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Welcome to a chapter of the e-book Disaster Investigation.


'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

 'Reports should include, wherever possible:
.4 a narrative detailing the circumstances of the casualty;
.5 analysis and comment which should enable the report to reach logical conclusions, or findings, establishing all the factors that contributed to the casualty;'

IMO res. A849 (20) 14.6  

1.21 The 20th Meeting of the Commission. A 100% false Final Report 1997

The 20th and final meeting of the Commission took place in March 1997 and the investigation was completed and the Final report (5) was agreed even if no manuscript exists in the archive. Only proof reading and printing of the report (that didn't exist) remained, media announced..

The manuscript agreed in March 1997 thus does not exist. Nobody knows what the Commission had agreed in March 1997. Was it the Final report issued in December 1997?

In May, after the Final report had been agreed, Forssberg was dismissed or resigned from the Swedish Board of Accident Investigation, SHK, and had to leave the Commission. Ann-Louise Eksborg, legal counsel at the Swedish Ministry of Defence, replaced Forssberg as director general of the SHK and she also took Forssberg's position in the Commission, (which was her part of the deal with the government). Eksborg took a great interest in the Final report that had already been agreed ... and probably changed it. Can it be that the Final report agreed in March 1997 was so bad that they had to get rid of some clowns agreeing it?

The Final report (5) was published on 3 December 1997. We do not know if it is the same report agreed in March. It starts with a lie on the cover, which is repeated on pages 1 and 3 (page 2 is blank):

that it is the Final report 'on the capsizing' of the 'Estonia'. The 'Estonia' evidently never capsized but sank slowly during 35 minutes (how The Final report could not explain)!

According to the Commission the 'Estonia' was floating on its hull at 01.14 hrs, when she suddenly listed to starboard due to alleged water in the superstructure above the hull. The 'Estonia' was then making 14-15 knots straight into big waves! The visor had fallen off and ripped completely open an inner ramp protecting the superstructure ... water was quickly filling the superstructure ... and therefore the ship listed. But she never capsized, as you would have expected.

Instead the 'Estonia' turned 180° back towards Tallinn, the engines stopped and the vessel drifted at constant speed >2.2 knots with increasing angle of heel - and suddenly she sank at 01.52 hrs.

She thus sank - lost buoyancy - during at least 38 minutes, but she never capsized.

How the buoyancy of the hull (14 watertight compartments below the bulkhead deck - 18 000 m3) was lost before, during or after this time was not explained by the Commission and is not considered anywhere in the Final report.

A ship floats on its hull and sinks only when the hull is flooded. The sinking takes place when the weight of the ship exceeds its buoyancy, which the Commission never understood. A ship capsizes when an imposed heeling moment (e.g. water in the side of a superstructure) exceeds the inherent righting moment of the ship. After capsize the ship floats upside down.

Did the 'Estonia' sink or capsize?

Six years after the accident the Swedish government ordered its Board of Psychological Defence, SPF, to explain how the ship's hull was water filled and how the buoyancy of the hull was lost between about 01.30 and 01.52 hrs (the end of the events), when the ship allegedly, finally sank, 1.49 and 1.50. The beginning of the events was water in the superstructure since 01.15 hrs and in the deck house since about 01.20 hrs, while the underwater hull was dry at those times. It was evidently not possible and the SPF had not started the work in 2002.

That the ship probably sank due to hull leakage starting 00.50-00.58 hrs should not be investigated by the SPF, the government instructed. The SPF should explain how the vessel was water filled based on the information in the Final report!

In the Preface (page 7) to (5) the Commission says dutifully that it has

"considered all available (sic) information directly related (sic) to the accident".

The available information is alleged data about the ship, its operation, testimonies, weather, dive examinations and analysis of the visor. Information with an indirect (?) connection or information not available has apparently not been considered, e.g. the German information and (1). But even if the Commission apparently has considered all available information, it has decided to ignore most of it, so what remains shall 'suit' the false conclusions.

Sinking not described

In order to get full understanding about the course of events the Commission states that is has carried out studies of the ship's movements and loads in irregular seas, strength analysis, manoeuvre characteristics and "stability when flooded".

The latter is not true. The Final report does not explain at all how and when the ship underwater part - the alleged undamaged hull - with the buoyancy was flooded, so that the ship could sink, and as a consequence no correct stability calculations were done. Correct stability calculations would of course have shown that the ship capsized and floated upside down with a certain amount of water in the superstructure. It could not be said!

As shown in this book all essential studies of the Commission had then to be manipulated to 'suit' the official lies about water in the superstructure. Not one of any study can be re-done by independent scientists and naval architects to obtain the same result. In most cases the result is of course opposite to what the Commission concluded.

No proven Cause

Furthermore the Commission states:

"This final report covers all factors and circumstances considered to have contributed to the development and outcome of the accident".

This is clever, misleading wording. The accident is apparently the visor falling off under way due to defective locks, but it is not even proven in the report. It then blames the whole accident on the visor locks, which allegedly were incorrectly designed and manufactured in 1979/1980, i.e. 14 years before the accident.

