'Also the uselessness of lifeboats and poor condition of davits, the improvements of which should certainly be recommended, was pointed out. There are also suggestions that the life rafts should be improved in many ways'
Paragraph 11 of act A208*
'A ship is seaworthy only if it designed, built and maintained so that in respect of its purpose and the trade it sails offers adequate safety against accidents"
Swedish law for safety at sea (SFS 1988:49) 28 January 1988 - Chapter 2, 1§
'V. Observations of the Committee with regards to issues falling beyond the scope of the functions of the Investigation Committee.
…
It remains to be seen why the JAIC and the criminal proceedings have not paid attention to issues related to the certification of the ship. These questions inter alia include: on what grounds was a certificate confirming seaworthiness of the ferry Estonia issued? Did the vessel actually meet all the technical requirements giving the right to sail in deep waters? How can one assess the expert evaluations of the technical state of the vessel produced at that time? The fact that a vessel possessing a coastal navigation right was at a certain point granted the +I 3/3 E, Deep Sea, Ice IA, Car/Passenger Ferry + (AUT) certificate gives rise to questions.
It is known that the Maritime Safety Administration of Finland granted the ship a passenger ship sea safety certificate which allowed the ship to sail in coastal waters.
Until 14 January 1993 the maritime safety of the ship was monitored by the (Finnish) Maritime Administration. Bureau Veritas was then authorized to monitor the technical condition of the vessel and its compliance with the international requirements. After the date mentioned above the responsibility for the technical condition of the ship was placed upon the Maritime Agency of Estonia which extended the authorization of Bureau Veritas to exercise control over the maritime safety of the vessel in accordance with SOLAS and other international maritime safety conventions.
The Committee believes that in the light of the last seaworthiness certificate issued the technical compliance of the ferry Estonia requires further clarification: on what grounds was the ferry Estonia granted seaworthiness certificates? Did the ferry Estonia meet all the technical requirements to have the right to navigate in the deep sea? What evaluations did the experts then give to the technical condition of the vessel?
…
VII Proposals to the Government of the Republic
1. Propose to the Government of the Republic to ensure the complete involvement of the Republic of Estonia in current and future investigations of the ferry Estonia. The Government of the Republic must find ways to ensure complete cooperation with the Government and agencies of the Kingdom of Sweden, in order to ensure access to all relevant materials and information.
2. Propose to the Government of the Republic to create necessary legal mechanisms for investigating into catastrophes so that a Catastrophe Committee could be founded, whose members would be able to carry out investigation, when necessary, on temporary full-time basis.
3. Proceeding from the fact that several persons who allegedly survived the catastrophe of the ferry Estonia are still missing, and taking into account the fact that they might have important information concerning the ferry Estonia.'
Riigikogu Committee of Investigation to Ascertain the Circumstances Related to the Export of Military Equipment from the Territory of the Republic of Estonia on the Ferry Estonia in 1994 - FINAL REPORT - (Tallinn, 19 December 2006)
1.33 No Lifeboat Alarm. Incorrect Life Saving Equipment. Invalid Certificates - all censored
The Final Report (5) contains many strange things but in chapter 4.4.2 it correctly states that the lifeboat alarm consists of seven short sound signals followed by a long, which is repeatedly given by alarm bells (inside the ship) and/or with the vessel's horn (on open deck). You cannot avoid hearing such an alarm, unless you are deaf. But the Final report does not clarify, if the passengers or crew (sic) ever understood, what such an alarm meant.
Let's assume that such an alarm - lifeboat alarm - was raised - seven signals - horns or bells - and then a long signal - repeated several times several minutes! It must have made a lot of noise. Did the passengers understand what it was all about? Had anybody told them? Did they know that they were supposed to calmly proceed to the muster stations (with their life jackets, if they had been in a cabin), where the crew would accompany them to lifeboats and life rafts? Did the crew understand that some of them would inspect/check all cabins for passengers and tell them to proceed to the muster stations? Did other crew understand that they should proceed to the lifeboats and life rafts and make them ready for launching? Had this big evacuation of 2 000 passengers by 186 crew ever been trained?
Chapter 1 of the Final report (5)says that three alarms were given - at 01.20 hrs an alarm in Estonian "Häire, häire …" over the public address system (loud speakers) (i.e. ALARM, ALARM in Estonian), followed by a spoken crew (fire) alarm (sic) message 'Mr. Skylight …', also via the public address system.
