Welcome to a chapter of the e-book Disaster Investigation.
"... (it) is meaningless to start a discussion about the cause of the sinking of the 'Estonia' before all (sic) documents are on the table, i.e. when the Final Report of the Commission is made public. I want however to point out that behind the content of the Part report was a united Commission with access to highly qualified experts within your field of expertise"
Olof Forssberg, 'consultant' at the Swedish Ministry of Transport, to the writer 971030
'Reports, or relevant parts of reports, into the circumstances and causes of a marine casualty should be completed as quickly as practicable, and be made available to the public and the shipping industry in order to enhance safety at sea and protection of the marine environment through improved awareness of the factors which combine to cause marine casualties'
IMO res. A.849 (20) 12.3
include, wherever possible:
IMO res. A.849 (20) 14.6
1.19 The Swedish Government interferes. A 100% false Part Report. Falsified Model Tests to support the Part Report
The Swedish social democratic government (i.a. prime minister Ingvar Carlsson and transport minister Inez Uusmann) decided on 15 December 1994 that the 'Estonia' should not be salvaged and that no bodies of victims should be recovered.
Thus the same day when the Commission met for only the third time 1.17 and produced a modified but fully unproven sequence of events (the ramp was fully open, etc) and long before the Final Report (5) was published December 1997 and all documents were public in March 1998 and long before anybody knew what exactly had happened, the Swedish government decided that salvage would not take place. In retrospect the decision of the government 1994 was a tragedy and a strong support for a conspiracy.
It is today clear that all essential facts presented by the Commission 28 September - 15 December 1994 to the government, media and public were false due to the secrecy arrangements adopted from the start of the investigation.
The strange visor position - a mile West of the wreck of which a false position had been announced - had only been determined a week earlier (9 December) and had not been explained. But it is a historic fact that the Swedish government brutally interfered in the accident investigation and drastically permitted a change of course of the investigation with fantasy modifications of the sequence of events.
The government decided that the area of the wreck would be regarded as a grave. To secure its peace the wreck should be covered up in concrete or by stones and particular rules established together with Finland and Estonia to legally protect the grave. It meant that no further examinations of the wreck were possible. Luckily this decision was never fully implemented and it is today fairly easy to dive and inspect the wreck.
The Swedish NMA (Franson) presented a report on 10 February 1995 how to cover the wreck.
The Swedish government decided on 2 March 1995 that the Swedish NMA should cover up the wreck with concrete or similar and to liaise with the Finnish authorities. That the Swedish NMA had no competence or expertise to cover up a wreck on the bottom of the sea was not considered.
Who has ever heard about a government deciding, before the inquiry into the accident was completed (it took another three years), that a wreck shall be covered up in concrete? Cargo owners, relatives and survivors were not asked about their property being salvaged. And interested parties were not asked if more evidence needed to be collected from the wreck. And the official dive investigation of the wreck 2-4 December 1994 later turned out to be totally manipulated. All films of the diving were edited not to show anything of interest.
Due to the Swedish decision 15 December 1994 the Swedish Foreign Office contacted their Finnish and Estonian counterparts how to legally 'protect' the wreck and the dead bodies. Both governments were willing to cooperate. At a meeting at Stockholm on 16 January 1995 all three governments agreed to introduce national laws to prosecute anyone disturbing the peace at the wreck and that an international agreement would be adopted to the same effect. The relatives of the 'dead bodies' were not consulted.
At a follow-up meeting on 7 February 1995 at Tallinn the international agreement was agreed - it was then signed on 23 February 1995. They also discussed common principals to apply national law. To disturb the peace at the wreck should be regarded a criminal act. ARTICLE 4.1 of the agreement stated:
1. The Contracting Parties undertake to institute legislation, in accordance with their national procedures, aiming at the criminalization of any activities disturbing the peace of the final place of rest, in particular any diving or other activities with the purpose of recovering victims or property from the wreck or the sea-bed.