There is no evidence at all for this in the confusingly written report.

And there are no details about the weather tight door/ramp locks of the superstructure behind the visor in the report and how water entering into the superstructure could have sunk the ship without causing immediate capsize/floating upside down.

The Preface (page 7 of (5)) is full of lies! Easy for a normal reader to spot.

All information from the German yard, which built the visor, is ignored! No other possible causes of accident are mentioned, e.g. leakage,67 dangerous goods, bad maintenance, e.g. corrosion in the sauna/pool compartment or the sewage tanks, incorrectly installed fin stabilisers, crew error, incorrect design of watertight doors and/or bilge system, sabotage, welding aboard (explosion), drug smuggling, too high speed,68 heavy weather, collision, etc. The Final report then states that the ramp in the superstructure was fully open but then evidently could not explain the course of accident with a fully open ramp 1.9. Why didn't the ship capsize and float upside down? And when, and how, did the watertight hull fill up with water, so that the ship could sink?

The only evidence that the ship was in good condition was a number of anonymous persons just stating it.

All testimonies of the opposite were censored. Evidently many witnesses suggested that the condition of the ship was not good.

A falsified Certificate confirms Seaworthiness

The members of the Commission never bothered to check for themselves the real condition of the ferry. That the ship was seaworthy is explained by that it was certified to this effect. That the certificates were false is not investigated! The certificates are not even included in the Final report! All information that the ship was not seaworthy has been censored in the Final report as shown in this book. It not only incompetence by the Commission - it is criminal!

The Final report, chapter 8.5.1, page 120 states that

"No external damages on the wreck have been observed, except the damages on the visor and in the area around the bow ramp."

This is a very strange statement. As seen in 1.16 no examination of the hull was specified and was thus not carried out at the diving in December 1994. Later, when the 'edited' video films of the wreck became available to the public, independent observers have noted many un-reported and un-investigated hull damages - openings in the hull Appendix 5. And the area with the big damage in the front bulkhead 3.10 is reported by the Commission to be undamaged, so it is not explained.

This writer believes that this particular superstructure damage was caused, when the visor was removed from the bow under water after the sinking using explosive devices. To finalize the job the visor was pulled off the wreck, when the visor hinges were torn apart.

The full Truth and nothing but the Truth

According a statement of the Estonian president, Lennart Meri, who received the Final Report at Tallinn, it - the Final Report - was expected to contain the full truth and nothing but the truth about the accident.69 There is no Truth in the Final report and therefore the Final report - the Truth - cannot be officially discussed in Estonia - the media and the public are silent. The Estonian president is the first supporter of continued falsification of History after the fall of the Soviet Union 4.5 and the Estonian media and public seem to support this policy.

As a reward for the falsification of History president Meri in February 1999 awarded an Estonian order - Riigivapi - of the third class to the Commission chairman Uno Laur.

When the Final report was issued the German group of experts in December 1997, the Swedish nautical magazine Nautisk Tidskrift and the Swedish Ship Masters Association in January 1998 stated that it was not convincing. The Swedish weather bureau SMHI did not approve 971204 the interpretations of the Commission of the weather.70 The Royal Institution of Naval Architect magazine The Naval Architect disapproved completely the Final report in April 1998. Professor Anders Ulfvarson, Chalmers Tekniska Högskola, Göteborg wrote in the Swedish daily Svenska Dagbladet 980923 that the Final report lacked (a) an analysis how the ramp had opened and b) how the ship could have sunk. The Nordic (NTF) and the International (ITF) Transport workers Federations representing 600 000 seamen disapproved totally the report on 18 November 1998.71 In October 1999 the Swedish ship engineers magazine Maskinbefälet demanded a new investigation. The Commission did not reply. Actually the Swedish Board of Psychological Defence had recommended all authorities to ignore any comments in the media 1.49!

It is only the Swedish director of safety at sea, Johan Franson, Swedish NMA at Norrköping and minister Mona Sahlin who officially several times have stated that the Final report is complete (sic) and that there is nothing to criticise. But Franson is of course part of the case - he directed the dive examinations, 1.16 and 3.10, and gave misleading information to the government. Why minister Mona Sahlin is not interested in the Truth is not clear, but probably she is simply protecting friends and colleagues. Is there something to hide? And Ms Sahlin is not logic - six years after the accident she asked the Board of Psychological Defence, SPF, to clarify, how the hull was flooded so that the ship sank - but based on the Commission allegations; water enters only the superstructure. The hull is undamaged. In 2004 the SPF still has not been able to finalize this job, 1.51.

What a Final Report shall contain

The ultimate goal of a marine investigation is to advance maritime safety and protection of the marine environment. This goal is achieved by identifying safety deficiencies through a systematic investigation of marine casualties and incidents, and then recommending or effecting change in the maritime system to correct these deficiencies.

