ramp has been more open than found at the bottom of the sea, at least during some phase of the development of the accident'. This statement is very odd - according to the second interim report 1.11.4 we should believe that the inner ramp opened up more during the accident than found at the bottom, whatever that means, allowed 1 100 tons of water to enter the garage so the 'Estonia' listed suddenly 18-20°, and then, when the vessel was still afloat or had sunk - we do not know what 'at least during some phase of the developments of the accident' means - we are told that the ramp closed again to a partly open position, 2.19 and 2.21.
Note August 2000 - later observations of the underwater videos tend to confirm that the ramp was (a) not locked before departure (it was held back by ropes) and (b) had never been pulled open by the visor. The reason why the Commission on December 15 stated that the ramp had opened up completely and then closed itself during the accident was that sufficient water to sudden list the ship could not enter a partly open ramp - it had to be fully open. But the JAIC did not then understand that the 'Estonia' would tip upside down within seconds with a fully open ramp.
Another remarkable thing about item 3 of the press release December 15, 1994, is that it states that the strength of the locking devices is the main cause of the accident. However, it was not until December 19, 1994, that the Commission ordered the Royal Institute of Technology, Stockholm, to carry out a very limited strength analysis of the visor locking devices (6). The result of this analysis was only ready much later and was still not completed 24 months later 1.21.
The request by the Commission is quite revealing how the dive survey was cut short. The Royal Institute was requested to investigate the plates of the visor, where the side lock lugs were welded. Then it says: 'The lugs remain on the wreck and cannot further be examined'. You wonder why these small lugs, which apparently were detached from the visor, and the locking bolt and the hull lugs had not been brought up to the surface for examination by the divers! In a previous letter (7) from the Finnish materials and structural integrity company VTT dated November 29, 1994, i.e. four days before the dive survey was done, it was suggested and the suggestion is underlined/bold in the letter:
"For complete investigation and modelling, the side locking lugs and broken halves of the Atlantic lock should be recovered from the wreck."
However, the Commission decided to leave these vital parts of the investigation at the bottom of the sea. It means that the Commission could not determine the condition of the side locks just before the accident, which shows the incompetence of the Commission.
To do a strength analysis of the visor locks, apart from establishing the actual 'as is' condition of the locks, it is first necessary to establish the environment where the locks were used and the loads (demand) applied on the locks. The weather was not very severe (SW force 7). It seems that only a very rudimentary (hydrodynamic) load calculation was done of the total load on the visor by a periodic hydrodynamic wave load. However such a simple estimation does not say how much load is transmitted by each lock, each hinge and each of all the other contact points of the visor to the hull and in what order the locks and hinges break.
In this case the Commission only assumed that an external periodic load acted on the visor in the upward and aft directions. The Commission never investigated if the load could have been internal (added weight of water that had leaked into the visor as suggested by the Germans) acting downward and forward. The Commission never thought that the load might have been sideways (transient impactive load = 10 times bigger than any external periodic wave load) when the vessel was already listing.
When the strength analysis is finished you have to check the result against criteria of acceptance. If the strength does not meet the criteria, there is failure.
There are two types of failure - fractures and ductile failure.
Fractures occur at lower excessive loads. Ductile failure (deformation, rupture) occurs when the load is really excessive. In this case the Commission stated that ductile failure had occurred, i.e. the loads had been excessive tension and the connections of the locks had been ripped apart.
The Commission never answered the obvious question, why the locks had never only fractured and/or deformed earlier under less severe loads, if the design of the locks was so bad as alleged. No check of fractures was ever done.
Anyway, the 'strength analysis' was just window dressing by the Commission, as it had already stated its result before it was ordered to be done by the Royal Institute of Technology.
The Part-Report, April 1995, is a technical document (9). It is the only part-report ever issued by the Commission. As it was known before the Part-Report was issued, that it declared the builder of the 'Estonia' responsible for the design and manufacture of the alleged faulty locks, the shipyard had some time earlier suggested to the Commission that the visor may have separated from the ship due to another cause. The shipyard simply stated that the maintenance of the visor had been deficient during the fourteen years after the ship was delivered and that the strength of the visor outfit had suffered. It added that due to bad maintenance the visor was leaking, that it then filled up with water during heavy weather, and that the weight of the water might have broken the hinges of the visor and that then the visor tipped forward and broke the locks, etc. The Commission dismissed this theory without comments. Instead, the Part-Report said:
'The Commission has previously concluded that the accident was initiated by the locking devices for the bow visor being unable to withstand the loads imposed during the prevailing speed, heading and sea conditions. This conclusion is still valid'.