You get the impression that any diving with the purpose of only securing technical evidence establishing the real cause of accident would still be possible. But it was a false impression - no diving of any kind to secure evidence was to be permitted.
The Swedish Law of Graveyard Peace
The Swedish law of graveyard peace is described in proposition1994/95:190 to the Parliament. It was adopted on 30 March 1995 and signed by Prime Minister Ingvar Carlsson and justice minister Laila Freivalds. Thus a few days before the Commission was going to present its 'part' report (which later turned out to be 100% false) - see below - the wreck was off limits for anyone interested in the accident. It must be recalled that at this time all relevant evidence was confidential and that the public had no access to the meetings of the Commission. Individual members of the Commission had said nothing. The public only knew what the Commission had stated in various press releases. All essential information of the Commission at this time has later been proven false.
The law itself entered into force 1 July 1995.
The law (in the Swedish language) is below. It is similar but not identical to the UK law adopted four years later (right below):
With this law the Swedish (and other) government(s) may have succeeded to prevent all further Swedish (and others) work to examine the wreck to clarify the accident. You can end up in prison in Sweden two years breaking the law (in the UK you are only fined)! Any objects recovered from the wreck will be confiscated. The Swedish government can however, in order to do work to protect (read cover up with concrete) the wreck itself, allow diving. The UK law is much milder - only diving is forbidden and you are only fined, if you break the law. The British will not confiscate any objects recovered. But the British law is still a mystery - there are 1 000's of wrecks around Britain and no law to preventing to dive on them and film and to have a look. Why is the United Kingdom prepared to prevent its citizens to dive on the 'Estonia' in the Baltic? Isn't the United Kingdom interested in safety at sea? United Kingdom was interested in why 44 British subjects had died on the 'Derbyshire' 1980 and reopened the investigation 1998 Foreword. Why is it of no interest to know why >850 persons on the 'Estonia' died? The British law is badly written - it prevents diving made by, e.g. a Swedish contractor to protect the environment!
It is in this light that the Part Report (16) must be seen. The Commission could now say and manipulate evidence any way it liked - nobody could disagree, as the wreck was off limits and all evidence confidential.
However it should be possible to dive - it seems that only the diver himself may be prosecuted. Persons directing the diving - even if they are aboard the dive vessel - may escape prosecution according to the Swedish law. The English law may prosecute a person that may cause or permit a diver to dive, whatever that means. However, if the purpose of the diving is not to explore the wreck from inside but only to have a look from outside, you may escape prosecution in the UK. You will only be prosecuted for using dive equipment. Strange laws to ensure graveyard peace. However, diving is not required to re-open the 'Estonia' investigation. Just review the official 'allegations' against the later facts.
A correct Analysis
Once all facts are collected, they need to be analyzed to help establish the sequence of events of the accident, and to draw conclusions about safety deficiencies uncovered by the investigation.
Analysis is a disciplined activity that employs logic and reasoning to build a bridge between the factual information and the conclusions.
The first step in analysis is to review the factual information to clarify what is relevant, and what is not, and to ensure the information is complete. Thus, this process can give guidance to the investigator as to what additional investigation needs to be carried out.
In normal investigation practice, gaps in information that cannot be resolved are usually filled in by logical extrapolation and reasonable assumptions. Such extrapolation and assumptions should be identified and a statement of the measure of certainty provided.
Despite best efforts, analysis may not lead to firm conclusions. In these cases, the more likely hypotheses should be presented.
After fact finding and analysis it should be possible to give a description of the occurrence, its background, tuning, and the events leading to it in, e.g. a Part report.