Then at about 01.22 hrs the lifeboat alarm was sounded by bells and horn which must have lasted several minutes and made a lot of noise without any public address call.
What could a normal passenger, who had been on the ship a couple of hours, make out of all that, when the ship was already listing since five, seven minutes?
That he should collect his life west in his cabin and then proceed to a 'muster' station somewhere? Of course not!
Two different Alarms were allegedly sent
What would the crew believe after the sudden listing at 01.15 hrs?
First an irregular alarm - "Häire, häire ... " and then a fire alarm (sic) - 'Mr Skylight ...' at 01.20 hrs! The latter meant, in fact, that some crew should proceed to the fire stations and to fight a fire, and that some other crew should ensure that affected passengers - in the fire zone - were moved to safety in the adjacent fire zone.
Confusing?
The Commission had - after three years of deliberations - no comment at all that two different alarms were sent sending the crew - and passengers - into different directions when the ship was listing >20 degrees. And then a life boat alarm at 01.22 hrs when the ship was listing 35 degrees. Actually, the Commission never interrogated any crew members or passengers about the alarms at all. The fairy tale of the 'life-boat-alarm' was just an invention of the writer of the Final report (5) to make it appear more credible.
On an over-night (12 hours trip) ferry like the 'Estonia', where you apparently do not practice any safety systems with the passengers, you cannot just start ringing bells or blowing horns for several minutes and assume that anybody understands what it is all about. You have to explain - in pure language - over the public address system, what is happening. But nobody on the 'Estonia' explained anything to the passengers over the loud speakers at any time. And anyway - in this case most passengers were already running up to the open decks, when the alleged 'alarms' were raised.
On any passenger aeroplane - even if the flight is only 45 minutes - there is a short safety announcement, what to do in an emergency - a forced landing or loss of air pressure. On the 'Estonia' there was nothing. The passengers should only know two things - (A) the general alarm (bells + public information call) - and that they then should proceed to the muster stations with their life jackets and (B) what a life jacket is - and how to put it on. It should have taken two, three minutes to explain, but it was not done. Many years later the same procedures are used on most Swedish short-sea ferries. No safety announcements at all.
In the unlikely event that a fire has started inside a muster station, crew members evidently have to direct the passengers to a safe zone adjacent to the fire/muster zone. Abandonment of the ship is then not urgent - the urgent matter is to extinguish the fire after having protected the passengers.
The Lifeboat Alarm
Chapter 16.3 of the Final report (5) says that the lifeboat/general alarm - bells ringing, horn blowing - was given about 01.22 hrs - not followed by any public address information. Then the angle of list was 35 degrees according figure 13.2 in (5) 1.9. It means of course that the 'alarm' was much too late. At 35 degrees list it was impossible to launch the port side lifeboats resting inboard against the ship and davits - but the starboard boats could in principle be launched. But to launch the lifeboats you must first muster the passengers. And the passengers were never mustered. They had no idea, what the lifeboat alarm was all about. And did any crew member prepare any lifeboat for launching? The investigators in the Commission believe that it was a good thing that the lifeboat/general alarm was raised by the crew, but they do not investigate, if the alarm was correctly executed and understood.
Who heard the Lifeboat Alarm?
In chapter 6.2.1 in (5) is not stated, if the extra second mate heard it.
In chapter 6.2.2 likewise is not stated, if fire patrolman Linde heard the alarm - the protocols, when he was questioned, do not mention any alarms.
In chapter 6.2.3 3/E Treu states that the lifeboat alarm was sent over the public address system (sic) at 01.22 hrs (probably it was the alarm in the Estonian language) and that the bells were ringing, when he was in the ECR on deck 1. What was 3/E Treu supposed to do when he heard the alarm? He should of course abandon ship and not remain in the ECR!
In chapter 6.2.4 systems engineer Sillaste says that he heard the alarm, when he was in the ECR on deck 1 after the sudden listing. Later he escaped via the stairs up to open deck 8 and heard the alarm by the horn. What was Sillaste supposed to do when he heard the alarm? Abandon ship but orderly - he probably had a function in the overall plan to abandon ship.