'The content of the current Part-Report may be amended and editorially modified as part of the Final Report, but it is anticipated that all facts and conclusions reported herein will remain unchanged in substance'.
It was now only six months after the accident. The Commission had explained everything in the open, but the public had had no possibility to evaluate what the Commission had said. The extra-ordinary cause of accident declared only nineteen traumatic days after the accident was upheld as truth. The visor had separated from the vessel when it was underway (vessel was otherwise un-damaged) at 01.15 hrs. Water had entered at the inner ramp (even if the ramp was found virtually closed on the wreck). The vessel had capsized, i.e. turned belly up, and had sunk (while all survivors had only suddenly experienced an abrupt list to 50° starboard, after which the vessel re-gained stability at 15° starboard list and only slowly sank permitting over 230 persons to abandon the ship and 137 to survive). Everyone expected the Final Report to be a formality to be published a few months later as promised.
But the Final Report was still not published 30 months later.
The Part-Report was very easy to criticise.
· It did not explain why the visor was lost 1 570 metres West of the wreck and the ship's course and speed before and after the accident 1.13.
On 14 April 1995 the author wrote for the first time to the Commission to protest against the quick conclusions. The Commission never replied.
After the Part-Report was issued nothing really happened apart from people resigning from the Commission 1.18. The Commission met about 20 times. The Commission now and then (six times!) stated that the Final Report was going to be published, e.g. September 1995, beginning 1996, July 1, 1996, end of 1996, February 1997, etc. The absolute final meeting to agree the final report was March 12, 1997. The Commission met, agreed the report and went home. On October 24, 1997 Uno Laur informed (Lloyd's List) that the Final Report was to be published in early December 1997. The Final Report was published December 3, 1997 chapter 4.
Enn Neidre resigned from the Commission in April 1996, and was replaced by Mr. Priit Männik, a senior security police chief in Estonia. Mr Männik had led the interviews of all Estonian crew and survivors in 1994. Mr. Männik was forced to resign in his turn November 5, 1997 and was replaced by Jaan Metsaveer, a professor and expert to the Commission.
Andi Meister resigned from the Commission in July 1996, and was replaced by Mr. Heino Jaakula, a naval architect and expert of the Commission. Mr. Meister accused the Swedish members of the Commission to have manipulated the video films taken of the wreck by divers and ROVs 1.23. The Commission was then without chairman. During the autumn 1996 the President of Estonia appointed Uno Laur as chairman.
Börje Stenström died end February 1997. It was indicated that Dr. Michael Huss, of the Royal Institute of Technology, tockholm, and expert to JAIC would conclude the work of Stenström.
Olof Forssberg resigned in May 1997 after having admitted that he had lied about a letter he mishandled as director general of the Swedish Accident Investigation Board (SHK). Forssberg also resigned as director general from the SHK. Forssberg and Stenström were replaced by Mrs. Ann-Louise Eksborg, new director general of the SHK, and Mr. Noord, a master mariner and expert of JAIC. It is noteworthy that Forssberg, after admitting lying, was offered a new job with the Swedish government keeping his salary and title.
Mr. Bengt Schager, Introduction and 1.19, resigned as expert (of psychology) from the Commission in September 1997. Schager did not believe any longer in the Commission's findings according to newspapers. It was never clear what an expert of psychology was doing in the investigation. Mr. Schager was appointed an expert to the Commission directly by the Swedish government at an hourly rate of USD 250:- per hour and his total bill was about USD 700 000:- before he resigned (Swedish newspaper Expressen 971016). His input to the investigation has never been explained. It seems that he spent most of the time 'editing' survivors' testimonies, 4.7 and (12).
The Commission based its theory mainly on statements given by two surviving crew members - 3/E Treu and fire patrol man Linde. Statements from other survivors, crew and passengers, were completely ignored by the Commission. Both crew members talked to the press after the accident and described what happened aboard before, during and after the accident. These 'virgin' statements do not support the theory of the Commission.
Linde told Swedish newspaper Dagens Nyheter October 7, 1994, that he made the fire patrol and experienced a heavy impact in the garage, 1.22 and 4.7. Later, when he was back on the bridge, there was a telephone call about water on deck no. 1, which Linde was sent down to check.