The Part report should include such factual items as:
· the weather conditions;
· the operation(s) involved;
· the equipment in use, its capabilities, performance and any failures;
· the location of key personnel and their actions immediately before the accident;
· the pertinent regulations and instructions;
· uncontrolled hazards;
· changes of staff, procedures, equipment or processes that could have contributed to the accident;
· what safeguards were or were not in place to prevent the accident;
· response to the accident (first-aid, evacuation, search and rescue);
· medical treatment actions taken to mitigate the effects of the accident and the condition of injured parties, particularly if disabling injuries or death ensured;
· damage control including salvage;
· inventory of all consequences of the accident (injury, loss, damage or environmental damage); and general ship's condition.
It should also be possible to identify active and underlying factors such as:
· operational deviations;
· design aspects of hull structural failure;
· defects in resources and equipment;
· inappropriate use of resources and equipment;
· relevant personnel skill levels and their application;
· physiological factors (eg. fatigue, stress alcohol, illegal drugs, prescription medicine);
· why safeguards in place were inadequate or failed;
· role of safety programs;
· problems relating to the effectiveness of regulations and instructions;
· management issues; and
· communication issues.
In the 'Estonia' investigation the Commission avoided carefully during the first six months to present any facts and analysis of above self-evident type but was of course forced to present some information. The result was the Part report. It was a necessary part of the cover-up.
The Part Report - a first Test to misinform the Public
The Part report (16) is only 32 pages and was issued on 3 April 1995. It is a purely technical report only about one thing - the defective visor and how it supposedly fell off.
The Part report does not explain that the 'Estonia' was initially floating on its watertight, subdivided hull with a good freeboard and with a superstructure above the hull and bulkhead deck with a deck house on top. But it clearly states (on page 31) that the vessel capsized (sic) due to water in the superstructure and because the deck house was flooded. But the ship never capsized - it sank slowly. How the hull was flooded has never been explained.
The Part report does not include anything about hull leakage, bilge pumps, watertight doors, life saving equipment, safety systems, maintenance, crew competence, etc. or about stability with water on the car deck in the superstructure and how to abandon ship.
The alleged sequence of events 1.9 was not described and no reports of survivors testimonies were included 2.1 - the Commission evidently had no idea how to present these things - they totally contradicted everything in the Part report - so they could not get published - they were in fact censored.
The Commission instead stated in the completely misleading Part report that
"The Final Report, that will be issued later, will include all other factors and circumstances, which have contributed to the accident".
Of course that was not the case, when the Final report was issued on 3 December 1997.
Then only further falsified factors and circumstances were presented, as will be described later. The Part report only repeated exactly the cause of accident from 17 October (the second meeting) as modified 15 December 1994 (the third meeting of the Commission 1.12) and it was not much to report in the media.
In retrospect year 2001 it is easy to conclude that the Part report was an intentional attempt 1994 to cover up the real cause of the accident. All essential facts in the Part report are false, falsified or not proven.
As it was common knowledge before the publication of Part report that it declared the shipyard of the 'Estonia' responsible for the alleged defective design and manufacture of the alleged defective visor locks 1.22 - a design fault, the yard had previously informally proposed another cause - defective maintenance during 14 years of service (particularly the last 18 months) and associated reduced strength of the visor locks. The yard added that lack of maintenance also had resulted in a leaking visor, water inside the visor, added weight, increased loads on the locks and that it was this weight and load that made the visor hinges break and the visor to tip forward and to break the locks. If that had actually caused the ship to sink, the Germans never admitted. The Commission reputed the informal German proposal without any comments neither in the Part (16) or the Final (5) reports.
All Facts and Conclusions will remain unchanged
Instead the Commission wrote in the preamble of the Part report:-
'The Commission has earlier concluded54 that the accident was initiated by the locks of the bow visor, which could not resist the resulting loads under actual conditions due to the speed, course and sea conditions. This conclusion is still valid '.
'The content in this Part Report may be expanded and revised but it may be assumed that all facts and conclusions as now presented will remain unchanged in principle'.55
The amazing sequence of early - not proven - events established only nineteen days after the accident, when the Commission met for the second time, was again confirmed as the Truth and fact.
The accident was 'initiated by too weak locks' of the visor.
It has not been proven!