In chapter 6.2.5 oiler/motorman Kadak says that 'several lamps flashed' the lifeboat alarm in the ECR on deck 1 and that he soon after was on deck 8. But these people were crewmembers - they should know what a fire and/or life boat alarm is - or? Anyway - they just ignored the alarms and tried to help themselves. Actually - Treu, Sillaste and Kadak have lied about their escape from the ECR so their statements about the alarms cannot be trusted 1.48. The writer believes that the Commission itself had no idea what the life boat/general alarm was, when they interrogated Treu, Sillaste and Kadak, so they just accepted whatever was said and later changed it to suit.
In chapters 6.3.2-9, a summary of testimonies of persons - mostly passengers - on decks 1 and 4-8 and in stairwells and other places inside the ship, it is concluded that no passenger heard any alarm bells inside the ship during the evacuation, i.e. all survivors had reached open deck 7 at 01.22 hrs, when the alarm by bells inside the ship with 35 degrees list was allegedly raised. But would it have mattered? What did the alarm bells mean?
Strangely enough chapter 6.2.10 in the Final report (5) with testimonies from open decks has no confirmation of anybody hearing the lifeboat alarm at 01.22 hrs onwards - repeated horn signals. Passengers on open deck heard the alarm "Häire, häire … ", when the list was 30 degrees. But no passenger heard the ship's horn - seven short blasts and one long!
According chapter 7.3.3 a Mayday was sent at 01.22-01.30 hrs per VHF and then the horn signals should have been heard in the background. But the recording of the Mayday does not include any horn signals. Either the Mayday recording is a fake - like most of the information in the Final report (5) or no horn signals were made. But again - did it matter? Did a passenger understand, what the horn signals meant? Did he/she care? The ship was listing and sinking - and the persons on the open decks at 01.22 hrs had already reached the embarkation places for the lifesaving equipment. They found that the lifesaving equipment could not be used - it was useless.
In chapter 13.2.7 - Evacuation - the Commission repeats that the lifeboat alarm was raised at 01.22 hrs. In chapter 13.3 - Action on the bridge - the Commission regrets that the lifeboat alarm was not raised until five (seven?) minutes after the list developed, and that the lifeboat alarm was given simultaneously with the Mayday. The Commission forgets that no public address message was sent - only a Mayday that evidently could not be heard by the passengers.
The Mayday and the Public Address Call
As the list actually developed already 01.02-01.05 hrs, the alleged lifeboat alarm was 17 minutes late. In that time no public address information was given from the bridge. But in chapter 16.3 - Alarms and activities by the bridge - they say
'Some survivors have reported hearing the alarms, but others report not having heard any alarms at all'.
The alarm that concerned the passengers - the lifeboat alarm - is not particularly mentioned - and an alarm should be followed up by a public address call what is going on. The only survivors hearing the alarms seem to be crewmembers. And they just tried to help themselves!
Assuming that the bells and horn actually were in working order, it is still probable that the lifeboat alarm was never raised. The Commission seems to have deliberated, and then agreed or conspired the statement, that the lifeboat alarm was sent - based on super witness 3/E Treu's testimony. It sounded good - a lifeboat alarm was sent. If the passengers did not understand that, they had to blame themselves.
The only reason why the Final report (5) writes about a lifeboat alarm is to create the appearance that the crew followed some undefined emergency routines. If the passengers actually understood, what the signals with bells and horns meant, is not investigated by the Commission for 38 months! It is clear evidence that the Commission didn't give a damn about what it was supposed to investigate - all causes why so many innocent persons - passengers - died! Instead the Commission only investigated an alleged visor 'design fault' and concluded that the ship and crew were 100% OK. And the Commission got away with such outright lies. Of course the Swedish government helped a lot.
Missing Lifesaving Equipment
Regardless if the lifeboat alarm was raised, the 'Estonia' had only 10 lifeboats for 692 persons and 12 life rafts under davits/cranes for 300 persons - totally 992 persons, in spite of being certified for 2 188 (sic) persons aboard.
The Final Report incorrectly states that the 'Estonia' fulfilled the international safety rules SOLAS.75
The 'Estonia' had also 49 off life rafts SOLAS 60 type, which should be thrown overboard manually or, if it failed, they would automatically release, when the ship came under water after having sunk (sic)! To reach these rafts you were supposed to (1) jump into the water before the ship sank (2) swim to the raft, which might float up after the ship had sunk, and (3) try to get into the raft.
These rafts and routines did not fulfil any requirements of the SOLAS for passenger ships on international voyages. They were totally useless.