Later, in March 1995, when questioned by the Commission, Linde was telling a completely different story. Now the telephone call was about noise at the inner ramp and that Linde was ordered down to check the garage! The problem, the time and the persons on the bridge have changed. The modified statement was meant to fit the theory of the Commission. Then of course, as Linde was not telling the truth, his statement became very contradictory and unbelievable. It is strange that the Commission members doing the interview or questioning did not ask Linde about what he had told Dagens Nyheter, about telling the truth or about having been told to change his statement to fit the Commission's theory.
Treu's case is similar. After the accident he told a story, evidently to fit the Commission's theory. However, Treu and Linde had not co-ordinated their new stories to fit each other - therefore Treu and Linde contradicted each other 4.7.
The author read Dagens Nyheter early October 1994 and Linde's original story, and used it as one little support for my accident theory. When the writer approached an expert of the Commission (Schager), he was told that Linde had given a completely different story to the Commission! That Treu and Linde contradict each other is public knowledge. The interested reader may refer to other sources (10) i.e. Jörle/Hellberg, 'Katastrofkurs' ISBN 91-27-05715-1.
There is no doubt that the two crew members have changed their early statements about the accident to the media into something else later, which 'better fits' the theory of the Commission.
Addendum January 2001 - the reason for the changed statements is probably the following. When the surviving crew first came ashore they were apparently told to say on the 28 September that they had all seen the visor already missing from the ship when they abandoned it at about 01.30 hrs. However, when the wreck was located on the 30 September the visor was apparently found still hanging on starboard below the bow, where the ship had finally sunk at 01.32-01.36 hrs, a few minutes after they had left the ship. It naturally meant that the false statements would be revealed if the finding of the visor became known, so (a) the crew statements were adjusted a little and (b) the finding of the visor was kept secret 1.22 and the visor was later removed from the wreck by explosives and pulling but salvaged at the wreck! It is very likely that watch keeping AB Linde's first statement is correct i.e. that he was sent down long before 01.00 hrs to check leakage below waterline into the ship and that the sudden listing occurred at 01.02 hrs as a majority of survivors stated. Actually - Linde may have discovered the leakage in the first place earlier -and reported it - and the crew including Treu and Sillaste was working to stop it - however, Linde described it only as a sudden impact when he was on the car deck. Later Linde may have been sent down again to see how the preventive work progressed when the listing occurred).
It is strange that the members and experts of the Commission did not discover the contradictions given by these key witnesses. Of course the Commission used the altered statements to support its theory, but it may not have been aware that the statements then had been modified.
The Final Report (13) should of course report all the different statements given by Linde and Treu as reported in the press in October, 1994, to the Estonian security police (Mr Männik 1.9) and the final statements given by the same people to the Commission in March, 1995. In reality the Final Report (13) does not mention Linde's statement to DN.
The statements given by passengers and most other crew have apparently also been modified 4.7. Disregarding the testimonies that do not contribute at all to finding the cause of the accident, there are very few statements by the passengers supporting the theory of the Commission. This should also be clear in the Final Report, if it included the complete statements given by passengers. In fact the Final Report only includes 'edited' testimonies of the passengers 4.7.
The Final Report (13) was apparently agreed in March 1997 and was supposed to be published end May, beginning June 1997. However, then Forssberg 1.18 resigned in May and the Final Report was postponed. It was rumoured that it was going to be published in December 1997.
For over three years the Commission had only mentioned one cause of accident, which was established seven dramatic days after the accident 1.4. All work was then done only to confirm the Commission's implied proximate cause of accident. The Final Report (13) does not even mention any other possible causes.
The Commission never made public any other possible causes of the accident or that it has discussed any other cause of accident.
Experts of the Commission told me that it has discussed other theories. When the writer asked for details, he was met by silence.
It seems that most information published by the Commission does not stand detailed scrutiny and that the Commission can not admit it. The Commission adhered to its statement in the Part Report 1.17 - all facts (sic!) remained unchanged. This was confirmed when the Final report was published chapter 4. Nothing was changed from what had been said already October 4, 1994, 1.4.
Mr Lehtola said (Lloyd's List December 4, 1996) that the Commission's final report manuscript should be ready for release by February (1997).
Mr Lehtola also said:
'It is very possible the structure of the bow visor was not as good as it should have been. We have carried out a lot of calculations, and we have more still to do. I cannot really comment more - the results are not yet in and it is too early to draw final conclusions' .