The visor had fallen off under way to Sweden (the ship was otherwise undamaged) at 01.15 hrs.
That the visor had fallen off has never been proven!
Water had forced itself into the superstructure at the ramp opening - the ramp was fully open - but the ramp had closed itself later - when? - as found on the wreck.
Every seaman knows what would have happened - immediate capsize.
But in spite of the fact that the ramp was fully open and the speed was in excess of 14 knots, the ship had only 'capsized' (sic) slowly, i.e. started to heel at 01.16 hrs but did not sink until after 01.50 hrs.
And during these 34+ minutes the ferry turned 180° and drifted more than two miles. It was not stated in the Part report but had to be announced in the Final report 32 months later. The latter suggestion is of course false.
There was not one word in the Part Report that surviving passengers reported a sudden listing >30 degrees starboard already at 01.02/5 hrs and that the ship then was in a stable condition with about 15 degrees list 2.1, i.e. it did not capsize, and only sank slowly, permitting at least 230 persons (probably more) to escape to open decks and to abandon ship and 137 to survive. Actually the Commission treated the survivors with outmost contempt at this crucial time - they were not in a position to contribute to the investigation - they were shocked victims, the observations of which could not be taken into consideration.
The Commission made it clear that the Final report was a formality to be published a few months later. However, the public had to wait for 32 months for a Final report in English and 44 months for a Final report in Swedish (or Finnish or Estonian). In the meantime one Commission member and one expert died and five members were dismissed or resigned 1.20. It is clear that there were big problems inside the Commission to write the Final report based on the false statements of Part report and falsified testimonies of some crew members (which were continuously changed).
It is not a healthy business to write a false accident investigation report.
Nine False Facts and Conclusions
The part Report (16) presented nine conclusions, which today (year 2001) have no foundation.
The Part Report is thus very easy to criticise (apart from lies and falsifications of History).
Plenty of hidden Facts
The Part Report made three recommendations:
In retrospect it is easy to see that the whole Part report was disinformation and falsification of History. It was no doubt written only by Stenström and Forssberg.57
The Commission evidently refused to discuss the Part report with the public.58 It can be seen from the records in the SHK archive that Forssberg and Stenström were worried about the reaction of the public about the report. The reaction in the media was tepid as the report only repeated what had been said before and the public had no idea of the real facts. But it hardly helped the Commission. It should now write the Final report.
On 3 August 1995 the German Group of Experts made its first oral presentation for the Commission. The Germans disapproved of most of the information of the Part report but never made any suggestion that the report was totally false.
The Germans later gave written evidence on14 August and 11 October 1995 to support their observations given earlier. All German information was made secret/confidential by the Commission (acts B104** and B122**) according a Swedish secrecy law and became official only in March 1998. Only a reporter of the biggest Swedish daily Dagens Nyheter, Anders Hellberg, could access the letters and use the content to produce more disinformation 1.44
The German letter (51 pages) in act B104** is quite interesting and supported by photos, drawings, etc.
Even a layman understands that these defects indicated that the visor was not in good shape. The Commission decided to ignore all this German information in the Final report, where it instead states that according to unnamed person the visor was in perfect shape (sic).
The German report - act B104** above - was however discussed at the seventh meeting of the Commission on 22 and 23 August 1995, but as mentioned the critical reports of the Germans are not included in the Final Report (5); 1.22, 3.13 and Appendix 5 - collusion!
The Commission summarized the German information as follows in its meeting record 23 August 1995:
"their way of analysing is different and they try to find a connection between the accident and the maintenance of the ship"
That was all! The Commission then never mentioned the different German way of analysing the accident. In the Final report (5) 1.21 the German observations are not mentioned at all. Instead the Commission (page 35 in (5)) states that
"Individuals concerned with maintenance of the ship during the various periods of her life have generally expressed satisfaction with the vessel as a sound and trouble-free one.".
Actually the maintenance of the ship the last 18 months was not investigated at all by the Commission 1.46.