They remained since the ship was certified by Finland for coastal trade between Finland and Sweden. Evidently you could not have life rafts on a passenger ships that were supposed to float up after the ship had sunk. Such rafts may be fitted on cargo ships as a last back up in event of sudden sinking. Cargo ships are not built to withstand flooding of a hold and can thus sink quickly, and it is the reason to require SOLAS 60 rafts on such ships.
Cargo ships are crewed by seamen. They may use a SOLAS 60 raft. But can you expect that a 65+ years old passenger on the 'Estonia' shall jump into the water, swim to a raft and try to get into it? The Commission considers that the procedure is correct! Evidently the Commission had no idea about safety at sea and no respect for ferry passengers lives.
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Chapter 17.7.1 in (5) says 'the rafts were were found very difficult to use in the severe sea conditions', and nine reasons for this is given - an illegal raft is shown in figure 17.7 of (5). Such a raft was not of an approved type for passenger ships, when the 'Estonia' changed her trade over the open Baltic in 1993. The life rafts were arranged aboard the
'Estonia' as shown on figure 1.33.1 right. The
picture is of a similar ferry taken year 2002 (
the arrangement is dangerous and useless).
When abandoning the ship, a crew member shall
release the 12 rafts, which then drop freely into
the sea. The raft opens in the water and drifts
away. The passengers shall either jump from the
open deck into the sea or climb down two rope
ladders on the side and the jump into the water.
The passenger shall then swim to the raft and try
to get in! They have to watch out not to be hit by
falling raft. It is certain that the 'Estonia' had an identical arrangement - four stations with 12 off rafts each to drop into the water. The Estonian administration made a serious, criminal error certifying the 'Estonia' with such rafts and arrangements. Had the accident occurred later, e.g. during the winter, when the water temperature was lower, all persons in the ice-cold water would have died immediately. |
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SOLAS 1974 chapter III, rule 27 (c)(iii) (page 153 in SOLAS printed 1975) says 'in any ship engaged on short international voyages the number of persons carried shall not exceed the total capacity of the lifeboats provided, unless the Administration considers that this is necessitated by the volume of traffic...' i.e. in 1975 100% lifeboat capacity was required for short international voyages. But the 'Viking Sally' was only certified for coastal trading with reduced number of lifeboats. |
Figure 1.33.2 - Illegal life raft arrangement - year 2002! |
When the 'Viking Sally' or 'Wasa King' became the 'Estonia' in 1993, the SOLAS had changed - the existing lifeboats with reduced capacity were in order, but the rules also required about 60 life rafts for 25 persons each, which could be launched by at least 10 cranes. But the 'Estonia' had only 12 such life rafts and four cranes.
Åke Sjöblom and Gunnar Zahlér disapprove the Rafts - and do nothing
This defect was discovered by chief inspector Åke Sjöblom and inspector Gunnar Zahlér of the Swedish NMA, at Tallinn only ten hours before the accident (31). They also remarked that the 'Estonia' did not have e.g. an exemption certificate for the irregular (criminal!) life rafts. The 'Estonia' was according Sjöblom/Zahlér incorrectly equipped and certified with regard to life rafts in September 1994 (page 25 in (31)) since February 1993 - 19 months! In 2002 the boss of Sjöblom/Zahlér - Johan Franson - stated in the Swedish Shipping Gazette (March 2002) that Sjöblom/Zahlér had stated to the Commission that there were no defects whatsoever! This is not correct. This is one of Franson's numerous lies.
Åke Sjöblom and Gunnar Zahlér advised the defects to the Commission on 2 November 1994 (act D6a*). The information that the 'Estonia' was not seaworthy was immediately censured by Olof Forssberg and was of course not mentioned in the Final Report (5).
Mr Sjöblom and Mr Zahlér have later stated that they could not have prevented the 'Estonia' leaving Tallinn in her unseaworthy state because they didn't have the power to do so in Estonia. But this is stupid - they should simply have stated that (A) the ferry would be immediately arrested on arrival at Stockholm or (B) that entry to Sweden would have been forbidden or (C) that it would cost more to make the 'Estonia' seaworthy at Stockholm or (D) that the owners were criminal to allow the 'Estonia' sailing in her present state. As incompetent civil servants they did nothing.
Easiest solution would have been reducing the number of people allowed aboard to be the number in available approved boats and rafts until new life raft cranes and correct rafts were fitted. Strange that the life raft supplier never suggested that!