Thus two months before the manuscript should be ready for release, 'we (the Commission) have still more (calculations) to do',....'the results are not yet in... too early to draw final conclusions'. This was said 20 months after the Part-Report was published in April 1995 1.17 and 24 months after the strength analysis was ordered to be done by the Royal Institute of Technology at Stockholm 1.16. Ten months after Lehtola made his statement no Final Report had been published.
The statement of Lehtola was quite revealing. The reason the report was stopped in 1996 was that the German group of Experts presented its findings to the Commission in August 1996. The Germans showed that the maintenance and the condition of the visor were bad. The Commission had evidently not checked the maintenance and condition of the visor and did not know what to do - more work was necessary. But no more work was done - no new technical reports about the visor were handed in and filed with the Commission after the pathetic statement of Lehtola (the record of reports, etc. was public - the reports themselves were secret). In the end JAIC gave up and decided to publish its Final Report (13), where the visor was in perfect condition but incorrectly designed before the accident 4.6.
Note August 2000 - actually the Commission met frequently between March-December 1997 modifying and changing the Final Report (13) written by an unknown ghot writer, which explains the many contradictions in the Final Report. No manuscript of the Final report dated March 1997 exists.
The first version is as follows:- In Dagens Nyheter October 7, 1994, in the interview of Linde by an Estonian speaking Swedish reporter, it is said that fire patrol man Linde was at 00.30 hrs in the garage when he experienced that the vessel suffered a heavy impact, so that Linde fell to the deck. Linde contacted the bridge by talkie-walkie and reported the incident and was told to check the forward ramp and to continue the fire patrol round.
Linde found nothing wrong at the ramp, he continued his patrol round and returned to the bridge at 00.40 hrs, where he reported to 2/0 Peeter Kannussaar and saw 3/0 Andres Tammes and the Master (Arvo Andresson).
Linde also noted that the vessel's speed was 15 knots. At about 00.45 hrs there was a telephone call to the bridge taken by 2/0 Kannussaar. It was about the presence of water on deck no. 1. Kannussaar told Linde to go down and check deck no. 1. Linde descended the forward stairway and reached deck no. 4 level, where the stairway is reduced in width down to deck no. 1. There Linde met many passengers from deck no. 1 saying that there was water on deck no. 1. Linde could not go down against the flow of passengers. Linde contacted the bridge by way of talkie-walkie and reported this. The abrupt listing 50° to starboard and back to upright and to equilibrium at 15° starboard list occurred soon thereafter. Linde then reached deck no. 7 and assisted passengers into liferafts.
According to MÖ 2.12 the abrupt listing took place at 01.02 hrs.
In a second statement to the Commission Linde stated another version to the effect that he was in the garage much later (10). He experienced the heavy impact, reported it by talkie-walki to the bridge (2/0 Kannussaar) and was told to check the forward ramp for five minutes. Linde did not notice anything suspicious. He then returned to the bridge where he met 2/0 Tormi Ainsalu and 4/0 Kaimar Kikas. (The reason for this was that the watch had been changed at 01.00 hrs. Note also that 'Estonia' had two second officers (2/0), Kannussaar and Ainsalu).
Linde stated clearly to the Commission that 2/0 Kannussaar and 3/0 Tammes had left the bridge and he did not mention the presence of the Master. The time was thus after 01.00 hrs.
According to the second statement Linde was then on the bridge a few minutes, when there was a telephone call taken by 2/0 Ainsalu. The call was about strange noises at the inner ramp and Linde was ordered to go down to the cardeck and check. He descended the stairway and reached deck no. 5 level and asked the reception to open the fire doors to the garage. Then there was the abrupt list 20° to starboard. And then the passengers started to escape from deck no. 1 saying there was water on deck no. 1. Linde followed the passengers to deck no. 7 and, there he reported by talkie-walkie to the bridge (2/0 Ainsalu), that there was water on deck no. 1.
After Linde left the bridge to attend the emergency in the garage, the Commission suggested that the Master visited the bridge at 01.07 hrs (Lloyd's List March 17, 1997). The Master is quoted to have said 'we are one hour late' and then he left. How the Commission knows this is not known to the writer. All persons on the bridge at that time, whoever they were, are dead, and according to many passengers, the vessel was already listing since 01.02 hrs.