The Commission just asked a few anonymous persons about the ship and they apparently stated that the ship was OK - several years back. But if you do not do any maintenance the last 18 months, doesn't it affect the condition of the ship?
Falsified Model Tests to support the Part Report
The Commission continued to regularly spread disinformation in the media. Thus the Swedish daily Dagens Nyheter on its first page 31 August 1995 stated:
'One wave may have knocked out the 'Estonia' - model tests provide a new picture of the disaster'.
Stenström announced that measurements at model tests by the SSPA Marin AB at Gothenburg, Sweden showed that if the 'Estonia' made 14,5 knots then the load of one single big wave during the night of the accident was sufficient to knock out all safety systems Appendix 2. The assumption was that the 'Estonia' pitched down into the approaching wave and that the visor was hit straight on. It was nicely illustrated by three pictures - (a) the wave hits the visor, (b) all locks are simultaneously ripped apart/the visor moves and the hinges are also ripped apart and (c) the visor falls off pulling open the ramp and a few seconds later the superstructure forward part was open to the sea. That the Commission previously had stated that the visor was hitting up/down on the forepeak deck during 10 minutes was thus forgotten. Stenström stated further that:
'Our original theory is correct; it was the locks that were broken first - that the locks were too weak we concluded already in the spring - they had only one third of the required strength'.
As per 3.6, 3.7 and 3.8 one wave cannot possibly damage all locks at once, but Stenström announced the opposite. Stenström forgot to mention that the model tests did not measure any loads on individual locks or hinges. It was only the total load on the visor in a seaway that had allegedly been measured. But such details are easily forgotten when you spread disinformation. Now the public got the impression that the SSPA Marin AB officially was behind the Commission. And correct strength tests of the locks were done much later - with the opposite result - the locks were stronger than expected.
Then Stenström added that
'it took only ten minutes from the first damage until she was lying with the bow open against the sea and the waves were rolling in on the car deck'.
When Stenström made the statement he knew for sure that water on the car deck would have caused the 'Estonia' to capsize and to float upside down after a few minutes.
But the reporters of Dagens Nyheter did not check the model test report themselves and did not ask any pertinent questions. Dagens Nyheter just printed the unproven statements of Stenström. It might have been to ask too much of the reporters to check the model test report (it was secret until the end of the investigation), but if they had done so, or had asked an expert to have a look, they would have been told that the model test report was probably false!
Evidently 100-tons loads do not hit the visor every minute or 600-tons loads every four minutes in 4,2 meter waves.
And how on earth can a 1 000-tons load suddenly hit the visor as pointed out by Stenström. The loads on the visor in regular 4,2 meter waves were periodical and very moderate - small - only due to a little buoyancy - 40 tons - when the visor was submerged for one and a half second. No impacts! How could suddenly the load become 25 times greater in irregular waves of same height 4,2 meters when the visor was only half submerged?
The answer is that the SSPA Marine AB report was faked Appendix 2.
The reason was simple - various people had asked the Commission, if really one or more waves could knock off a visor on a ferry in the Baltic. The classification society Lloyd's Register had >100 ferries with similar visors in areas with much bigger waves and had never had any problems whatsoever. The answer was of course the model tests - look here, we have measured very big loads! What could you answer? But the test report itself was secret. Later - to back up the faked model tests, similarly faked 'simulations' were calculated and they were likewise manipulated to show the same result. The statements in chapter 12.2.4 in the Final report (5) to these effects are thus false. The Commission states:
"Qualitatively the simulated results agree well with the experimental data".
This statement in the Final report (5) is a lie to support the false experimental data.
Obviously anyone asking the question how a 700-tons or 1 000-tons force could have been measured in model tests would only have been dismissed by the statement that simulations produce similar loads. Furthermore the Commission states:
"The experimental time histories of the vertical load on the visor have high upward peaks similar to those of the simulated records and in the downward direction the loads are negligible".