Wet Evacuation
As the 'Estonia' was equipped 1994, the safety system assumed that 1 196 persons jumped overboard and swam ashore at an evacuation of the ship! And this illegal system had been tested and approved by the national maritime adimnistrations 1.34!
It was called 'wet evacuation' and was not approved standard, when the 'Estonia' was certified 1993.
It might have been approved for coastal trade during warm summer months by an incompetent national administration - when you carry more passengers - but not during the winter, when fewer passengers were carried. Who knows?
But 'wet evacuation' was used - year-round. The Commission erroneously considers 'wet evacuation' correct. Then you would expect that the life jackets were at least of an approved type.
The Final Report (5) chapter 17.7.1 says that the life jackets were of an approved type, but does not say who had approved them, when and how, etc. It is very likely that the life jackets were not of any approved type at all. Most survivors reported big difficulties with the jackets. They were ripped off, when the persons jumped into the water. Chapter 21 - Conclusions - and 22 - Recommendations - of the Final Report (5) have no suggestions that correct life jackets would have saved say 50-100 persons. The Commission was only interested to hide these facts.76 It is evidently a big difference between a life jacket that you carry as extra precaution, when you enter a lifeboat or a raft during a dry evacuation, and a life jacket that shall be effective when you first jump into the water from 17 meters above the waterline and then swim to the raft. But could you really expect that an old passenger would jump into the water at all? Or climb down a rope ladder on the side of the ship.
The 'Estonia' 1994 was in many respects a repeat performance of the 'Titanic' in 1912. But this the media could never report - it dutifully reported that the lifesaving equipment was in order. The Swedish director of safety at sea, Johan Franson, has in letters to big Swedish dailies stated that the 'Estonia' life rafts and evacuation procedure were in order.
No Certificates
Chapter 3.6.2 of the Final Report (5) (page 45) states that the 'Estonia' was correctly certified:
"... the status of the certificates were ... an interim Passenger Ship Safety Certificate issued on 26 June 1994. ... interim Load Line Certificate issued on 9 (or 11?) September 1994. ... The valid certificates ... are shown in the Supplement."
However the Supplement does not show the above alleged 'valid' certificates!
The Passenger Ship Safety Certificate
In the Supplement no. 217 is shown a full term Passenger Ship Safety Certificate issued at Copenhagen on 23 (sic) June 1994, however without the 'Record of Equipment (Form P), which is necessary for a valid certificate. This certificate says that ... 2.3 the life saving equipments ... was ... as per the rules. In the Supplement there is another interim Certificate dated 27 January 1994, valid until 27 June 1994, with a Record of Equipment (Form P) dated 14 June 1993, which states that the 'Estonia' was certified to transport 2 000 passengers and that there was life saving equipment for 2 188 persons. However - this was simply not the case.
The Load Line Certificate
There are no Load Line certificates in the Supplement.77
Supplement no. 224 shows surveys carried out and certificates issued. It says that a permanent Passenger Ship Safety Certificate was issued on 23 June 1994 at Copenhagen with the note (clerical mishandling) and that an interim Passenger Ship Safety Certificate was issued at Stockholm on 26 June 1994. It also says that an interim Load Line Certificate was issued on 9 September 1994 at Stockholm. However it is a fact that these certificates are not shown in the Final Report or its Supplement and there is no evidence that they existed.
Intact and Damage Stability Information
One condition of a Load Line certificate is that there is proper intact and damage stability information on the ship and instructions what to do in an emergency. The Final Report does not say if such information was available 2.17, where it is stated that the latest stability data was approved 16 September 1994, i.e. a week after the interim Load line certificate was issued.
A ship does not sink due to incorrect or false certificates but it is an indication that something is wrong with the ship or its operator/owner. By hiding this fact the Commission actually supported the owners and neglected the passengers and cargo owners.
The conclusions of this chapter are (A) that no lifeboat alarm was given, but regardless, (B) the passengers would not have known what the 'lifeboat alarm' meant, and (C) that the 'Estonia' lacked proper life saving equipment and (D) that the certificates were manipulated to hide these facts and (E) that the Swedish NMA was fully aware of the 'Estonia' being unseaworthy and (F) could have prevented the 'Estonia' from entering a Swedish port, i.e. leaving Tallinn, and (G) that the Swedish NMA did nothing (except cover up their own mistakes). As the Commission apparently decided to present a false cause of accident, it also decided to falsify the information about the lifeboat alarm and arrangements and the certificates and the Swedish NMA. Actually, the Commission falsified every essential piece of information about the ferry and the accident. Therefore it was so difficult to produce a Final report (5).