3/E Treu has told the Commission that he overheard the last conversation between Linde on deck no. 7 and 2/0 Ainsalu on his talkie-walkie/portable VHF unit in the engine control room. Treu states that Linde told Ainsalu that 'there was water in the garage', not on deck no. 1 as Linde stated. Treu has also told the Commission that he (Treu) saw water entering the garage at the forward ramp at 01.15 hrs. Treu is the star witness of the Commission. It is his statement the Commission refers to in 1.11.1. The abrupt listing should then have taken place after 01.15 hrs. 3/E Treu has also stated to the Commission that, after the abrupt listing had occurred, he talked to 4/0 Kaimar Kikas on the bridge about the possibility to shift ballast in order to reduce the listing caused by free water in the garage (sic!). This conversation took place between 01.20 and 01.25 hrs. There are two possibilities:
1. The abrupt listing took place at 01.02 hrs and it is likely that 2/0 Peeter Kannussaar, 3/0 Andres Tammes and the Master Andresson were on the bridge at that time, as Linde had left them there a few minutes earlier. However 3/0 Tammes' body has been found in the Baltic.
2. The abrupt listing took place after 01.15 hrs and 2/0 Tormi Ainasalu and 4/0 Kaimar Kikas were on the bridge as Linde has told the Commission in his second statement and which is confirmed by 3/0 Treu who had (a) heard Linde (on deck no. 7) talk to Ainsalu (on the bridge) via talkie-walkie/VHF and (b) had talked to Kikas on the bridge on the phone later. The question may be answered by 'Who sent the Mayday at 01.22 hrs?'
At 01.22 hrs there was a first Mayday by VHF (Channel 16) from 'Estonia' received by M/S Mariella. The Commission states that the desperate caller is 2/0 Tormi Ainsalu. The total communication is 2 minutes and 9 seconds long with many interruptions and of no real value (10).
Then the first caller is replaced by 3/0 Andres Tammes at 01.24 hrs. The communication is now clear and orderly 1.11.8. Tammes gives the position of 'Estonia'. The voice of Andres Tammes has been identified by both Treu and Linde and others on the recording of the transmission, where in the background also the voice of 1/0 Juhan Herma has been identified, when it calls out the position. At 01.30,06 hrs the transmission was broken (10).
It is therefore quite clear that 3/0 Tammes and 1/0 Herma were on the bridge. (The body of Tammes was later found in the Baltic. He thus managed to get out of the bridge).
There are three bodies on the bridge. The Commission assumes they are 1/0 Herma, 2/0 Ainsalu and 4/0 Kikas to support its (and Treu's) cause of accident. It is also possible that they belong to 1/0 Herma, 2/0 Kannussaar and the Master Andresson, and then the Commission's cause of accident is not valid and 3/E Treu is caught lying.
The Commission's diving survey never checked the identities of the bodies.
Note August 2000 - it is now easy to establish that the first version is nearer to the truth than the second version about the times, but that probably both versions do not reflect what actually happened aboard the 'Estonia' during the accident. The writer thinks today that both Linde and Treu lied about what they experienced and that crew members on the bridge survived ... and disappeared.
The various underwater surveys were recorded on video and it is likely that the above question could have been resolved by checking the video films. During 1996 some Estonian members of the Commission accused that the videos had been edited or tampered with by the Swedish members. The matter was dropped after Meister and Neidre had resigned from the Commission.
Considering above you should conclude:
1. The Commission decided the cause of accident only nineteen days after the accident 1.10.
Taking above thirteen points together you reach the surprising conclusion that it is certain that the garage was completely dry when the abrupt listing occurred (at 01.02 hrs). This is not what the Commission wants the public to believe and you should wonder what actually happened.
Immediately after the accident there were reports in the press 1.12.5) that 'Estonia' had changed course before the accident. At the same time Linde and others told the press that there was water on deck no. 1 below the car deck, before the sudden listing occurred. Then the press published corrections about the course change - it was not confirmed - and the Commission published its statement, that water on the car deck caused the accident. Water on deck no. 1 was forgotten. But at that time the Commission had no solid proof at all that there had been water on the car deck. The Final Report (13) does not produce any proof at all that there was water on the car deck, except a statement by 3/E Treu that water came in at 01.15 hrs.
The writer finds it quite extraordinary that nobody within the Commission including the experts and observers has ever questioned the hastily conclusion that there was water on the car deck. Linde never saw any water on the car deck. The systems engineer 1.9 never saw any water on the car deck. He said that the 3/E told him that he saw water on the car deck 4.23. All stability theory says that there could not have been any water on the car deck, 2.16 and 5.5. A ship does not sink with water on the car deck. So what could have happened? Chapter 2 is my suggestion what happened.