In a report that clearly lays out the facts relevant to the occurrence, and then logically analyzes those facts to draw reasoned conclusions including those relating to human factors, the required safety action may appear self-evident to the reader. Recommended safety actions in whatever form should clearly identify what needs to be done, who or what organization is the agent of change, and, where possible, the urgency for completion. The 'Estonia' Final report (5) fails in all respects to achieve these goals.

The IMO

The UN maritime organization IMO does not say anything - the IMO is not interested in particular accidents, even if it appointed a special panel to review the safety rules after the accident without checking the facts of the 'Estonia' accident. The IMO panel just thought that ships sink with water on car decks in a superstructure and that visors suddenly fall off ships. No proper Formal Safety Analysis, FSA, was done before the Solas rules were changed (chapter 5 of (1)).

The accident is of course still being discussed and the public has different opinions (these web pages have had >100 000 visitors since May 2000 to May 2004, but unfortunately with little result). Many believe that the accident was caused by too high speed, which caused the visor to be ripped open, water inflow in the superstructure followed sinking. The Final report does not consider it, as too high speed would have been criticism of the crew. Evidently the Commission chose already (or was told) 1994/5 to blame the accident on design faults of the visor locks and that the shipyard was finally to blame. However - all factual information from the shipyard was censored in the Final report (see next chapter) and the shipyard has never protested. Strange!

The Commission does not only falsify the information about the open ramp. It falsifies much, much more to protect the real culprits of the accident.

In principle all essential facts in the investigation report are falsified.

The opinion of the writer is that the Commission thought that it had managed to cheat the public about the visor and ramp in 1994/5, so that it then 1995-1998 could falsify all other information too without being discovered. This unbelievable, shameful act has in principle succeeded. There was silence about the Final report and the 'Estonia' accident for several years. The writers of the Final report refuse to discuss the matter. They know it is best to say nothing. Their concern for safety at sea is zero. They show no respect for survivors and relatives of the victims. The following chapters will show how the Swedish administration covered up the errors in the Final report and protected the Commission.

The whole Final report must be considered a purposeful manipulation.

---

67 The Swedish daily DN wrote an editorial on 970927, just after the resignation of Schager 1.20, with the following:

"It had been interesting to see how the Commission more comprehensively discounts the different theory of naval architect Anders Björkman who suggests that the 'Estonia' sank due to a leakage below the waterline. But his theory has always been dismissed".

It was the last time that DN mentioned the writer or leakage as cause of accident 1.44.

68 According Swedish daily Svenska Dagbladet 970923:

"The Commission says - which is new - that the 'Estonia' had about the same speed as the 'Silja Europa' when the accident occurred ... The Final report therefore does not repeat that the 'Estonia' was driven too fast, and that for that reason you cannot criticise the crew".

According figure 17.1 in (5) the 'Silja Europa' sailed about 6.3 miles between 01.00 and 01.32 hrs - speed 11.81 knots!

69 When the writer pointed out some obvious errors for president Meri and his Public Relations secretary Ms. Epp Alatalu, epp@vpk.ee , that the final report does not quote surviving passengers correctly, there is no reply.

70 The Swedish daily Svd 971204:

"The wind speed just before the accident was 16-20 m/s ... the wave height was about four meters ... such conditions and worse occur more than 300 hours per year. The wind speed was not particular. Such weather ... occurs 8-10 times per year" says Svante Andersson. "... - It is not reasonable that a ship sinks in these weather conditions, then there would be no shipping in the Baltic".

71 ITF Assistant General Secretary Mark Dickinson has called for a new investigation into the 'Estonia' … disaster … Dickinson made the demand while speaking in Stockholm at a joint ITF/NTF conference on 18 November 1998, which looked at an independent analysis of the official Joint Accident Investigation Commission's (JAIC's) report into the tragedy as well as details of the work of a German group of experts... The independent analysis commissioned by the ITF from Corlett, Burnett & Partners shows that the official JAIC's findings are questionable and that a number of its central assumptions are not sustainable. The report presented a different time scale for the casualty and highlighted shortcomings such as poor maintenance in the operation of the vessel.

"Most importantly it is clear that the 'Estonia' was not seaworthy that night, and that she was not in compliance with international minimum requirements. These findings present a large amount of relevant information that could have a bearing on the chain of events leading to the casualty. They reinforce our concerns about the JAIC report and the investigation. It seems that the JAIC process was more of a political fix, concerned with appeasing vested interests, rather than identifying the circumstances surrounding the loss of the 'Estonia' and establishing the causes by gathering information and drawing objective conclusions. That is why the ITF is calling for a re-examination of the loss of the 'Estonia'."

Dickinson said and added that the new investigation should be transparent.

"To do otherwise would set an unfortunate precedent to be seized upon by those flag states, which have little regard either for the safety of life at sea or for the protection of the marine environment,"

he concluded. In April 2001 the Swedish government concluded that the ITF investigation had not provided any information that affected the official course of events and the cause of accident. The ITF did not object. Sweden just confirmed that it was one of those flag states, which have little regard for the safety at sea.

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