Welcome to a chapter of the e-book Disaster Investigation.
1.37 The Work of the Swedish NMA 1994-2001 against better Safety at Sea
The Group of Analysis never examined the Sea Safety Inspection department of the Swedish National Maritime Administration (Sjöfartsinspektionen - Sjöfartsverket). It has the main responsibility of safety at sea in Sweden, i.e. the government and the Ministry of Communications have delegated the responsibility there.
The Sea Safety Inspection at Stockholm had regularly inspected the 'Estonia' at least five times 1993-1994 without noticing any defects and many more times 1980-1992, when the ship sailed under Finnish flag Appendix 7. After the accident 1994 the head of the Sea Safety Inspection Mr Bengt Erik Stenmark resigned quickly. Why? What does he do today?81
The Group of Analysis should have reviewed what happened at the Sea Safety Inspection department of the NMA. As interim head Mr Roger Sundström was appointed, who apparently did not want or was not permitted to become regular head. Why? After a while -early 1995 - the government appointed the head of the legal department, Mr Johan Franson as head of the Sea Safety Inspection department 1.16. The Group of Analysis had severely criticized Franson for various investigations about the 'Estonia' and now Franson was head of the Sea Safety Inspection department! Why? Franson knew absolutely nothing about safety at sea. Safety at sea is means, procedures, arrangements and equipment to reduce the probability for accidents at sea and is best handled by seafarers, master mariners, naval architects, safety experts - not a legal mind (who has never been to sea).
One of the first decisions of Franson was to prevent the staff of the Sea Safety Inspection department to publicly discuss the safety and stability of the 'Estonia' particularly that ferries floats on their hulls and that water on the car deck in the superstructure above the hull heels the hull until it capsizes and floats upside down.
The Group of Analysis should have examined why the Swedish civil servants responsible for safety at sea in Sweden were ordered not to discuss the matter of buoyancy and stability. It should have been clear to anybody that Swedish Port State Control should have informed the owners of the 'Estonia's already in 1993 (and the previous owners 1980-1992) that she was incorrectly equipped for trading across the Baltic and that she must be upgraded. But the Swedish NMA (Franson) had always stated that the 'Estonia' complied with all safety rules, etc., which the Sea Safety Inspection department at Stockholm had confirmed at least five times at PSCs 1993-1994. There was no reason to criticize the NMA according Franson (sic) - the legal counsel of the NMA. And the Swedish NMA staff was apparently happy - they had naturally made some errors on the job - it happens frequently - and now they had a boss who protected them by lying without shame about it.
What has the NMA done to improve safety at sea since the accident? Has it done anything, which could have prevented the accident? The Group of Analysis should have reviewed the matter.
The Swedish NMA (Franson) has, e.g. voted for new rules at the IMO, 1995 (see also chapter 5 of the book Lies and Truths ... ). None of the rule changes would have prevented the 'Estonia' accident. Many of the rule changes do not even improve safety. Many rule changes are badly written causing interpretation problems. No rule change was done as per the IMO procedures.
Fast Rescue Boats
A new rule is that all ferries of type the 'Estonia' shall have a fast rescue boat.
Could a fast rescue boat on ferries assisting the 'Estonia' have rescued any persons in the water? No - it could not have been launched nor recovered. It is very embarrassing. The IMO states in its new rules that the fast rescue boat on a ferry shall only be able to be launched and recovered in 'severe' weather. But the IMO defines 'severe' weather as Beaufort 6 and wave height 3 meters (which is not very severe), while the 'Estonia' accident took place at Beaufort 7+ and wave heights >4 meters. It would of course have been better to specify that existing lifesaving equipment on any ship can be launched (but not recovered) in Beaufort 7.
Another rule the NMA has voted for is that all ferries of the 'Estonia' type (but no other types of ships) shall have means to rescue survivors in the water.
What the means shall consist of is not clear. Cargo ships, tankers, passenger ships shall not have any means to rescue survivors in the water - only ferries. Has the Swedish NMA developed any ideas how to fulfil the rules? No! Yes - maybe - a net at the side of the ferry - the survivor shall jump into the ice cold water and swim to the net and climb up 20 meters on the side of the assisting ferry. Marvellous!
Actually the Swedish NMA has not done any serious contribution to safety at sea since 1994. It has only been interested to cover up past sins - particularly about the 'Estonia'.
The Stockholm Agreement
The Swedish NMA worked hard for the so-called Stockholm agreement (Res. 14, annex 5, page 535 SOLAS 97 edition) but it was rejected by the IMO. It was instead made a local rule in North Europe by bi-lateral treaties. The Stockholm agreement 3.21 requires installation of doors on the car deck of a ferry to improve stability with a theoretical amount of water on the car deck in the superstructure (albeit after a collision (sic) and after two compartments flooding of the hull (sic) and when all this occurs in 'severe' weather (sic) - a very low probability - and with the further assumption that no preventive measures are taken, e.g. listing the damaged vessel on the undamaged side). The ship is then assumed to roll with the damaged side towards the waves. Water is then assumed to flow up into the superstructure according to some theoretical rules - which causes the ship to capsize. To prevent this transverse doors must be fitted inside the superstructure. The alternative is to do model tests (under similar assumptions) to see what happens. Model tests showed that the theoretical assumptions in the Stockholm agreement rules were wrong - model tests showed that much less water entered, when the damage ferry was helplessly rolling with a hole in the side (sic) and that often no doors were required on the car deck. Model tests also showed that with little seamanship of the crew - heeling the ferry so that the damaged side came higher above the water, or turning the ferry with the damaged side in the lee - would prevent any inflow at all. Systematic model tests have later shown that the scientific background of the Stockholm agreement is totally wrong. Those ship owners - mostly Norwegian - which invested hundreds of millions to fit doors on their car decks made a stupid error - the doors do not improve safety. It is easy to show with FSA.