More Persons could have been saved
A logical question is - would more persons have been saved, if the life saving equipment had been correct?
It is a proven fact that four or five assisting ships of the same type as the 'Estonia' and with correct or maybe incorrect equipment could not launch any own lifeboats or rescue boats to assist the persons from the 'Estonia' in the water 1.20. But one ship - the 'Mariella' - managed to lower some of its life rafts with cranes. These life rafts obviously bumped against the side of the rolling ship but nobody was hurt. Later they could haul up some of their own rafts into which survivors in the water had managed to get! It is remarkable that no ship even tried to launch e.g. a lifeboat to pick up persons in the water. They did not dare - they said!
But the writer thinks that many more would have been saved, if the equipment and systems on the 'Estonia' were correct. As soon as something suspect was detected, you should have given clear instructions over the public address system to the passengers - e.g. go to deck 7 and bring your life jacket, if you were in your cabin. With 60 correct rafts that you launch by davits/cranes on deck, a few crewmembers should have been able to activate these rafts on the sloping deck between 01.05 and 01.20 hrs. There would have been 30 rafts on the port side - each could in an emergency have taken 40 persons! These rafts are robust and could have been activated on the side of the ship at 01.30 hrs. Of course you could have saved more people, if the crew had been more alert and if the life rafts had been correct!
The defective life saving equipment and systems and a negligent crew on the 'Estonia' contributed to the very high number of drowned persons. The Commission could not have overlooked these obvious defects during three years of investigations but decided to state the opposite in the Final report (5) - all was in order! The Swedish NMA was aware of the defects before the accident and did nothing, or asked Sten Anderson of the NMA to push the Commission to cover up this fact. This is one of the inhuman scams of the investigation/cover-up!
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74 As the angle of list then was 35 degrees, all engines and pumps had stopped and all different alarms were activated simultaneously - sound and light! The situation in the ECR should have been terrible! So the writer thinks that the engine crew had deserted the ECR much earlier 1.48. However, according 3/E Treu everything was normal in the ECR, while the list increased. Treu tried to start pumps and to ballast the ship upright for about 10 minutes, while the main and auxiliary engines stopped one after another, alarms sounded, etc., until the heel was 70-80 degrees, when Treu left the ECR. The statements of 3/E Treu cannot be true. A Commission that believes the statement of 3/E Treu cannot be competent.
75 At the 15th meeting of the Commission Tuesday 18 December 1996, i.e. two years and two months after the accident, the Commission concluded:
"Also the uselessness of lifeboats and poor condition of davits, the improvements of which should certainly be recommended, was pointed out. There are also suggestions that the life rafts should be improved in many ways" (point 11 in act A208* ).
Thus - the Commission noted that the lifeboats were useless and the davits were in bad condition and that the life rafts should be improved but nothing is mentioned in the Final Report (5). The Commission never noted that there were two different types of life rafts on the ship - 12 off to be launched by cranes, 49 off to be thrown overboard or, if it was not done by the crew, released themselves under water, after the ship had sunk!
76 After the 'Sleipner' accident in November 1999 ( the 'Sleipner' was a Norwegian catamaran, which grounded and sank) when 16 persons drowned, the Norwegian NMA disapproved the life jackets, which had type approval first by the Italian NMA 1997 and later by the UK NMA. Norway had first 'approved' the jackets based on the Italian/British approvals. After the Norwegian decision also the UK NMA retracted its approval. Italy has decided to make new tests. All life jackets of that type have been identified. If they have been replaced is not known.
77 The writer has got a copy of the Bureau Veritas inspection report (GTB/93/2I) from the change of flag Finland/Estonia in January 1993 (is not included in the Final Report). Mr Anders Wirstam did the inspection at Tallinn, 930128 Appendix 7. The report was issued at Gothenburg 930207. The report is not signed by Mr Wirstam but by Mr H. Olsson, chief of the BV Gothenburg district. There is no information that previous certificates were for 'short international voyage'. It is possible that Mr Wirstam actually pointed out that the 'Estonia' should have been upgraded at the change of flag, but that his boss decided differently - the start-up of traffic had been delayed. Thus Mr Wirstam did not sign the report or issued any certificate. Wirstam has later never explained anything about his surveys of the 'Estonia'.