This statement is also false. It is more probable that the very high upward modelled peaks are false as no simulated records exist (!) to support the experimental data.
But Stenström and the Commission were at this time forced to back up its weak invention about the visor in the Part report with false model tests with the results spread in the media. It was absolutely necessary to fool the public. Otherwise the disinformation campaign would never succeed.
The ferry industry kept quiet. It had never experienced any problems with wave impacts on fore ships of their ferries before or after the 'Estonia' accident, i.e. full scale experience contradicted the Commission and just confirmed that with model tests and simulations you can produce any result you like.
(The ultimate manipulation - how SSPA faked further the model tests (to hide the true cause of accident!) - June 5 2008)
15 Secret Meetings to write the false Final Report
After the publication of the Part Report the Commission met at least 15 times to write the Final Report. All work was confidential - the public had no access - and no proper records of the deliberations were kept 1.12. It was not a serious accident investigation - the total sequence of events and the cause of accident had been made up already in 1994 - and a majority of the 'scientific' reports handed in to the Commission 1995-1997 had to be edited to suit. It takes time to falsify a report.
All members of the Commission must now have been aware of the swindle.
But they all happily worked on. Of course there were resignations, dismissals and two persons passed away during the investigation but nobody dared to suggest that the whole investigation was - a swindle.
It was not healthy to participate in the falsifications.
It may be easy to falsify a proximate cause of accident and a course of events - but all statements must be proven. That is the difficulty. But it simplifies with understanding governments that prevent collecting the evidence by making international agreements to this effect.
Thus after the Part report had been issued the Commission started to write the Final report 1.21. Every delegation had a particular interest to protect in the swindle - the Estonians wanted that the report would conclude that the crew had acted prudently, the Finnish wanted that the report would conclude that their initial approval of the ship was in order and that the rescue operations had been done correctly and the Swedes wanted that the report concluded that the safety arrangements and all surveys were in order (as the Estonian NMA had subcontracted all these matters to the Swedes).
It was probably the reason why they all agreed to the completely unrealistic sequence of events 1.9 and that the visor was to blame. They would all smell like roses, when the Final report was issued.
The Commission never appointed an official information secretary to handle contacts with outside, interested parties. It was logical, as the investigation was secret and all parties had agreed not to tell the public anything - in spite of protests from relatives and survivors. The Swedish government therefore on 21 October 1996 appointed the Board of Psychological Defence, (SPF), Stockholm, 1.49 to maintain contact with the (Swedish) relatives and, later, with the survivors. SPF suggested to the authorities not to discuss any questions raised by, i.a. the writer.
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 and 24 months after the strength analysis was ordered to be done by the Royal Institute of Technology at Stockholm. The Final report (5) was in fact published exactly one year later.
All essential information in the Final report (5) has later been proven false. The visor fell never off the ferry.
54 The Commission had of course never concluded anything earlier - it had suggested that the visor had fallen off under way, etc. in various press releases, but noting was proven.
55 Several conclusions were changed/modified in the Final Report (5), e.g. how the visor hinges broke 3.9. But it didn't change the alleged cause of accident.
56 An explosion between visor and ramp could result in a sudden tensile overload in the hinges, which 'blew off' the visor forward and bent the ramp inwards, aft.
57 Forssberg suddenly wrote to the writer on 30 October 1997 under the letter head of the government and suggested that
"... (it) is meaningless to start a discussion about the cause of the sinking of the 'Estonia' before all documents are on the table, i.e. when the Final Report of the Commission is made public. I want however to point out that behind the content of the part report was a united Commission with access to highly qualified experts within your field of expertise".
The letter was written after Forssberg had resigned or been dismissed from the Commission and the SHK 1.20, 30 months after the publication of the Part Report, when still most of the records of the Commission were secret. All 'highly qualified experts' still refuse to discuss the matter - but of course - the Commission had only access to them. It means that the 'highly qualified experts' were used as part of the cover up.