The Stockholm agreement - and the theoretical rules - were just a ploy by the Swedish NMA to cover up the real cause of the 'Estonia' accident. The Stockholm agreement does not improve safety at sea at all.
Enormous amounts of money have been wasted enforcing the Stockholm agreement.
The NMA Director General resigns
The director general of the NMA, Anders Lindström, resigned or retired after the Final report (5) was published and the Stockholm agreement was adopted.
In 1999 the Swedish government appointed Jan Olof Selén as new director general. He knows very little about safety at sea too - he was legal head at the Ministry of Transport 1994/5 and stopped the salvage of bodies from the 'Estonia' and developed the law preventing diving to the wreck 1.19.
Mr Ulf Hobro, the safety superintendent of the 'Estonia' 1994 became head of the Stockholm Sea Safety Inspection department in 1999. Mr Sjöblom who made the last inspection of the 'Estonia' at Tallinn 27 September became head of the Sea Safety Inspection department at Gothenburg. Dr. Huss 1.9 was made head of the Technical Department of the NMA in April 2001.
The above 'experts' of the Swedish NMA always state that all information in this book does not contribute to better safety at sea. Actually it is quite sad - many persons that contributed to the 'Estonia' accident 1994 or assisted in the cover up of the truth and the falsification of History 1994-1997 are now, 2001, working in leading positions at the Sea Safety Inspection department of the Swedish NMA! Couldn't they have been given jobs elsewhere Preamble?
The Swedish NMA has 1994-2001 actively contributed to the cover-up of the 'Estonia' accident and has not made any positive contribution to better safety at sea. On the contrary - as the initiator and writer of the Stockholm agreement, which is based on false theoretical rules and assumptions - the Swedish NMA has ensured that enormous amounts of money has been wasted on totally worthless modifications of ferries.
The Group of Analysis never investigated the Swedish NMA involvement of the 'Estonia' cover up.
81 He studies at the University at Luleå. He has never replied to any letters from the writer to find out what happened at the NMA and to comment upon the observations in this book. Apparently Stenmark was an honest man - he was kicked out to make place for a smoother boss - Franson. But Stenmark has not complained. Instead he wrote a pathetic thesis entitled about "Sjösäkerhet och säkerhetsstyrning: om säkerhetskulturen på ett fartyg och i ett rederi: en kulturpsykologisk fallbeskrivning" (2000-04-26) ISSN 1402-1757 / ISRN LTU-LIC--00/11--SE / NR 2000:11 (Safety at sea and governing safety: about the culture of safety on a ship and in a shipping company: a cultural psychological case description). Stenmark summarizes his thesis:
""Safety Culture" is a concept, which during recent years has been mentioned related to maritime safety as a meta-aspect but without a comprehensive definition. This study aims at finding a workable definition of safety culture within a framework of organisational psychology.
The research method was built upon a base of literature studies. The task was to perform a case study of a shipping company and one of its ships. An important element of the study was to examine how the ISM code complied with the organizational culture of the company during the implementation of the code.
The case study consists of five sub cases, chosen from work situations guided by the perspective of "critical incidents" and "generative themes". The research task was systematised into five subcases.
The research method implied the researcher's presence onboard during a voyage. During the voyage interviews with the crew members were carried out. Sequences of work were documented by video recording and were completed by field observations and walking around observations. Observant participating in meetings and crewmembers' professional and social conversation took place. Relevant correspondence and documentation were also analysed. Daily meetings with the ship management were performed to consolidate the observations made.
The company's head office was visited twice in order to obtain a holistic view of the interaction between shipboard management and central management functions ashore and to follow up findings from the study.
The analytical work was composed of an iterative process of alternating collecting of data writing down field notes listening to recorded interviews, watching video films combined with reflection and talk within the research team. The final synthesis was the integration of the data in an explanatory framework. The conceptual or explanatory framework reflects the cultural psychological view that culture is composed of artefacts, espoused values and basic assumptions, which together are governing the actions of the involved subjects. The analysis of the cases has also included elements of the cultural historical activity theory. Finally, the safety culture is described by eight dimensions. These dimensions express a qualitative estimation of a safety culture. They are dualistic i.e. they can be given "positive" or "negative" values with respect to an overall hypothetical concept of "good safety culture".
This way to describe the safety culture is workable as language in a learning context when presenting and explaining the elements of the safety culture to the members of the organisation.
Starting from the experiences, obtained from the above mentioned interventions in the onboard organisation, learning models are designed to understand and change the safety culture.
As the study was performed in a shipping company, submitted to the culture of today, the question of future validity arises. Organisation has been defined as relations between organisation as members. If these relations are changing to other kinds of relations by information technology, will the cultural conditions of today's learning organisation still remain? This is the question, which is proposed as a task for further research work." As a grave stone on the 'Estonia' it is not too bad. But Stenmark never dared to comment about this writers's findings.